Screening Log Print this Form Not Started · Screening Log Print this Form Not Started Center Code...

© 2016 PHTS [test]

Screening Log Not StartedPrint this Form

Center Code DCC

Patient Initials If middle initial is not known, enter a hyphen ()

1 Is patient under the age of 18 at the time of listing?

If the patient is 18 years of age or older at the time of listing, they are not eligible for PHTS.

NoYes

PTLT18

2 Was informed consent and HIPAA Authorization obtained?

NoYes/my center has a waiver

PTIC

3 Was the patient listed for a heart/lung transplant? Heart/lung listings are not currently eligible for PHTS.

All other simultaneous organ listings are eligible.

YesNo

NOHLTX

5 Is this the patient’s first listing for a heart transplant?

NoYes

PRIMELS

RL Turner

Rectangle

RL Turner

Rectangle

RL Turner

Rectangle

RL Turner

Rectangle

RL Turner

Rectangle

RL Turner

Rectangle

Patient Details Hidden ShowShow/Hide Annotations

Demographics Not StartedPrint this Form

1 Date of Birth MM/DD/YYYY

2 Sex FemaleMale

3 Race Check all that apply.

AfricanAmerican or BlackAmerican Indian or Alaskan NativeAsianHawaiian or other Pacific IslanderUnknown/UndisclosedWhiteOther, specify

4 Hispanic or Latino Yes if of Mexican, Puerto Rican, Cuban, Central

or South American or other Spanish culture of origin, regardless of race.

NoYesUnknown

5 Primary Etiology Cardiac TumorCardiomyopathyCongenital Heart DiseaseMyocarditisOther, specify

5 Cardiomyopathy ARVD/CDilatedHypertrophicMIXEDRestrictiveUnknownOther, specify

5 Cardiomyopathy: Dilated ChemotherapyInducedConduction DefectFamilialIschemicIsolated/IdiopathicLVNCMetabolic/Syndromic/MitochondrialNeuromusculars/p MyocarditisUnknown

Other, specify

5 Cardiomyopathy: Dilated, Ischemic

ALCAPAKawasakiUnknownOther, specify

5 Cardiomyopathy:Hypertrophic

FamilialIsolated/IdiopathicMetabolic/Syndromic/MitochondrialNeuromuscularUnknownOther, specify

5 Cardiomyopathy:Restrictive

ChemotherapyInducedIsolated/IdiopathicLVNCMetabolic/Syndromic/Mitochondrials/p RadiationUnknownOther, specify

5 Congenital Heart Disease ASD/VSDComplete AV Septal Defect/AV CanalCong. Corrected Trans. (ITGA) (CCTGA)Coronary AnomalyDouble Inlet Left VentricleEbstein's AnomalyHypoplastic Left HeartHypoplastic Right HeartLeft Heart Valve/Structural HypoplasiaLeft Ventricular Outflow Tract ObstructionNo additional diagnosis other than Single VentriclePAPVRPulmonary Atresia with IVSRight Heart Valve/Structural HypoplasiaTAPVRTOF/TOF Variant/DORV/RVOTOTransposition of the Great Arteries (dTGA)Tricuspid AtresiaTruncus ArteriosusUnknownOther, specify

5 Single Ventricle NoYesUnknown

© 2016 PHTS [test]

5 If pulmonary atresia withIVS,

RV dependent coronarycirculation

NoYesUnknown

6 Blood Type AABBOUnknown

6 Blood A Subtype A1A2Unknown

7 Rh NegativePositiveUnknown

Calculated

BSA: n/a BMI: n/a


Height and Weight

Surgeries Prior to Listing

Form 1: Listing Not StartedPrint this Form

1 Listing Date MM/DD/YYYY

2 Height Centimeters Inches

Missing Reason: Not Done Unknown

3 Weight Kilograms Pounds


4 Main reason for listing Select only one primary reason for listing.

CHD too high risk for palliative surgical optionsGrowth failure due to the heart diseaseHypercyanosis without further palliative surgicaloptionsMalignant arrhythmiaMedically refractory heart failurePlastic bronchitisProgressive liver diseaseProgressive pulmonary hypertensionProtein losing enteropathyUnknownOther, specify

4 Medically refractory heartfailure

BothDiastolic FailureSystolic FailureUnknown

5 Did the patient have any cardiac surgery prior to listing?

NoYesUnknown

Surgery Details

5 If Congenital cardiac surgery,specify surgery:

AP ShuntArterial switch operationASD RepairAtrial switch (Senning/Mustard)CABGComplete AV Septal Defect RepairCongenitally Corrected Transposition Repair(classic)Congenitally Corrected Transposition Repair(double switch)Damus Kaye Stansel (DKS)dTransposition of the Great Vessels RepairEbstein's Anomaly RepairFontan ProcedureGlenn ProcedureHybrid PalliationNorwood Stage I: BT ShuntNorwood Stage I: Sano/RVPA conduitPA BandingTOF/DORV/RVOTO RepairTruncus Arteriosus RepairValve ReplacementVSD RepairOther, specify

5 Date of Surgery Missing Reason: Unknown

5 Congenital cardiac surgery, d Transposition of the Great

Vessels Repair

Arterial Switch OperationAtrial Switch (Senning/Mustard)

5 Congenital cardiac surgery, Valve Replacement

Aortic Valve ReplacementMitral Valve ReplacementPulmonary Valve ReplacementTricuspid Valve ReplacementOther, specify

5 Homograft Tissue in Aortic ValveReplacement?

YesNoUnknown

5 Pulmonary valvereplacement?

YesNoUnknown

Status Details at Listing

6 Status at Listing BrazilCanadaUnited KingdomUnited States

6a Status at Listing, US 1 (this option is only for listings prior to 1999)1A1B27

6a Canada 1233.544S

6a United Kingdom RoutineUrgent

6a Brazil NonPriorityPriority

6b Was patient in or out of hospitalat time of listing?

In hospitalOut of hospital

6b.i Was patient in the ICU attime of listing?

NoYesUnknown

6b.ii Did the patient requirecontinuous invasive

mechanical ventilation?

NoYesUnknown

6c Did the patient requirecontinuous inotropes at time of

listing?

YesNoUnknown

6c.i Inotropes Dose Dose UnknownHigh Dose or Multiple IVSingle Low Dose

Yes

Infectious Disease Screening

6d Did the patient have ductaldependent pulmonary or

systemic circulation, with ductalpatency maintained by stent or

prostaglandin infusion?

NoUnknown

6e Was patient listed for ABOIncompatible?

NoYesUnknown

6f Was patient on a VAD or ECMO attime of listing?

VADECMONot on support at time of listing

6f Specify initiation date (VAD) Missing Reason: Unknown

6f Specify initiation date (ECMO) Missing Reason: Unknown

6g Was patient listed for DCD(Donation after Cardiac Death)

organ?

YesNoUnknownThis is not current practice at our center

77

HIV Serology AIDS testing

Negative Not Done Positive Unknown

7 CMV Serology Negative Not Done Positive Unknown

7 CMV PCR Negative Not Done Positive Unknown

7 EBV Serology Negative Not Done Positive Unknown

7 EBV PCR Negative Not Done Positive Unknown

7 IFA Toxo Toxoplasma testing


7 HBs Ag Hepatitis B surface antigen


7 HB core Ab Hepatitis B core antibody


7 HBs Ab Hepatitis B surface antibody


Medical History at time of Listing

7 Hep C Ab Hepatitis C antibody


7 RPR/Syphilis Syphilis testing


8 Medical History NoYesUnknown

8 Type of medical history atListing

ArrythmiaCardiac Arrest/CPRDiabetesGI/NutritionHeterotaxy/IsomerismMalignancyMetabolic/DisorderMitochondrial DisorderNeurologicPacemakerPeripheral Myopathy/Neuromuscular diseasePrenatal DiagnosisPrior TransfusionsRenal InsufficiencyRespiratoryShockSyndromeOther, specify

8 Arrhythmia Afib/flutterComplete heart blockV FibrillationV TachycardiaUnknownOther, specify

8 Cardiac arrest/CPR Date MM/DD/YYYY

Missing Reason: Unknown

8 Pacemaker Defibrilliator/AICDPacemaker, CRT/biventricular pacingPacemaker, not CRT and not ICD

8 Pacemaker, not CRT and not

ICD, Date Placed

MM/DD/YYYY


8 Pacemaker, CRT/biventricular

pacing, Date Placed

MM/DD/YYYY


8 Pacemaker, Defibrillator/AICD

Date Placed MM/DD/YYYY


8 Shock, Date of last appropriate

Shock MM/DD/YYYY


8 Diabetes, Date of last Hgb A1c

MM/DD/YYYY


8 Diabetes, Value of last Hgb A1c


8 Diabetes, Treating with insulin

NoYesUnknown

8 Medical History, GI/Nutrition

Failure to thrive/cachexiaFontan associated liver diseaseInfectious hepatitisProtein losing EnteropathyOther, specify

8 GI/Nutrition, Infectious hepatitis

type

ABCUnknownOther, specify

8 Medical History, Heterotaxy/Isomerism

AspleniaPolyspleniaSitus InversusUnspecifiedOther, specify

Medical History, Lymphoma, leukemia

8 Malignancy s/p BMTs/p Chest RadiationSolid organ cancerUnknownOther, specify

8 Medical History, Neurologic

Anoxic brain injuryHemorrhagic and/or thromboembolic strokeOther, specify

8 Neurologic, Anoxic brain injury

Last Date MM/DD/YYYY


8 Neurologic, Hemorrhagic and/or

thromboembolicstroke

Date Last MM/DD/YYYY


8 Medical History, Peripheral

myopathy/neuromusculardisease

Becker MuscularDystrophyDuschenne Muscular DystrophyFreidrich's AtaxiaUnspecifiedOther, specify

8 Medical History, Respiratory

AsthmaPlastic BronchitisTracheostomyUnknownOther, specify

8 History Dialysis Dialysis, acute (within past 30 days)Dialysis, chronic (>1 month duration)Dysfunction, not dialysisUnknownOther, specify

8 Medical History, Syndrome

Cardiofaciocutaneous SyndromeCostello SyndromeDigeorge (22q11 deletion)Down's/Trisomy 21EhlersDanlos SyndromeLEOPARD/Multiple LentigenesLoeysDietz Syndrome

Insurance

Charitable Donation – Indicates that a company, institution or individual(s)donated funds to pay for the care of the listed patient.Free – Indicates that the listing hospital will not charge the patient for the costof the hospitalizationGovernment – Other US or state government insurance. For Example,Medicaid, Medicare, CHIP (Children’s Health Insurance Program), Departmentof VA refers to funds from the Veterans Administration or others.Private – Refers to funds from agencies such as Blue Cross/Blue Shield, etc.Self Pay – Indicates that the recipient will pay for the largest portion of the costof the hospitalization.Other – For example, funds from a foreign government. Specify foreign countryin the space provided.

