Upload
others
View
13
Download
0
Embed Size (px)
Citation preview
© 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
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
Patient Details Hidden ShowShow/Hide Annotations
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
Missing Reason: Not Done Unknown
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
Negative Not Done Positive Unknown
7 HBs Ag Hepatitis B surface antigen
Negative Not Done Positive Unknown
7 HB core Ab Hepatitis B core antibody
Negative Not Done Positive Unknown
7 HBs Ab Hepatitis B surface antibody
Negative Not Done Positive Unknown
Medical History at time of Listing
7 Hep C Ab Hepatitis C antibody
Negative Not Done Positive Unknown
7 RPR/Syphilis Syphilis testing
Negative Not Done Positive Unknown
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
Missing Reason: Unknown
8 Pacemaker, CRT/biventricular
pacing, Date Placed
MM/DD/YYYY
Missing Reason: Unknown
8 Pacemaker, Defibrillator/AICD
Date Placed MM/DD/YYYY
Missing Reason: Unknown
8 Shock, Date of last appropriate
Shock MM/DD/YYYY
Missing Reason: Unknown
8 Diabetes, Date of last Hgb A1c
MM/DD/YYYY
Missing Reason: Unknown
8 Diabetes, Value of last Hgb A1c
Missing Reason: Unknown
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
Missing Reason: Unknown
8 Neurologic, Hemorrhagic and/or
thromboembolicstroke
Date Last MM/DD/YYYY
Missing Reason: Unknown
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)
Missing Reason: Unknown
10c Flow Cytometry or LuminexPRA
DoneNot Done
10c Class I % Missing Reason: Unknown
10c Class II % Missing Reason: Unknown
10c Date MM/DD/YYYY
Missing Reason: Unknown
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
Missing Reason: Not Done Unknown
11a Fontan Mean Pressure Missing Reason: Not Done Unknown
11a RAm (RAP or CVP) Right Atrial Mean Pressure
Missing Reason: Not Done Unknown
11a PAm Pulmonary Artery Mean
Missing Reason: Not Done Unknown
11a PCW Mean Pulmonary Capillary Wedge Pressure
Missing Reason: Not Done Unknown
11a SVC Sat Oxygen Saturation in the SVC
Missing Reason: Not Done Unknown
11a AO Sat Aortic Saturation
Missing Reason: Not Done Unknown
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
wu x m2 Missing Reason: Not Done Unknown
11a EDP End diastolic pressure of systemic ventricle
Missing Reason: Not Done Unknown
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.
Missing Reason: Unknown
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)
U/L Missing Reason: Not Done Unknown
14BNP
Btype natriuretic peptide
pg/mL or ng/L Missing Reason: Not Done Unknown
14 Pro BNP Pro NT Btype natriuretic peptide
pg/mL or ng/L Missing Reason: Not Done Unknown
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
mg/dL Missing Reason: Not Done Unknown
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
mg/dL Missing Reason: Not Done Unknown
14 TG Triglycerides
mg/dL Missing Reason: Not Done Unknown
14 LDL Low density lipoprotein
mg/dL Missing Reason: Not Done Unknown
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
mg/dL Missing Reason: Not Done Unknown
15 NYHA Class 1234Not DoneUnknown
15 Ross' Heart Failure Class 1234Not DoneUnknown
Calculated
BSA: n/a BMI: n/a
Patient Details Hidden ShowShow/Hide Annotations
Height and Weight
Form 1RL: Relisting Not StartedPrint this Form
1 Date of Relisting
2 Height Centimeters Inches
Missing Reason: Not Done Unknown
3 Weight Kilograms Pounds
Missing Reason: Not Done Unknown
4 Has this patient been transplanted NoYes
4 Indicate total number of priortransplants
This includes transplants that were and were not done atyour hospital.
Missing Reason: Unknown
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?
In hospitalOut of hospital
7b.i Was patient in the ICU attime of relisting?
NoYesUnknown
7b.ii Did the patient requirecontinuous invasive
mechanical ventilation?
NoYesUnknown
7c Did the patient requirecontinuous inotropes at time of
listing?
YesNoUnknown
Infectious Disease Screening
7c.i Inotropes does Dose UnknownHigh Dose or Multiple IVSingle Low Dose
7d Did the patient have ductaldependent pulmonary or
systemic circulation, with ductalpatency maintained by stent or
prostaglandin infusion?