Percent or Panel Reactive Antibody (closest to listing)

Marfan Syndrome

Noonan SyndromeOther Marfanlike SyndromeTurner SyndromeUnspecifiedWilliams SyndromeOther, specify

8 Specify MetabolicDisorder

8 Medical History, Mitochondrial Disorder,

specify

Barth'sUnspecifiedOther, specify

9 Primary Insurance Charitable DonationFreeGovernmentPrivateSelf PayUnknownOther, Specify

10a Cytotoxic PRA ie. Serum is tested against panel of lymphocytes

DoneNot Done

10aT Cell % Missing Reason:

Not Done Unknown

10a B Cell % Missing Reason: Not Done Unknown

10a Date (Cytotoxic PRA) Missing Reason: Unknown

10b Cytotoxic PRA, DTE/DTT Panel performed on serum treated with DTE or DTT (or

equivalent) to reduce the IgM antibodies and identify high PRA results

presumably secondary to a drug or other causes.

DoneNot Done

10b T Cell % Missing Reason: Unknown

10b B Cell % Missing Reason: Unknown

10b Date (Cytotoxic PRA,DTE/DTT)


10c Flow Cytometry or LuminexPRA

DoneNot Done

10c Class I % Missing Reason: Unknown

10c Class II % Missing Reason: Unknown

10c Date MM/DD/YYYY


10d Listed for prospectivecrossmatch

NoYesUnknown

10d Prospective CrossmatchResults

Donor CellsDonor Cells and VirtualVirtualUnknown

10d Virtual Crossmatch Avoidance of donor antigens to all antibodiespresentAvoidance of donor antigens to antibodies aboveprespecified thresholdAvoidance of donor antigens to C1q fixingantibodies onlyUnknown

Hemodynamics Prior to ListingIndicate the hemodynamics even if the patient is on pressors or inotropes. Best hemodynamics are those performed during theadministration of agents given specifically to lower the pulmonary arterial pressure or the pulmonary vascular resistance. All pressuresshould be listed in mmHg. If unclear, please consult with your PI.

11a Were hemodynamics done prior to listing?

NoYesUnknown

11a Date MM/DD/YYYY


11a Fontan Mean Pressure Missing Reason: Not Done Unknown

11a RAm (RAP or CVP) Right Atrial Mean Pressure


11a PAm Pulmonary Artery Mean


11a PCW Mean Pulmonary Capillary Wedge Pressure


11a SVC Sat Oxygen Saturation in the SVC


11a AO Sat Aortic Saturation


11a Rp, PVRI Pulmonary resistance indexed to body surface

area (BSA) Woods Units x m2

wu x m2 Missing Reason: Not Done Unknown

11a Rs, SVRI Systemic resistance indexed to body surface area

(BSA) Woods Units x m2


11a EDP End diastolic pressure of systemic ventricle


Schooling

11aC.O.

Cardiac output (i.e. Qs) in L/min

L/min Missing Reason: Not Done Unknown

11a C.I. Cardiac index (i.e. C.O. divided by m2) in L/min/m2

L/min/m2 Missing Reason: Not Done Unknown

11bWas patient on mechanicalsupport

at time of Hemodynamics

NoYesUnknown

11b Hemodynamic AgentsUsed

NoYesUnknown

11b Indicate agent for best

hemodynamics

100% O2DobutamineDopamineEpinephrineIsoproterenol (Isuprel)Milrinone (Primacor)NesiritideNitric OxideNitroglycerinNitroprusside (Nipride)NorepinephrinePGE (Alprostadil)PGI (Flolan)Phenylephrine/ NeosynephrineSildenafilVasopressinUnknownOther, specify

12 Is the patient in school? NoNot Applicable, <6 yearsYesUnknown

12 Are they at the ageappropiate level

NoYesUnknown

12 Are they in a specialeducation class

NoYesUnknown

Exercise Test

Laboratory Values closest to time of this reportNote: labs may have been collected on different dates.

13 Was exercise test performed? NoYesUnknown

13 If exercise test notperformed,

specify reason

Age inappropriateToo sickUnknownOther, specify

13Max VO2% Predicted for Age Refers to predicted maximum VO2 for patient

(should be listed in exercise report; if not, exercise lab personnel should be able to provide this data)

% Missing Reason: Unknown

13 Max VO2 Maximum oxygen consumption

ml/kg/min Missing Reason: Unknown

13 Respiratory Value at Peak RER or Respiratory Quotient:R Value at peak is the

respiratory quotient of carbon dioxide production divided by oxygen consumption,

and is used as an index of how vigorously the patient exercised. A value above 1.05 is generally considered to represent an adequate

effort.


14 Total Bilirubin mg/dL Missing Reason: Not Done Unknown

14 Direct Bilirubin mg/dL Missing Reason: Not Done Unknown

14 AST Aspartate transaminase (also SGOT)

U/L Missing Reason: Not Done Unknown

14 ALT Alanine transaminase (also SGPT)


14BNP

Btype natriuretic peptide

pg/mL or ng/L Missing Reason: Not Done Unknown

14 Pro BNP Pro NT Btype natriuretic peptide


14 CRP C reactive protein

mg/dL Missing Reason: Not Done Unknown

14Creatinine mg/dL Missing Reason:

Not Done Unknown

14 BUN Blood urea nitrogen


14 Cystatin C mg/L Missing Reason: Not Done Unknown

14 Total Protein g/dL Missing Reason: Not Done Unknown

14 Pre Albumin mg/dL Missing Reason: Not Done Unknown

14 Serum Albumin g/dL Missing Reason: Not Done Unknown

14 Cholesterol Total Cholesterol


14 TG Triglycerides


14 LDL Low density lipoprotein


14 HDL High density lipoprotein

mg/dL Missing Reason: Not Done

© 2016 PHTS [test]

NYHA and Ross' Heart Failure

NYHA Classes

Class I: No symptoms at any level of exertion and no limitation in ordinaryphysical activity.Class II: Mild symptoms and slight limitation during regular activity.Comfortable at rest.Class III: Noticeable limitation due to symptoms, even during minimal activity.Comfortable only at rest.Class IV: Severe limitations. Experience symptoms even while at rest (sittingin a recliner or watching TV).

Ross Heart Failure Classes

Class I: No limitations or symptomsClass II: Mild tachypnea and/or diaphoresis with feeds in infants; dyspnea onexercise in older children. No growth failure.Class III: Marked tachypnea and/or diaphoresis with feeds or exertion andprolonged feeding time with growth failure.Class IV: Symptomatic at rest with tachypnea, retractions, grunting ordiaphoresis.

Unknown

14 VLDL Very low density lipoprotein


15 NYHA Class 1234Not DoneUnknown

15 Ross' Heart Failure Class 1234Not DoneUnknown

Calculated

BSA: n/a BMI: n/a


Height and Weight

Form 1RL: Relisting Not StartedPrint this Form

1 Date of Relisting





4 Has this patient been transplanted NoYes

4 Indicate total number of priortransplants

This includes transplants that were and were not done atyour hospital.


5Main reason for ReListing Coronary artery disease, (infarction, arrhythmia,

CHF post MI)NonSpecific Graft Failure (>30 days posttransplant)Pulmonary Hypertension/RV Failure Rejection,acuteRejection Hyperacute (onset < 24 hours posttransplant)Rejection, AcuteSudden Cardiac Death, no MI documentedOther, specify

6 Contributing reason for ReListing Coronary artery disease, (infarction, arrhythmia,CHF post MI)NoncomplianceNonspecific graft failure (>30 days post transplant)

Status Details at ReListing

Pulmonary Hypertension/RV FailureRejection, acuteRejection, hyperacute (onset < 24 hours posttransplant)Sudden cardiac death, no MI documentedOther, specify

7 Status at ReListing BrazilCanadaUnited KingdomUnited States

7a Status at ReListing, US 1 (this option is only for listings prior to 1999)1A1B27

7aStatus at ReListing, Canada 0

1233.54

7a Status at ReListing, UK RoutineUrgent

7a Status at ReListing, Brazil NonPriorityPriority

7b Was patient in or out of hospitalat time of listing?


7b.i Was patient in the ICU attime of relisting?

NoYesUnknown



NoYesUnknown


listing?

YesNoUnknown

Infectious Disease Screening

7c.i Inotropes does Dose UnknownHigh Dose or Multiple IVSingle Low Dose




YesNoUnknown

7e ABO incompatible NoYesUnknown

7f Was patient on a VAD or ECMO attime of relisting?

VADECMONot on support at time of Relisting




organ?


8 HIV Serology AIDS testing


8 CMV Serology Negative Not Done Positive Unknown

8 CMV PCR Negative Not Done Positive Unknown

8 EBV Serology Negative Not Done Positive Unknown

8EBV PCR Negative Not Done Positive

Unknown



Negative Not Done Positive

Medical History at time of ReListing


Unknown





8 Hep C Ab Hepatitis C antibody


8 RPR/Syphilis Syphilis testing


9 Medical History NoYesUnknown

9 Medical History Details Select all medical history the patient had at the time of

listing.

Arrhythmia (current heart only)Cardiac arrest/CPR (current heart)DiabetesGI/NutritionHeterotaxy/IsomerismMalignancyMetabolic DisorderMitochondrial DisorderNeurologicalPacemaker (current heart)Peripheral myopathy/neuromuscular diseasePrenatal DiagnosisPrior transfusionsRenal insufficencyRespiratoryShock (current heart)SyndromeOther, specify

9 Arrhythmia Afib/flutterComplete heart blockV FibrilliationV TachycardiaUnknownOther, specify

9Date of last cardiac arrest/CPR MM/DD/YYYY


9 Pacemaker Defibrillator/AICDPacemaker, CRT/Biventricular pacing

Pacemaker, not CRT and not ICD

9 Pacemaker, not CRT and not ICD,

Date placed MM/DD/YYYY


9 Pacemaker, CRT/Biventricular pacing

Date placed MM/DD/YYYY


9 Defibrillator/AICD, Date Placed

MM/DD/YYYY


9 Date of last appropriate Shock MM/DD/YYYY


9 Date of Last Hgb A1c MM/DD/YYYY


9 Value of Last Hgb A1c Missing Reason: Not Done Unknown

9 Treating with Insulin NoYesUnknown

9 GI/Nutrition Failure to thrive/cachexiaFontan associated liver diseaseInfectious hepatitisProtein losing EnteropathyOther, specify

9 Hepatitis History ABCUnknownOther, specify

9 Heterotaxy/Isomerism AspleniaPolyspleniaSitus inversusUnspecifiedOther, specify

9 Malignancy Lymphoma, leukemias/p BMTs/p Chest RadiationSolid organ cancerUnknownOther, specify

9 Neurologic Anoxic brain injuryHemorrhagic and/or thromboembolic strokeOther, specify

9 Anoxic Brain Injury Date MM/DD/YYYY


9 Hemorrhagic and/or Thromboembolic Stroke,

Date Last MM/DD/YYYY


9 Peripheral myopathy/ neuromuscular disease

Becker muscular dystrophyDuschenne muscular dystrophyFreidrich's ataxiaUnspecifiedOther, specify

9 Respiratory AsthmaPlastic BronchitisTracheostomyUnknownOther, specify

9 Syndrome Cardiofaciocutaneous syndromeCostello syndromeDiGeorge (22q11 deletion)Down's/Trisomy 21EhlersDanlos SyndromeLEOPARD/Multiple LentigenesLoeysDietz SyndromeMarfan SyndromeNoonan syndromeOther Marfanlike syndromeTurner SyndromeUnspecifiedWilliams syndromeOther, specify

Renal Insufficiency Dialysis, acute (within past 30 days)

Insurance

Charitable Donation – Indicates that a company, institution or individual(s)donated funds to pay for the care of the listed patient.Free – Indicates that the listing hospital will not charge the patient for the costof the hospitalizationGovernment – Other US or state government insurance. For Example,Medicaid, Medicare, CHIP (Children’s Health Insurance Program), Departmentof VA refers to funds from the Veterans Administration or others.Private – Refers to funds from agencies such as Blue Cross/Blue Shield, etc.Self Pay – Indicates that the recipient will pay for the largest portion of the costof the hospitalization.Other – For example, funds from a foreign government. Specify foreign countryin the space provided.

Percent or Panel Reactive Antibody (closest to relisting)

9 Dialysis, chronic (>1 month duration)Dysfunction, not dialysisUnknownOther, specify

9 Specify Metabolic Disorder

9 Medical History, Mitochondrial Disorder, specify

Barth'sUnspecifiedOther, specify

10 Primary Insurance Charitable DonationFreeGovernmentPrivateSelf PayUnknownOther, specify

11a Cytotoxic PRA ie. Serum is tested against panel of lymphocytes

DoneNot Done

11a T Cell % Missing Reason: Not Done Unknown

11a B Cell % Missing Reason: Not Done Unknown

11a Date (Cytotoxic PRA) Missing Reason: Not Done Unknown

11b Cytotoxic PRA, DTE/DTT Panel performed on serum treated with DTE or DTT (or

equivalent) to reduce the IgM antibodies and identify high PRA results

presumably secondary to a drug or other causes.

DoneNot Done

11b T Cell % Missing Reason: Not Done Unknown

11b B Cell % Missing Reason: Not Done Unknown

11b Date (Cytotoxic PRA,DTE/DTT)


11c Flow Cytometry or LuminexPRA

DoneNot Done

11c Class I % Missing Reason: Unknown

11c Class II % Missing Reason: Unknown

11c Date MM/DD/YYYY


11d Relisted for prospectivecrossmatch

NoYesUnknown

11d Prospective CrossmatchType

Donor CellsDonor Cells and VirtualVirtualUnknown

11d Virtual Crossmatch Avoidance of donor antigens to all antibodiespresentAvoidance of donor antigens to antibodies aboveprespecified thresholdAvoidance of donor antigens to C1q fixingantibodies onlyUnknown

Hemodynamics Prior to ReListingIndicate the hemodynamics even if the patient is on pressors or inotropes. Best hemodynamics are those performed during theadministration of agents given specifically to lower the pulmonary arterial pressure or the pulmonary vascular resistance. All pressuresshould be listed in mmHg. If unclear, please consult with your PI.

12a Were hemodynamics done prior to relisting?

NoYesUnknown

12a Date MM/DD/YYYY



12a RAm (RAP or CVP) Right Atrial Mean Pressure


12a PAm Pulmonary Artery Mean


12a PCW Mean Pulmonary Capillary Wedge Pressure


12a SVC Sat Oxygen Saturation in the SVC


12a AO Sat Aortic Saturation



area (BSA) Woods Units x m2



(BSA) Woods Units x m2


12a EDP End diastolic pressure of systemic ventricle


12a C.O. Cardiac output (i.e. Qs) in L/min


Schooling

Exercise Test



12b Was patient onmechanical support

at time of Hemodynamics

NoYesUnknown

12b Hemodynamic Agents NoYesUnknown

12b Indicate agent for best

hemodynamics

100% O2DobutamineDopamineEpinephrineIsuproterenol (Isuprel)Milrinone (Primacor)NesiritideNitric OxideNitroglycerinNitroprusside (Nipride)NorepinephrinePGE (Alprostadil)PGI (Flolan)Phenylephrine/ NeosynephrineSildenafilVasopressinOther, specify

13 Is patient in school? NoNot ApplicableYesUnknown

13 Are they at the ageappropiate level

NoYesUnknown

13 Are they in a specialeducation class

NoYesUnknown


14 Was exercise test performed? NoYesUnknown

14 If test no, specify reason Age InappropriateToo SickUnknownOther, specify


(should be listed in exercise report; if not, exercise lab personnel should be able to provide this data)

% Missing Reason: Not Done Unknown




effort.


14 Max VO2 Maximum oxygen consumption

ml/kg/min Missing Reason: Not Done Unknown







15 BNP Btype natriuretic peptide






15 Creatinine mg/dL Missing Reason: Not Done Unknown






15Serum Albumin g/dL Missing Reason:

Not Done Unknown



15 TG Triglycerides







mg/dL Missing Reason: Not Done

© 2016 PHTS [test]

NYHA and Ross' Heart Failure

NYHA Classes

Class I: No symptoms at any level of exertion and no limitation in ordinaryphysical activity.Class II: Mild symptoms and slight limitation during regular activity.Comfortable at rest.Class III: Noticeable limitation due to symptoms, even during minimal activity.Comfortable only at rest.Class IV: Severe limitations. Experience symptoms even while at rest (sittingin a recliner or watching TV).

Ross Heart Failure Classes

Class I: No limitations or symptomsClass II: Mild tachypnea and/or diaphoresis with feeds in infants; dyspnea onexercise in older children. No growth failure.Class III: Marked tachypnea and/or diaphoresis with feeds or exertion andprolonged feeding time with growth failure.Class IV: Symptomatic at rest with tachypnea, retractions, grunting ordiaphoresis.

Unknown

16 NYHA Class 1234Not DoneUnknown

16 Ross Heart Failure Class 1234Not DoneUnknown

Calculated

BSA: n/a BMI: n/a


Height and Weight

Status Details at Transplant

Form 1T: Transplant Not StartedPrint this Form

1 Date of Transplant MM/DD/YYYY

2 Simultaneous organ Check all that apply.

KidneyLiverNoneUnknownOther, specify

3 Type of Transplant Orthotopic: recipient heart is replaced by donor heart.

Heterotopic: donor heart is transplant into recipient without theremoval of

the recipient’s heart (also called piggyback transplant)

HeterotopicOrthotopicUnknown





6 Status at Transplant BrazilCanadaUnited KingdomUnited States

6a United States 1 (this option is only for listings prior to 1999)1A1B

2

7

6a Brazil Non PriorityPriority2

6a Canada 1233.544S

6a United Kingdon RoutineUrgent

6b Was patient in or out of hospitalat time of transplant?


6b.i Was patient in the ICU attime of transplant?

YesNoUnknown



YesNoUnknown


transplant?

YesNoUnknown

6c.i Inotropes Dose High Dose or Multiple IVSingle Low DoseUnknown




YesNoUnknown

6e Was the patient transplanted with an ABO incompatible

transplant?

NoYesUnknown

6f Was patient on a VAD or ECMO attime of transplant?

VADECMO

Percent or Panel Antibody (closest to Transplant)

Not on support at time of Transplant




organ?


7a Cytotoxic PRA DoneNot Done

7a T Cell Values above 10 will require section 10:

Peroperative management for PRA to be completed.


7a B Cell Values above 10 will require section 10:



7a Date MM/DD/YYYY


7b Cytotoxic PRA DTE/DTT DoneNot Done

7b T Cell Values above 10 will require section 10:



7b B Cell Values above 10 will require section 10:



7b Date MM/DD/YYYY


7c Flow Cytometry or Luminex PRA DoneNot Done

PreTransplant Interventions for Elevated PRA

7cClass I

Values above 10 will require section 10: Peroperative management for PRA to be completed.


7c Class II Values above 10 will require section 10:



7c Date Missing Reason: Unknown

8 Did this patient have a virtualcrossmatch?

NoYesUnknown

8 Crossmatch Results NegativePositiveUnknown

9 Donor Specific or RetrospectiveCrossmatch performed?

NoYesUnknown

9 Crossmatch Results NegativeNot DonePositiveUnknown

9Was the crossmatch performedprior

to the decision to accept thedonor?