YesNoUnknown
7e ABO incompatible NoYesUnknown
7f Was patient on a VAD or ECMO attime of relisting?
VADECMONot on support at time of Relisting
7f Specify initiation date (VAD) Missing Reason: Unknown
7f Specify initiation date (ECMO) Missing Reason: Unknown
7g Was patient listed for DCD(Donation after Cardiac Death)
organ?
YesNoUnknownThis is not current practice at our center
8 HIV Serology AIDS testing
Negative Not Done Positive Unknown
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
8 IFA Toxo Toxoplasma testing
Negative Not Done Positive Unknown
Negative Not Done Positive
Medical History at time of ReListing
8 HBs Ag Hepatitis B surface antigen
Unknown
8 HB core Ab Hepatitis B core antibody
Negative Not Done Positive Unknown
8 HBs Ab Hepatitis B surface antibody
Negative Not Done Positive Unknown
8 Hep C Ab Hepatitis C antibody
Negative Not Done Positive Unknown
8 RPR/Syphilis Syphilis testing
Negative Not Done Positive Unknown
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
Missing Reason: Unknown
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
Missing Reason: Unknown
9 Pacemaker, CRT/Biventricular pacing
Date placed MM/DD/YYYY
Missing Reason: Unknown
9 Defibrillator/AICD, Date Placed
MM/DD/YYYY
Missing Reason: Unknown
9 Date of last appropriate Shock MM/DD/YYYY
Missing Reason: Unknown
9 Date of Last Hgb A1c MM/DD/YYYY
Missing Reason: Unknown
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
Missing Reason: Unknown
9 Hemorrhagic and/or Thromboembolic Stroke,
Date Last MM/DD/YYYY
Missing Reason: Unknown
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)
Missing Reason: Unknown
11c Flow Cytometry or LuminexPRA
DoneNot Done
11c Class I % Missing Reason: Unknown
11c Class II % Missing Reason: Unknown
11c Date MM/DD/YYYY
Missing Reason: Unknown
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
Missing Reason: Unknown
12a Fontan Mean Pressure Missing Reason: Not Done Unknown
12a RAm (RAP or CVP) Right Atrial Mean Pressure
Missing Reason: Not Done Unknown
12a PAm Pulmonary Artery Mean
Missing Reason: Not Done Unknown
12a PCW Mean Pulmonary Capillary Wedge Pressure
Missing Reason: Not Done Unknown
12a SVC Sat Oxygen Saturation in the SVC
Missing Reason: Not Done Unknown
12a AO Sat Aortic Saturation
Missing Reason: Not Done Unknown
12a Rp, PVRI Pulmonary resistance indexed to body surface
area (BSA) Woods Units x m2
wu x m2 Missing Reason: Not Done Unknown
12a Rs, SVRI Systemic resistance indexed to body surface area
(BSA) Woods Units x m2
wu x m2 Missing Reason: Not Done Unknown
12a EDP End diastolic pressure of systemic ventricle
Missing Reason: Not Done Unknown
12a C.O. Cardiac output (i.e. Qs) in L/min
L/min Missing Reason: Not Done Unknown
Schooling
Exercise Test
12a C.I. Cardiac index (i.e. C.O. divided by m2) in L/min/m2
L/min/m2 Missing Reason: Not Done Unknown
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
Laboratory Values closest to time of this reportNote: labs may have been collected on different dates.
14 Was exercise test performed? NoYesUnknown
14 If test no, specify reason Age InappropriateToo SickUnknownOther, specify
14Max 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: Not Done Unknown
14 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.