NoYesUnknown

10a Did the patient receivetreatment

to lower or manage anelevated PRA

while awaiting transplantation?

NoYesUnknown

10a.1 Which therapy wasadministered?

Check all that apply.

Azathioprine (Imuran)Bortezomib (Velcade)Cytoxan (cyclophosphamide)Immunoglobulin (IVIG, IV IgG)Mycophenylate, MMF (Cellcept, Myfortic)Plasmapheresis/plasma exchangeRituximab (Rituxan)Unknown

Perioperative management for PRA

Other, specify

10a.2 How long was therapyadministered?


Only for a prespecified time/number of treatments:specify

Until Heart transplantation, regardless ofsubsequent PRA levels/sensitization profileUntil PRA level reduced to 0%/patient no longersensitizedUntil PRA/sensitization profile diminished to a prespecified goalUnknown

10b.i. Was prophylacticplasmapheresis/

exchange performed in the perioperative period

NoYesUnknown

10b.i.1 Was this performedduring

cardiopulmonarybypass?

NoYesUnknown

10b.i.2 Was this performedduring the

immediate postoperative period?

NoYesUnknown

10b.i.2 How manycycles?


10b.ii Were there additionaltherapies,

not routinely administeredto post

transplant patients in your center, given to this patient?

NoYesUnknown

10b.iiTherapies administeredCheck all that apply.

Alemtuzumab (Campath)Azathioprine (Imuran)Basiliximab (Simulect)Bortezomib (Velcade)Cytoxan (cyclophosphamide)Eculizumab (Soliris)Immunoglobulin (IVIG, IV IgG)MMF (Cellcept, Myfortic)Plasmapheresis/plasma exchangeRituximab (Rituxan)

B Cell and T Cell Results

Labaratory Values (closest to time of transplant)Note: labs may have been collected on different dates.

Steroids (methylprednisone, prednisone, orapred,prednisolone, solumederol, Medrol, etc.)Other, specify

11a B cell flow DSXM Negative Not Done Positive Unknown

11b B cell CDC/cytotoxicity DSXM Negative Not Done Positive Unknown

11c T cell flow DSXM Negative Not Done Positive Unknown

11d T cell CDC/cytotoxicity DSXM Negative Not Done Positive Unknown

12 Donor Specific Antigens (DSA) NoYesUnknown

12 Donor Specific Antigens(DSA) Results

Class IClass IIUnknown

12Was DSA compliment fixing?(i.e. positive C1q assay)

NoYesUnknown






















13 TG Triglycerides






Hemodynamics (closest to transplant)Indicate the hemodynamics even if the patient is on pressors or inotropes. Best hemodynamics are those performed during theadministration of agents given specifically to lower the pulmonary arterial pressure or the pulmonary vascular resistance. All pressuresshould be listed in mm Hg. If unclear, please confirm with your PI.



14a Hemodynamics NoYesUnknown

14a Date MM/DD/YYYY



14a RAm (RAP or CVP) Right atrial mean pressure


14a PAm Pulmonary artery mean


14a PCW Mean pulmonary capillary wedge pressure


14a SVC Sat Oxygen saturation in the SVC


14a AO Sat Aortic saturation



area (BSA)

Woods Units x m2 Missing Reason: Not Done Unknown


(BSA)

Woods Units x m2 Missing Reason: Not Done Unknown

EDP End diastolic pressure of systemic ventricle


Inotropes, Pressors, and Thyroid Hormones

14a

14a C.O. Cardiac output (i.e. Qs) in L/min




14b Hemodynamic Agents NoYesUnknown

14b Indicate agent forbest hemodynamics


100% O2DobutamineDopamineEpinephrineIsoproterenol (Isuprel)MilrinoneNesiritideNitric OxideNitroglycerineNitroprusside (Nipride)NorepinephrinePGE (Alprostadil)PGI (Flolan)Phenylephrine/NeosynephrineSildenafilVasopressinOther, specify

14b Was patient onmechanical support

at time of Hemodynamics?

NoYesUnknown

15 Was recipient on inotropes,pressors,

or thyroid hormones at time oftransplant?

NoYesUnknown

15 Inotropes, Pressors, or ThyroidHormones

100% O2DobutamineDopamineEpinephrineIsoproterenol (Isuprel)Milrinone

© 2016 PHTS [test]

Cardiopulmonary bypass, donor ischemic, and technique of transplant

NeosynephrineNesiritideNitric OxideNitroglycerineNitroprusside (Nipride)Norepinephrine (Levophed)PGE (Alprostadil)PGI (Flolan)Phenylephrine/NeosynephrineSildenafilT3 (Triiodothyronine)T4 (Levothyroxine)VasopressinOther, specify

16 Cardiopulmonary bypass time Report total number in minutes

minutes Missing Reason: Unknown

17 Total donor ischemic time Report minutes from recovery crossclamp to removal of crosscramp after transplant


18 Technique of transplant AtrialBicavalUnknown

Calculated

BSA: n/a BMI: n/a


Height and Weight

Form 2: Donor Not StartedPrint this Form

Transplant Date

1 Donor Age Indicate age in months, days, or years Days

Months Years


2 Donor Date of Birth Missing Reason: Unknown

3 Donor Height Centimeters Inches


4 Donor Weight Kilograms Pounds


5Donor Sex Female

MaleUnknown

6 Donor Race Check all that apply.

American Indian or Alaskan NativeAsianBlackPacific IslanderWhiteUnknownOther, specify

NoYes

7 Hispanic or Latino Yes if of Mexican, Puerto Rican, Cuban,

Central or South American or other Spanish culture of origin, regardless of race.

Unknown

8a Donor Date of Death MM/DD/YYYY


8b Donor Cause of Death Check only one.

AnoxiaCerebrovascularCNS TumorHead TraumaOther, specify

8c Donor Mechanism of death Check only one.

AsphyxiationBlunt InjuryCardiovascularCNS InfectionDrowningDrug IntoxicationElectricalGunshot WoundSeizureStabSudden Infant DeathUnknownOther, specify

8d Donor Circumstances of death Alleged Child AbuseAlleged HomicideAlleged SuicideMotor Vehicle AccidentNonMotor Vehicle AccidentUnknownOther, specify

9 Donor Downtime Previously called "Duration of Cardiac Arrest".

NoYesUnknown

9 Duration of Donor Downtime Previously called "Duration of Cardiac Arrest".

Enter duration in minutes.


10 Chest Compressions (CPR) NoYesUnknown

10 If yes, CPR Time Enter duration in minutes


11 Donor Blood Type AABBO

11Blood type A subtype A1

A2Unknown

12 Donor Rh NegativePositiveUnknown

13 Donor Past Medical History Check all that are known.

Cancer at time of procurementDiabetesHistory of CancerHypertensionInfection, specify

Mitral Valve ProlapseNoneUnknown

13 If donor had diabetes, was patient on insulin?

NoYesUnknown

14 Did the donor have an increasedrisk

for HIV, HBV, HCV?

NoYesUnknown

14 If yes, specify increased risk. At risk medical history (i.e. hemodialysis, newdiagnosis of or treatment for STD in past 12months)At risk social history (specify)Hemodiluted sample

14 If at risk social history,specify.

Check all that apply

IncarcerationInjected Drug UseMother with HIVSexual exposureUnknownOther, specify

Pretransplant Donor Echocardiogram

Pretransplant Donor Angiogram

Donor Serologies

15 PreTransplant DonorEchocardiogram (closest to time of procurement)

NoYesUnknown

15 Result of DonorEchocardiogram

AbnormalNormalUnknown

15 If abnormal, pleasespecify


Abnormal Septal MotionDiffuse Wall Motion AbnormalityFocal Wall Motion AbnormalityMitral RegurgitationTricuspid RegurgitationUnknown

15 Donor Fractional Shortening Missing Reason: Not Done Unknown

15 Donor Estimated LV EjectFraction


16Pretransplant Donor Angiogram NoYesUnknown

16 Angiogram results Abnormal, Specify

NormalUnknown

17 HIV Serology AIDS testing


17 CMV IgG Cytomegalovirus testing




17 EBV IgG Epstein Barr Virus


Negative Not Done Positive

© 2016 PHTS [test]

Donor on Inotropes, Pressors, or Thyroid Hormones at time of recovery/harvest?

17 RPR/Syphilis Syphillis testing

Unknown







17 Hep C ab Hepatitis C antibody


18a T3 Triiodothyronine (Thyroid hormone)

No Yes Unknown

18b T4 Levothyroxine (Thyroid hormone)

No Yes Unknown

18c Epinephrine Adrenaline (Inotrope, pressor)

No Yes Unknown

18d Dopamine (Inotrope)

No Yes Unknown

18e Dobutamine Dobutrex (Inotrope)

No Yes Unknown

18f Vasopressin Pitressin (Pituitary hormone)

No Yes Unknown

18g Levophed Norepinephrine (Inotrope, Pressor)

No Yes Unknown

18h Milrinone Primacor (Inotrope)

No Yes Unknown

18i Neosynephrine Phenylephrine (Pressor)

No Yes Unknown

18j Other No Yes Unknown


Induction TherapyInduction Therapy is defined as the prescribed use of lymphocyte cytolytic antibody or IL2R antagonist therapy (e.g., ATGAM,Thymoglobulin, Basiliximab, Daclizumab) given soon after transplant (started within 3 days), not used to specifically treat a known orsuspected rejection episode).

The use of noncytolytic agents pre or intraoperatively is not considered to be induction therapy.

Induction Agents

Induction Agent Details

Form 3: Initial Immunosuppression Not StartedPrint this Form

Transplant Date MM/DD/YYYY

1 Is Patient on Induction Therapy NoYesUnknown

Induction Immunosuppression Agent Alemtuzumab (Campath)Basiliximab (Simulect)Bortezomib (Velcade)Daclizumab (Zenapax)OKT3Rituximab (Rituxan)Thymoglobulin (ATG)UnknownOther, specify

Start Date MM/DD/YYYY


End Date MM/DD/YYYY


2 Azathioprine (Imuran) NoYesUnknown

2Was patient on medication at

30 days? NoYesUnknown

2 If patient is no longer onmedication

at 30 days, specify stopdate.

MM/DD/YYYY


3 Cyclosporine NoYesUnknown

3 Was patient on medication at30 days?

NoYesUnknown



MM/DD/YYYY


4 Mycophenolate (Cellcept, Myfortic) NoYesUnknown


NoYesUnknown



MM/DD/YYYY


5 Sirolimus (Rapamycin) NoYesUnknown


NoYesUnknown



MM/DD/YYYY


6 Tacrolimus (Prograf, FK506) NoYesUnknown


NoYesUnknown



MM/DD/YYYY


7 Everolimus NoYesUnknown


NoYesUnknown



MM/DD/YYYY


8 Cyclophoshamide (Cytoxan) NoYesUnknown


NoYesUnknown



MM/DD/YYYY


9a Was patient given preoperativesteroids?

NoYesUnknown

9b Was patient given intraoperativesteroids?

NoYes

Prophylactic Antibiotics/Antivirals started Preop through 30 days post opInfection Prophylaxis: Started during the first 30 days posttransplant (not used to treat known infection).

Unknown

9c Was patient given postoperativesteroids?

YesNoUnknown

9c Date of first postop dose MM/DD/YYYY


9c Daily dose at 30 days mg Missing Reason: No Steroids at 30 days Unknown

9d Planned Maintenance Steroids NoYesUnknown

9d If no, please specify End Date of steroid use

MM/DD/YYYY


10 Was patient given otherimmunosuppressants?

NoYesUnknown

10 Specify date of first post opdose

MM/DD/YYYY


10 Patient on medication at 30days

NoYesUnknown

10 If patient is no longeron medication


MM/DD/YYYY


11 ProphylacticAntibiotics/Antivirals

started Preop through 30 dayspost op


AcyclovirAntifungalCMV Immunoglobulin (Cytogam)DapsoneGanciclovir or ValganciclovirImmunoglobulin (IV Ig)Pentamidine

© 2016 PHTS [test]

TrimethaprimSulfamethoxazoleValacyclovirUnknownOther, specify

11 If antifungal, please specify Check all that apply

FluconazoleNystatinUnspecifiedOther, specify

11 If ganciclovir orvalganciclovir, please specify


IVPO

12 Date of Hospital Discharge MM/DD/YYYY

Missing Reason: Still In Hospital Unknown


Coronary Evaluation

Angiography

Form 4: Coronary Evaluation Not StartedPrint this Form

1 Date of Coronary Evaluation

2 Indication for Coronary Evaluation Check only one.

Angio NOT DONE: Noninvasive test performedFollowup from PTCA / Revascularization (to checkpatency)Noninvasive test prior to this date indicatedcoronary diseaseObjective evidence of graft dysfunction/CADResearch ProtocolRoutine, per established protocol (i.e. yearlyevaluation)Symptoms (suggesting CHF or angina equivalent)UnknownOther, specify

2 Noninvasive test prior to thisdate indicated coronary

disease, specify test Check only one.

Cardiac CTDobutamine Stress EchoExercise TestMRIRadionuclide Angiogram (MUGA)Resting EchoStress PerfusionUnknownOther, specify

2 Angio NOT DONE: Noninvasive test performed

Cardiac CTDobutamine Stress EchoExercise Stress EchoExercise TestMRIRadionuclide Angiogram (MUGA)Resting EchoStress PerfusionUnknownOther, specify

4b

Angiography Results

ISHLT CAV 0 (Not significant): No detectable angiographic lesionISHLT CAV 1 (Mild): Angiographic left main (LM) <50%, or primary vessel withmaximum lesion of <70%, or any branch stenosis <70% (including diffusenarrowing) without allograft dysfunctionISHLT CAV 2 (Moderate): Angiographic LM <50%; a single primary vessel>70%, or isolated branch stenosis >70% in branches of 2 systems, withoutallograft dysfunctionISHLT CAV 3 (Severe): Angiographic LM >50%, or two or more primaryvessels >70% stenosis, or isolated branch stenosis >70% in all 3 systems; orISHLT CAV 1 or CAV 2 with allograft dysfunction (defined as LVEF <45%usually in the presence of regional wall motion abnormalities)

L Main = Left Main Coronary ArteryLAD = Left Anterior DescendingLCx = Left CircumflexRCA = Right Coronary ArteryPDA = Posterior Descending

3aInjection sites


AortaLeft VentricleSelective Left CoronarySelective Right CoronaryUnknown

3b Method of Interpretation (Pertains to the angiogram)

Check only one.

CaliperComputer AssistedVisual EstimateUnknown

3c Preangiogram nitroglycerin NoYesUnknown

4a Angiography Results AbnormalNormalUnknown

4aIf abnormal, indicate ISHLT

CAV score (J Heart Lung Transplant July 2010;29(7):71727)

0123Not GradedUnknown

Normal

Not Visualized

Unknown

Absent (congenital)

Mild Stenosis (0% to 50%)

Moderate Stenosis (51% to 70%)

Severe Stenosis (71% to 100%)

Ectasia

L Main LAD LCx RCA PDA

Coronary FlowFunctional assessment of coronary flow performed using catheterbased methods Abnormal Fractional Flow Reserve (FFR) is defined as <0.75 Abnormal Coronary Flow Reserve (CFR) is defined as <2.0 Maximal Flow: Resting Flow

Intravascular Ultrasound

Severe Distal Pruning

5aFractional Flow Reserve

Performed NoYesUnknown

5a Vessels Studied Check all that apply.

LADLCxLeft MainRCAUnknown

5a FFR Abnormal for Left Main Coronary Artery (L

Main)

NoYesUnknown

5a FFR Abnormal for Left Anterior Descending

(LAD)

NoYesUnknown

5a FFR Abnormal for Left Circumflex (LCx)

NoYesUnknown

5a FFR Abnormal for Right Coronary Artery (RCA)

NoYesUnknown

5b Coronary Flow Reserve (CFR) Performed

NoYesUnknown

5b If CFR Performed, CFRabnormal

(Abnormal is defined as: ≤2.0 Maximal Flow: RestingFlow)

NoYesUnknown

6 Intravascular Ultrasound Performed NoYesUnknown

6 Vessels Studied LADLCxLeft MainRCAUnknown

6 If Left Main, Maximal IntimalThickness (MIT)

<0.3 mm>= 0.3mmUnknown

6 If Left Main, Stanford Score

01234Not DoneUnknown

6 If LAD, Maximal IntimalThickness (MIT)


6 If LAD, Stanford Score


6 If LCx, Maximal IntimalThickness (MIT)


6 If LCx, Stanford Score


6 If RCA, Maximal IntimalThickness (MIT)


6 If RCA, Stanford Score

012

Left Ventricular Function Evaluation

34Not DoneUnknown

7Left Ventricular Function EvaluationNearest to coronary angiogram

NoYesUnknown

7a Date of study Missing Reason: Not Done Unknown

7bMethod of Interpretation Contrast ventriculogram

EchocardiogramMRIRadionuclide angiogram (MUGA)Unknown

7c Left Ventricular EjectionFraction


7c Echo Shortening Fraction Missing Reason: Not Done Unknown

7d Wall Motion AkinesisDyskinesisHypokinesisNormalNot interpreted for wall motion abnormalitiesUnknown

7d Hypokinesis > 1 Segment1 SegmentDiffuseUnknown

7d Akinesis > 1 Segment1 SegmentDiffuseUnknown

7d Dyskinesis > 1 Segment1 SegmentDiffuseUnknown

Dobutamine or Exercise Stress Echo

8 Was Dobutamine or Exercise Stress Echo performed?

YesNoUnknown

8 Date Missing Reason: Unknown

8 Maximum Dobutamine Dose mcg/kg/min Missing Reason: Not Done Unknown

8 Baseline Akinesis/dyskinesisHypokinesisNormal

8 Is there segmentalhypokinesis

and if so, how manysegments?

> 1 Segment1 SegmentDiffuseUnknown

8 Is there segmentalAkinesis/dyskinesis and if so, how many

segments?

> 1 Segment1 SegmentDiffuseless than 1Unknown

8 Stress New Akinesis/dyskinesisNew HypokinesisNormal

8 If Stress is New Hypokinesis


8 If Stress is New Akinesis/dyskinesis


8Maximum Heart Rate Achieved Missing Reason: Unknown

8 LV Dilatation with Stress NoYesUnknown


Biopsy Prior to Rejection Event

Form 5: Rejection Not StartedPrint this Form

2 Select the baselineimmunosuppressive therapy at time

of rejection

AzathioprineCyclosporineEverolimusImmune globulinMethotrexateMycophenolatePlasmapheresisPrednisoneRituximabSirolimusTacrolimusCytoxan (cyclophosphamide)UnknownOther, specify

3 Biopsy Performed Prior toRejection Event

If performed prior to this rejection diagnosis, indicate the score of the most recent biopsy performed

that did not lead to rejection treatment.

NoYes

3 Biopsy Date Prior to Rejection MM/DD/YYYY


3 ACR Score 2004 revised ISHLT scoring system for ACR:

(J Heart Lung Transplant. 2005 Nov;24(11):171020.) ACR: acute cellular rejection (0, 1R, 2R, 3R)

01R2R3RUnknown

3 AMR Score 2013 revised ISHLT scoring system for pAMR:

J Heart Lung Transplant 2013 Dec 32(12):114762.) pAMR: pathologic antibody mediated rejection (0, 1h, 1i, 2, 3)

Both histology andimmunofluorescence/immunohistochemistryperformed (ie. C4d or C3d)Did not assess biopsy for evidence of AMROnly assessed histology/ did not performimmunofluorescence/immunohistochemistry (ie.C4d or C3d)Unknown

3 AMR Findings If only accessed histology/ did not perform

immunofluorescene or immunohistochemistry (ie.C4d or C3d

No histologic features AMRPositive histologic features AMR (ie. Vasculitis/pericapillaritis)

Rejection EventsStart with newly diagnosed rejection by biopsy (convert to ISHLT score) or other criteria leading to bolus immunotherapy. List all followupbiopsies or changes in therapy. The last entry should be the first biopsy or echo not prompting additional therapy. Enter each subsequentrejection event until episode is resolved.