Missing Reason: Not Done Unknown
14 Max VO2 Maximum oxygen consumption
ml/kg/min Missing Reason: Not Done Unknown
15 Total Bilirubin mg/dL Missing Reason: Not Done Unknown
15 Direct Bilirubin mg/dL Missing Reason: Not Done Unknown
15 AST Aspartate transaminase (also SGOT)
U/L Missing Reason: Not Done Unknown
15 ALT Alanine transaminase (also SGPT)
U/L Missing Reason: Not Done Unknown
15 BNP Btype natriuretic peptide
pg/mL or ng/L Missing Reason: Not Done Unknown
15 Pro BNP Pro NT Btype natriuretic peptide
pg/mL or ng/L Missing Reason: Not Done Unknown
15 CRP C reactive protein
mg/dL Missing Reason: Not Done Unknown
15 Creatinine mg/dL Missing Reason: Not Done Unknown
15 BUN Blood urea nitrogen
mg/dL Missing Reason: Not Done Unknown
15 Cystatin C mg/L Missing Reason: Not Done Unknown
15 Total Protein g/dL Missing Reason: Not Done Unknown
15 Pre Albumin mg/dL Missing Reason: Not Done Unknown
15Serum Albumin g/dL Missing Reason:
Not Done Unknown
15 Cholesterol Total Cholesterol
mg/dL Missing Reason: Not Done Unknown
15 TG Triglycerides
mg/dL Missing Reason: Not Done Unknown
15 LDL Low density lipoprotein
mg/dL Missing Reason: Not Done Unknown
15 HDL High density lipoprotein
mg/dL Missing Reason: Not Done Unknown
15 VLDL Very low 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
16 NYHA Class 1234Not DoneUnknown
16 Ross Heart Failure Class 1234Not DoneUnknown
Calculated
BSA: n/a BMI: n/a
Patient Details Hidden ShowShow/Hide Annotations
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
4 Height Centimeters Inches
Missing Reason: Not Done Unknown
5 Weight Kilograms Pounds
Missing Reason: Not Done Unknown
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?
In hospitalOut of hospital
6b.i Was patient in the ICU attime of transplant?
YesNoUnknown
6b.ii Did the patient requirecontinuous invasive
mechanical ventilation?
YesNoUnknown
6c Did the patient requirecontinuous inotropes at time of
transplant?
YesNoUnknown
6c.i Inotropes Dose High Dose or Multiple IVSingle Low DoseUnknown
6d Did the patient have ductaldependent pulmonary or
systemic circulation, with ductalpatency maintained by stent or
prostaglandin infusion?
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
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
7a Cytotoxic PRA DoneNot Done
7a T Cell Values above 10 will require section 10:
Peroperative management for PRA to be completed.
% Missing Reason: Unknown
7a B Cell Values above 10 will require section 10:
Peroperative management for PRA to be completed.
% Missing Reason: Unknown
7a Date MM/DD/YYYY
Missing Reason: Unknown
7b Cytotoxic PRA DTE/DTT DoneNot Done
7b T Cell Values above 10 will require section 10:
Peroperative management for PRA to be completed.
% Missing Reason: Unknown
7b B Cell Values above 10 will require section 10:
Peroperative management for PRA to be completed.
% Missing Reason: Unknown
7b Date MM/DD/YYYY
Missing Reason: Unknown
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.
Missing Reason: Unknown
7c Class II Values above 10 will require section 10:
Peroperative management for PRA to be completed.
Missing Reason: Unknown
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?
Check all that apply.
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?
Missing Reason: Unknown
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 Total Bilirubin mg/dL Missing Reason: Not Done Unknown
13 Direct Bilirubin mg/dL Missing Reason: Not Done Unknown
13 AST Aspartate transaminase (also SGOT)
U/L Missing Reason: Not Done Unknown
13 ALT Alanine transaminase (also SGPT)
U/L Missing Reason: Not Done Unknown
13 BNP Btype natriuretic peptide
pg/mL or ng/L Missing Reason: Not Done Unknown
13 Pro BNP Pro NT Btype natriuretic peptide
pg/mL or ng/L Missing Reason: Not Done Unknown
13 CRP C reactive protein
mg/dL Missing Reason: Not Done Unknown
13 Creatinine mg/dL Missing Reason: Not Done Unknown
13 BUN Blood urea nitrogen
mg/dL Missing Reason: Not Done Unknown
13 Cystatin C mg/L Missing Reason: Not Done Unknown
13 Total Protein g/dL Missing Reason: Not Done Unknown
13 Pre Albumin mg/dL Missing Reason: Not Done Unknown
13 Serum Albumin g/dL Missing Reason: Not Done Unknown
13 Cholesterol Total Cholesterol
mg/dL Missing Reason: Not Done Unknown
13 TG Triglycerides
mg/dL Missing Reason: Not Done Unknown
13 LDL Low density lipoprotein
mg/dL Missing Reason: Not Done Unknown
13 HDL High density lipoprotein
mg/dL Missing Reason: Not Done Unknown
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.