Rejection Event

3 pAMR score 2013 revised ISHLT scoring system for pAMR:

J Heart Lung Transplant 2013 Dec 32(12):114762.)

pAMR: pathologic antibody mediated rejection (0, 1h, 1i, 2, 3)

0 (negative)1h1i23Positive for AMR but pAMR score not known

4 Was donor specific Ab testingperformed

at the time of the rejection event

No, Did not send testing for any circulatingantibodiesYesUnknown

4 Which antibodies were tested and what were the results

HLA class I and/or class II DSAIsoagglutinin (A or B Ab) to ABOi graftNonHLA antibody (e.g. MICA, MICB, antiendothelial, vimentin, antimyosin, angiotensinreceptor (AR1T), or other nonHLAUnknown

4 HLA Class I and/or II DSA Result

NegativePositiveUnknown

4HLA class I and/or II DSA Result, Positive

Complement fixing (C1q positive)Increased from last date testedNewPresent but stable (no new abs and not increasedfrom baseline)Unknown

4 NonHLA Ab Result NonHLA antibody (e.g. MICA, MICB, anti

endothelial, vimentin, antimyosin, angiotensinreceptor (AR1T), or other nonHLA Results


4NonHLA Ab Result, Positive

NonHLA antibody (e.g. MICA, MICB,antiendothelial, vimentin, antimyosin, angiotensin receptor (AR1T), or

other nonHLA Results

Increased from last date testedNewPresent but stable (no new abs and not increasedfrom baseline)Unknown

4 Isoagglutinin (A or B Ab) to ABOi graft

Positive is defined as titer of 1:16 or higher


Date of rejection event Any episode leading to an increase in immunotherapy

to treat a biopsy or clinically diagnosed episode of rejection MM/DD/YYYY

5a Basis for Diagnosis of Current Rejection Event

BiopsyClinicalECHONew or increased AbsUnknown

5b Was biopsy performed? NoYes

5b Indication for biopsy Check all that apply.

Objective Evidence of Graft DysfunctionResearchRoutine (scheduled as part of protocolsurveillance)Symptoms

5b ACR Grading 2004 revised ISHLT scoring system for ACR:

(J Heart Lung Transplant. 2005 Nov;24(11):171020.) ACR: acute cellular rejection (0, 1R, 2R, 3R)

01R2R3RUnknown

5b AMR Grading 2013 revised ISHLT scoring system for pAMR:

J Heart Lung Transplant 2013 Dec 32(12):114762.) pAMR: pathologic antibody mediated rejection (0, 1h, 1i, 2, 3)

Both histology andimmunofluorescence/immunohistochemistryperformed (ie. C4d or C3d)Did not assess biopsy for evidence of AMROnly assessed histology/ did not performimmunofluorescence/immunohistochemistry (ie.C4d or C3d)Unknown

5b Histology results No histologic features AMRPositive histologic features AMR

5b If both histology andimmunofluorescence/

immunohistochemistry performed, indicate pAMR score

2013 revised ISHLT scoring system for pAMR: J Heart Lung Transplant 2013 Dec 32(12):114762.)

pAMR: pathologic antibody mediated rejection (0, 1h, 1i, 2, 3)

01h1i23Positive with Unknown Score

5cWas there therapy used

to treat this rejection episode? If no rejection therapy was used, no more rejection

episodes should be entered for this event.

NoYes

5c Select the therapy used ATG or ATGAMBortezomib

EculizumabImmune AdsorptionImmunoglobulinMethotrexatePhotopheresisPlasmapheresisRituximabSteroid TaperSteroids, IVSteroids, OralTacrolimusCytoxan (cyclophosphamide)Other, specify

5d Was episode of rejectionassociated

with hemodynamiccompromise?

None No significant change in cardiac function at the time of rejection Mild Worsening of cardiac function detected (decreased ejection

fraction, hypotension, EKG changes) not requiring inotropes.

Severe Inotropic support added due to this rejection episode.

Inotropic SupportMildNoneUnknown

6 Indicate date of the end of the rejection episode

MM/DD/YYYY

7 Was there baselineimmunosuppressive

therapy at time of resolution of rejection event

NoYes

7 Baseline immunosuppressivetherapy at time of resolution of

rejection event

Azathioprine (Imuran)Cyclosporine (Sandimmune, Neoral, Gengraf, CSA,CyA)EverolimusImmune globulinMethotrexateMycophenolate (Cellcept, Myfortic)PrednisoneRituximabSirolimus (Rapamycin, Rapamune)Tacrolimus (Prograf, FK506)Cytoxan (Cyclophosphamide)UnknownOther, Specify


Drug Therapy

Drug Therapy Details

Form 6: Infection Not StartedPrint this Form

Evidence of Infectious Process Requiring IV Therapy

If "no" to both, infection does not meet definition of PHTS severe infection and form should not be completed.

Use a separate form for each infection episode and or type of infection.

NoYesUnknown

Life Threatening Infection Requiring Oral Therapy

NoYesUnknown

1 Date of Infection Date of diagnosis or clinical presentation, whichever date is earliest.

MM/DD/YYYY

2 Drug Therapy at Time of Infection Indicate if there was an ongoing prophylactic drug therapy at time

(date) of infection diagnosis (i.e. valganciclovir for CMV prophylaxis post

transplant). Do not include drugs that have been prescribed to treat a specific previous

infection unless that previous infection is considered to be resolved and the patient is now on longterm prophylaxis.

Do not include therapy for the current infection – to be included undersection 6.

NoYesUnknown

2 Specify drug therapy at time ofinfection.

AcyclovirAlemtuzumab (Campath)ATGAMAzathioprineBasiliximab (Simulect)Bortezomib (Velcade)CMV Immunoglobulin, CytogamCyclosporineCytoxan (cyclophosphamide)DapsoneEverolimus (Certican)FluconazoleGanciclovir or ValganciclovirImmunoglobulin, IV IgMethotrexateMycophenolateNystatinOseltamivirPentamidine

Type of Organism(s)Indicate all organisms associated with the type of infection.

PrednisoneRituximab (Rituxan)Sirolimus (Rapamycin)Tacrolimus (Prograf, FK506)Thymoglobulin/ATGTrimethaprimsulfamethoxazole, SeptraValacyclovirOther, specify

2 Ganciclovir or Valganciclovir IVPO

3a Type of infection Use a separate form for each episode and/or type of infection.

BacterialFungalNo Organism IdentifiedProtozoanViralUnknown

3b Organism

4 Location of infection Check all that apply

Blood: Culture positiveBlood: PCR positiveBone: OsteomyelitisCentral nervous system/ brain (ie. Meningitis/Encephalitis)Chest tube site infectionGastrointestinal infection (ie. Gastritis, colitis,infectious diarrhea)Heart (includes endocarditis)Hepatic/ liver: Infectious hepatitisIntrabdominal/ Peritoneal: PeritonitisPericardium/ pericarditisRenal/ kidney/Urinary tractRespiratory (includes Pneumonia/Bronchiolitis/Tracheitis/ Pleuritis)Skin or soft tissue: Cellulitis/fasciitisVAD infectionWound infection within 30 days, deep sternal: Deepsternal wound infection with positive culture ortreated with prolonged antibiotics beyond

perioperative prophylaxis when culture not obtainedor pretreated involving muscle, bone, and/ormediastinum requiring operative interventionWound infection within 30 days, superficial sternal:Superficial, soft tissueUnknownOther, specify

4Was the blood infection directlyattributed to the presence of a

central line (ie. organism cultured from blood

is not related to an infection at another site)?

YesNoUnknown

4 VAD Infection Location Check all that apply

CannulaeDrivelineUnknown

5 Location of patient Emergency care, no admitIn HospitalOut of HospitalUnknown

6 Intervention Check all that apply

Drug therapy : OralDrug therapy: IV or IMMechanical VentilationSurgical therapy, specifyUnknownOther, specify

7 Outcome at 30 days postdate ofinfection Check only one.

Significant long term sequelae means any residual medical problem persisting

for > 30 days after the onset of the infection (e.g.)

renal failure, respiratory failure.

DeathResolutionSignificant Long Term Sequelae

Unresolved at 30 daysUnknown

7 If death occurred, did the infection contribute to cause of death?

NoYesUnknown

Calculated

BSA: n/a BMI: n/a


Height and Weight

Form 7: Malignancy/Lymphoproliferative Disorder Not StartedPrint this Form

1 Date of Diagnosis MM/DD/YYYY

2a Height cm in


2b Weight kg lb


3 Patient Diagnosis Initial DiagnosisRecurrence of previously diagnosed malignancythought to be "cured."Unknown

3 If recurrence, date of previousdiagnosis

MM/DD/YYYY


4 Nature of Malignancy Check only one.

Complete additional form(s) for other malignancies.

Lymphoproliferative Disease/LymphomaSarcomaSkinUnknownOther, specify

5 Site(s) of involvement at initialdiagnosis Check all that apply.

Abdomen, not GI tract (retroperitoneum, intraabdominal)BoneBone MarrowBreastCNSGI, Large BowelGI, Rectal

Lymphoproliferative/LymphomaDetails of EBV seroconversion. Question 6a relates to whether patient has EBV seroconverted since transplant. That is, if they were EBVnegative pretransplant and become positive posttransplant, we want to capture that event and question 6a should be completed.

GI, Small BowelGI, StomachHeartHepaticKidney/RenalLymph Nodes, deepLymph Nodes, subcutaneousMucous Membranes, genital/analMucous Membranes, craniofacialMusclePulmonary (lungs)Skin, facial scalpSkin, nonfacialSpleenTonsils and/or adenoidsUnknownOther, specify

6a EbsteinBarr Seroconversion (negative pre transplant to

positive titer posttransplant)

NoYesUnknown

6b If EbsteinBarrSeroconversion is Yes,

Date Last Negative EBV titer


6b If EbsteinBarrSeroconversion is Yes,

Date last Positive EBV titer


6c Was clonal analysis performed? NoYesUnknown

6c Clonal analysis results MonoclonalPolyclonalBothUnknown

6c Clonal analysis results B CellT CellBothUnknown

EBV PCR Negative

WHO Classification

Therapy at time of malignancy diagnosis and any changes made due todiagnosis within 30 days of diagnosis

Malignancy Lymph Disease Drug Details

6d PositiveUnknown

6d EBV PCR: DNA copies/ml Missing Reason: Unknown

6dIs tumor EBV positive? No

Not DoneYesUnknown

6e WHO classification Hodgkin's/Hodgkin'slikeMonomorphic PTLDPolymorphic PTLDUnknownOther, specify

6ii If Monomorphic PTLD, specify

BurkittsDiffuse large B cellOtherTcell lymphoma

7 Therapy at time of malignancydiagnosis

AcyclovirAzathioprine (Imuran)CyclophosphamideCyclosporineEverolimusGanciclovir/ValganciclovirMycophenolate (Cellcept, Myfotic)NoneRapamycinRituxanRituximabSirolimus (Rapamycin)SteroidsTacrolimus (FK506)UnknownOther, specify

© 2016 PHTS [test]

Outcome at 30 days post diagnosis

7 If Therapy, Ganciclovir orValganciclovir

IVPO

7 Changes made due to diagnosiswithin 30 days of diagnosis

(specify)

Dose DecreasedDrug AddedDrug discontinuedNo ChangeUnknown

8 Additional therapeutic measuresstarted within 30 days of diagnosis


ChemotherapyRadiation therapySurgery (excision, not performed solely fordiagnostic purposes)UnknownNoneOther, specify

9 Did malignancy/PTLD resolve? NoYesUnknown

9 Was immune suppressiondecreased further from above?

NoYesUnknown

Calculated

BSA: n/a BMI: n/a


Height and Weight

Form 8: Post Transplant Annual Followup Not StartedPrint this Form

1 Was patient seen for followup thisyear

Yes, patient was seen this yearNo, patient was not seen this year or the patientfollowup falls outside the followup window (+/ 90days of the transplant anniversary)

2 Date of FollowUp This is the date the patient was seen and the date for which the data

on the form is current. It is not the date that the form is filled out.





5 Were Hemodynamics Performed? YesNoUnknown

5 Hemodynamics If done during annual surveillance biopsy (if performed)

or during coronary assessment. MM/DD/YYYY


5 AoM Aortic mean


5 RAm Right atrial mean


Missing Reason:

Followup MedicationsAll medications that the patient was taking and prescribed at the time of the follow up date should be reported. Do not have to include PRN, topical, inhaled, or nebulizer medications.

Medication Details

5 PAm Pulmonary arterial mean

Not Done Unknown

5 PCW LV EDP Pulmonary capillary wedge


5 C.O. Cardiac output


5 C.I. Cardiac Index


6 Current residence ZIP code/Postal Code


7 Is patient currently followed at your PHTS Transplant center?

Patient currently followed at our PHTS TransplantcenterPatient followed exclusively at another center

7If currently followed All care is provided at our center

Only yearly evaluation at our center

7 If only followed yearly, specify date PHTS event

followup ceased


7 Last Date of Followup at YourCenter

8 Medications Missing Reason: None Unknown

9 Schooling Completed high school, >18 yoDelayed grade levelNot applicable, <6 yearsSpecial education

Charitable Donation – Indicates that a company, institution or individual(s)donated funds to pay for the care of the listed patient.Free – Indicates that the listing hospital will not charge the patient for the costof the hospitalizationGovernment – Other US or state government insurance. For Example,Medicaid, Medicare, CHIP (Children’s Health Insurance Program), Departmentof VA refers to funds from the Veterans Administration or others.Private – Refers to funds from agencies such as Blue Cross/Blue Shield, etc.Self Pay – Indicates that the recipient will pay for the largest portion of the costof the hospitalization.Other – For example, funds from a foreign government. Specify foreigncountry in the space provided.

Status unknownWithin one grade level

10 Exercise Test NoYesUnknown

10If exercise test not performed,

specify reason

Age inappropriateToo sickUnknownOther, specify


(should be listed in exercise report; if not, exercise labpersonnel

should be able to provide this data)

% Missing Reason: Not Done Unknown

10 VO2 at followup Maximum oxygen consumption

ml/kg/min Missing Reason: Not Done Unknown




effort.


11 Primary insurance at followup Charitable DonationFreeGovernmentPrivateSelf PayUnknownOther, specify














12Creatinine mg/dL Missing Reason:

Not Done Unknown






Glomular Filtritation Rate (GFR)

Viral Studies




12 TG Triglycerides




12HDL

High density lipoprotein




13a GFR method 12 or 24 hour urine collectionCalculated, specify method

Nuclear medicine scanNot DoneUnknown

Specify results

Specify Units

14a14a CMV serology Negative Not Done Positive Unknown

14a CMV PCR Negative Not Done Positive Unknown

14b EBV serology Negative Not Done Positive Unknown

EBV PCR Negative Not Done Positive

Events since transplant or last Form 8

14b Unknown

15 Coronary Evaluation If yes, complete form 4

NoYes

15 Coronary Evaluation EventDate:

15 Rejection If yes, complete form 5

NoYes

15 Rejection Event Date:

15 Infection If yes, complete form 6

NoYes

15 Infection Event Date:

15 Malignancy/PTLD If yes, complete form 7

NoYes

15 Malignancy Event Date:

15 Coronary Revascularization If yes, complete form 9

NoYes

15 Coronary RevascularizationEvent Date:

15 Death If yes, complete form 10

NoYes

15 Death Event Date:

15 Retransplantation If yes, complete form 1RL, 1T, 2, and 3

NoYes

© 2016 PHTS [test]

15 Retransplantation EventDate:

15 Renal Transplant If yes, complete form 14

NoYes

15Renal Transplant Event Date:

15 Dialysis If yes, complete form 14

NoYes

15 Dialysis Event Date:

15 Acute Dialysis NoYes

15 Chronic Dialysis NoYes

15Diabetes requiring insulin No

Yes

15 Diabetes Event Date:

15 Other major events NoYes

15 Other major events EventDate:


Functional Assessment of Coronary Flow Performed Using CatheterBasedMethodsFractional Flow Reserve (FFR) Abnormal is defined as ≤0.75

Form 9: Coronary Revascularization Not StartedPrint this Form

1 Date of Procedure MM/DD/YYYY

2a Fractional Flow ReservePerformed?

NoYesUnknown

2a Vessels Studied Check all that apply

LADLCxLeft MainRCAUnknown

2a FFR Abnormal for Left Main Coronary

Artery (L Main)

NoYesUnknown

2a FFR Abnormal for Left Anterior

Descending (LAD)

NoYesUnknown

2a FFR Abnormal for Left Circumflex (LCx)

NoYesUnknown

2a FFR Abnormal for Right Coronary Artery

(RCA)

NoYesUnknown

2b Coronary Flow Reserve (CFR)Performed

NoYesUnknown

2b CFR abnormal Abnormal is defined as ≤ 2.0 Maximal Flow: Resting

Flow)

NoYesUnknown

Intravascular Ultrasound

3 Intravascular Ultrasound Performed NoYesUnknown

3 Vessels studied LADLCxLeft MainRCAUnknown

3 If LAD, Median Intimal Thickness

(MIT)


3 If LAD, Standford Score


3 If LCx, Median Intimal Thickness

(MIT)


3 If LCx, Standford Score 01234Not DoneUnknown

3 If Left Main, Median Intimal Thickness

(MIT)


3 If Left Main, Standford Score


3 If RCA, Median Intimal Thickness

<0.3 mm>= 0.3mm

Percutaneous Procedures

Procedure Details

(MIT) Unknown

3 If RCA, Standford Score


4 Did the patient have aPTCA/Stent/Atheroctomy?

NoYesUnknown

4 Procedure AA (Angiojet Atherectomy)DA (Directional Atherectomy)PTCA (Angioplasty)RA (Rotational Atherectomy)StentOther, specify

4 Vessel LAD (Left Anterior Descending)LCx (Left Circumflex)Left Main Coronary ArteryPDA (Posterior Descending)RCA (Right Coronary Artery)Unknown

4 Lesion Characteristic ConcentricEccentricTubularUnknown

4 Location DistalMidProximalUnknown

4Pre Procedure Stenosis % Missing Reason:

Unknown

Post Procedure Stenosis % Missing Reason: Unknown

© 2016 PHTS [test]

Coronary Artery Bypass Grafting

4

4 Comments on Procedure(s) done Missing Reason: None

5 Coronary Artery Bypass Grafting NoYesUnknown

5 Vessel LADLCxLeft MainPDARCAUnknown


*American Heart Association definition of Sudden Cardiac Death (also called suddenarrest) is death resulting from an abrupt loss of heart function (cardiac arrest). Thevictim may or may not have diagnosed heart disease. The time and mode of deathare unexpected. It occurs within minutes after symptoms appear. Do not list supportwithdrawal as COD. Identify underlying reason – i.e .cardiac failure, pulmonaryhemorrhage, irreversible brain injury, etc…

Form 10: Death Not StartedPrint this Form

1 Date of Death MM/DD/YYYY

2 Primary cause of death Check only one.

CardiacHepatic FailureInfectionMajor bleedingMalignancy/CancerNeurologicPoor donor preservationPrimary graft failure (onset <24 hours posttransplant)Pulmonary embolismPulmonary hypertension/RV failureRejectionRenal FailureRespiratory failureSuicideTrauma/Accidental, specifyUnknownOther, specify

2 If Neurologic, specify Check only one.

Anoxic insultStroke/Cerebrovascular accident

2 If Cardiac, specify Check only one.

Congestive heart failureCoronary artery disease, (infarction)Fatal arrhythmiaSudden cardiac death, no arrhythmia or MIdocumented

2 If Malignancy/Cancer, specify Check only one.

Lymphoma/Lymphoproliferative diseaseMalignancy, nonlymphoma

2 If Major Bleeding, specify Check only one.

Postoperative hemorrhagePulmonary hemorrhage

2 If Rejection, specify Check only one.

AcuteChronicHyper acute (onset <24 hours posttransplant)

3 Did patient have a contributingcause of death?

YesNoUnknown

3 CardiacFamily decision to withdraw of supportHepatic FailureInfectionMajor bleedingMalignancy/CancerNeurologicNoncompliancePoor donor preservationPrimary graft failure (onset <24 hours posttransplant)Pulmonary embolismPulmonary hypertension/RV failureRejectionRenal FailureRespiratory failureSuicideTrauma/Accidental, specifyOther, specify

Unknown

3 If Cardiac, specify Congestive heart failureCoronary artery disease, (infarction)Fatal arrhythmiaSudden cardiac death, no arrhythmia or MIdocumentedOther, specify

3 If Malignancy/Cancer,specify

Lymphoma/Lymphoproliferative diseaseMalignancy, nonlymphomaOther, specify

3 If Major Bleeding, specify Postoperative hemorrhagePulmonary hemorrhageOther, specify

3 If Neurologic, specify Anoxic insultStroke/Cerebrovascular accidentOther, specify

3 If Rejection, specify Hyperacute (onset < 24 hours post transplant)AcuteChronicOther, specify

3 If Trauma/Accidental,specify

4Patient supported by

IABP/VAD/TAH/ECMO at time ofdeath

NoYesUnknown

5a Was patient listed or relisted attime of death?

NoYesUnknown

5b Status Details Check all that Apply Per UNOS Policy 6.1 On

6/14/2015

Has ductal dependent pulmonary or systemiccirculation, with ductal patency maintained by stentof prostaglandin infusionIn hospitalOut of hospitalRequires Inotropes

5b ICU NoYesUnknown

5b Requires continuousmechanical ventilationr

NoYesUnknown

5b On inotropes High dose or multiple IVSingle low dose IVUnknown Dose

5b ABO Incompatible NoYesUnknown

5c History of PRA > 10% NoYesUnknown

5d Did the patient receivetreatment

to lower or manage an elevated PRA while awaiting transplantation?

NoYes

5d Which therapywas

administered?

Azathioprine (Imuran)Bortezomib (Velcade)Cytoxan (cyclophosphamide)

2004 revised ISHLT scoring system for ACR: (J Heart Lung Transplant. 2005 Nov;24(11):171020.) ACR: acute cellular rejection (0, 1R, 2R, 3R)

2013 revised ISHLT scoring system for pAMR: J Heart Lung Transplant 2013 Dec 32(12):114762.) pAMR: pathologic antibody mediated rejection (0, 1h, 1i, 2, 3)

Immunoglobin (IVIG, IV IgG)Mycophenylate, MMF (Cellcept, Myfortic)Plasmapheresis/plasma exchangeRituximab (Rituxan)Other, specify

5d How long wastherapy

administered?

Only for a prespecified time/number of treatments:specifyUntil Heart transplantation, regardless ofsubsequent PRA levels/sensitization profileUntil PRA level reduced to 0%/patient no longersensitizedUntil PRA/sensitization profile diminished to a prespecified goalUnknown

6Post Mortem Examination (autopsy) NoYes

6 Cardiac pathology found Check all that apply.

Acute RejectionCAD, remote infarction (>1wk)Coronary artery disease, recent infarction (<= 1wk)Diffuse fibrosis, no acute rejectionGraftatherosclerosisNo cardiac pathology foundOther, specify

6 ACR Score 01R2R3RUnknown

6 pAMR Score 01h1i23Not evaluatedPositive, score not specified

7 Were there special circumstancessurrounding the death?

NoYes

Calculated

BSA: n/a BMI: n/a


Height and Weight

Status

Followup Status Change

Form 12: Pre Transplant Status Report Not StartedPrint this Form

1 Date of Follow Up MM/DD/YYYY

2 Height Indicate height at time of followup. Centimeters

Inches


3 Weight Indicate weight at time of followup. Kilograms

Pounds


4 Did the patient have any statuschanges since listing or the last

form 12?

YesNoUnknown

4 Current Status BrazilCanadaUnited KingdomUnited States

4 Old US Status Code 1 (this option is only for listings prior to 1999)1A1B27

4 New US Status Code 1 (this option is only for listings prior to 1999)1A1B27

4 Old United Kingdom StatusCode

RoutineUrgent

4 New United Kingdom StatusCode

RoutineUrgent

4 Old Canada Status Code 01233.544S

4 New Canada Status Code 01233.544S

4 Old Brazil Status Code NonPriorityPriority

4 New Brazil Status Code NonPriorityPriority

4 Reason for Status Change Age now > 6 monthsAlternate medical treatmentAlternate surgical treatmentDeteriorationFinancialImprovedInfectionNeurologicalParent/patient reluctancePsychosocialToo SickOther, specify

4 Date of Status Code Change MM/DD/YYYY

5 Previous Cardiac Surgical Historysince listing or last followup?

NoYesUnknown

Cardiac Surgery

Cardiac Surgery

5 Surgical Intervention AP Shunt (includes BT shunt, Waterston, Pott's,Mee procedure, Central shunt)ASD RepairCABGComplete AV Septal Defect RepairCongenitally Corrected Transposition Repair(classic)Congenitally Corrected Transposition Repair(double switch)Damus Kaye Stansel (DKS)dTransposition of the Great Vessels RepairEbstein's Anomaly RepairFontan ProcedureGlenn ProcedureHybrid Palliation (PA banding and PDA stent withor without septostomy)Norwood ProcedureNorwood Stage I: BT ShuntNorwood Stage I: Sano/RVPA conduitPA BandingPrevious Heart TransplantTOF/DORV/RVOTO RepairTruncus Arteriosus RepairValve ReplacementVSD RepairOther, specify

Unknown

5 Date of Surgical Intervention Missing Reason: Unknown

5Arterial Switch Operation whileListed

Arterial switch operationAtrial switch (Senning/Mustard)Unknown

5 Valve Replacement Details Aortic valve replacementMitral valve replacementPulmonary valve replacementTricuspid valve replacement

5 Aortic Valve, HomograftTissue while Listed

NoYesUnknown

5 Pulmonary Valve,Homograft Tissue while

Listed

NoYesUnknown

Patient StatusThis patient has two censor events reported (transferred and removed from list). A patient can only fall into one censor category. If a patient has been removed from the list and has also transferred, select “yes” to the event that happened first. Anything after this censor event should not be reported.

6 Catheter interventions/deviceplacements

Atrial Septostomy/Balloon Dilation of IASBalloon DilationCardiac Resynchronization TherapyDefibrillator/AICDNonePacemakerStentOther, specify

6 If stent, specify location ArchAtrial SeptumBT ShuntCoronary arteryPDAPulmonary arteryPulmonary veinRVPA conduitUnknownOther, specify

7 Was patient permanently removed from Transplant Waiting List since

listed or last Form 12?

Note: If patient was completely removed from the waiting list and is laterrelisted, the new listing should be treated as a whole new patient.

NoYesUnknownNot Applicable, patient died or transplanted

7 If yes, specify reason removed Alternate medical treatmentAlternate surgical treatmentConsidered too wellContraindications/too sickFinancialNeurologicalParent/patient reluctancePsychosocialOther, specify

8 Followed exclusively elsewhere Note: If yes, no more data can be entered on this patient.

NoYes


Renal Transplant

DialysisDialysis includes temporary CVVH in which BUN, Urea, Creatinine are being lowered. Dialysis does not include ultrafiltration, the removal of fluid only with preserved renal function.

Laboratory Values Closet to Time of Dialysis or Renal TransplantNote: labs may have been collected on different dates

Form 14: Dialysis or Renal Transplant Not StartedPrint this Form

1 Renal Transplant NoYesUnknown

1a Date of renal transplant MM/DD/YYYY


1b Type of donor DeceasedLiving, RelatedLiving, UnrelatedUnknown

2 Dialysis NoYesUnknown

2a Type of dialysis AcuteBothChronicUnknown

2b Date of first dialysis related to this event report


2c Date of last dialysis related to this event


2d Type of dialysis BothHemodialysisPeritonealUnknown


Form 15: Mechanical Circulatory Support Events Not StartedPrint this Form

1 Date of Initiation MM/DD/YYYY

2 Date of Discontinuation MM/DD/YYYY

If patient is still on MCSD support, check the "still in place" box.Then, you may edit this form with the discontinuation date once the

support has been removed.

Missing Reason: Still in place

3 Type of Support ECMOVADOther, specify

3a Type of ECMO BothVAVV

3b VAD Type LVAD aloneRVAD aloneTAH

3c Other temporary devicebrand

IABPImpellaOther

3b VAD Brands LVAD

Abiomed AB5000Abiomed BVS 5000Abiomed Impella 2.5Abiomed Impella 5.0Berlin Heart EXCORBiomedicusHeartMate II LVASHeartMate IPHeartMate VEHeartMate XVEHeartWare HVADImpella CPMaquet RotaflowMicromed DeBakey VAD ChildNovacor PCNovacor PCqSorin RevolutionTandem HeartThoratec Centrimag (Levitronix)Thoratec IVADThoratec Pedimag

© 2016 PHTS [test]

Thoratec PVADOther, specify

3b VAD Brands RVAD

Abiomed AB5000Abiomed BVS 5000Abiomed Impella 2.5Abiomed Impella 5.0Berlin Heart EXCORBiomedicusHeartWare HVADMaquet RotaflowSorin RevolutionTandem HeartThoratec Centrimag (Levitronix)Thoratec IVADThoratec PedimagThoratec PVADImpella CPImpella RPOther, specify

3b VAD Brands TAH

AbioCor TAHSynCardia CardioWest TAHOther, specify

Screening Log Print this Form Not Started · Screening Log Print this Form Not Started Center Code...

Documents

Transcript of Screening Log Print this Form Not Started · Screening Log Print this Form Not Started Center Code...