13 VLDL Very low density lipoprotein
mg/dL Missing Reason: Not Done Unknown
14a Hemodynamics NoYesUnknown
14a Date MM/DD/YYYY
Missing Reason: Unknown
14a Fontan Mean Pressure Missing Reason: Not Done Unknown
14a RAm (RAP or CVP) Right atrial mean pressure
Missing Reason: Not Done Unknown
14a PAm Pulmonary artery mean
Missing Reason: Not Done Unknown
14a PCW Mean pulmonary capillary wedge pressure
Missing Reason: Not Done Unknown
14a SVC Sat Oxygen saturation in the SVC
Missing Reason: Not Done Unknown
14a AO Sat Aortic saturation
Missing Reason: Not Done Unknown
14a Rp, PVRI Pulmonary resistance indexed to body surface
area (BSA)
Woods Units x m2 Missing Reason: Not Done Unknown
14a Rs, SVRI Systemic resistance indexed to body surface area
(BSA)
Woods Units x m2 Missing Reason: Not Done Unknown
EDP End diastolic pressure of systemic ventricle
Missing Reason: Not Done Unknown
Inotropes, Pressors, and Thyroid Hormones
14a
14a C.O. Cardiac output (i.e. Qs) in L/min
L/min Missing Reason: Not Done Unknown
14a C.I. Cardiac index (i.e. C.O. divided by m2) in L/min/m2
L/min/m2 Missing Reason: Not Done Unknown
14b Hemodynamic Agents NoYesUnknown
14b Indicate agent forbest hemodynamics
Check all that apply.
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
minutes Missing Reason: Unknown
18 Technique of transplant AtrialBicavalUnknown
Calculated
BSA: n/a BMI: n/a
Patient Details Hidden ShowShow/Hide Annotations
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
Missing Reason: Unknown
2 Donor Date of Birth Missing Reason: Unknown
3 Donor Height Centimeters Inches
Missing Reason: Not Done Unknown
4 Donor Weight Kilograms Pounds
Missing Reason: Not Done Unknown
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
Missing Reason: Unknown
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.
Missing Reason: Unknown
10 Chest Compressions (CPR) NoYesUnknown
10 If yes, CPR Time Enter duration in minutes
minutes Missing Reason: Unknown
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
Check all that apply.
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
Missing Reason: Not Done Unknown
16Pretransplant Donor Angiogram NoYesUnknown
16 Angiogram results Abnormal, Specify
NormalUnknown
17 HIV Serology AIDS testing
Negative Not Done Positive Unknown
17 CMV IgG Cytomegalovirus testing
Negative Not Done Positive Unknown
17 IFA Toxo Toxoplasma testing
Negative Not Done Positive Unknown
17 EBV IgG Epstein Barr Virus
Negative Not Done Positive Unknown
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 HBs Ag Hepatitis B surface antigen
Negative Not Done Positive Unknown
17 HB core Ab Hepatitis B core antibody
Negative Not Done Positive Unknown
17 HBs Ab Hepatitis B surface antibody
Negative Not Done Positive Unknown
17 Hep C ab Hepatitis C antibody
Negative Not Done Positive Unknown
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
Patient Details Hidden ShowShow/Hide Annotations
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
Missing Reason: Unknown
End Date MM/DD/YYYY
Missing Reason: Unknown
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
Missing Reason: Unknown
3 Cyclosporine NoYesUnknown
3 Was patient on medication at30 days?
NoYesUnknown
3 If patient is no longer onmedication
at 30 days, specify stopdate.
MM/DD/YYYY
Missing Reason: Unknown
4 Mycophenolate (Cellcept, Myfortic) NoYesUnknown
4 Was patient on medication at30 days?
NoYesUnknown
4 If patient is no longer onmedication
at 30 days, specify stopdate.
MM/DD/YYYY
Missing Reason: Unknown
5 Sirolimus (Rapamycin) NoYesUnknown
5 Was patient on medication at30 days?
NoYesUnknown
5 If patient is no longer onmedication
at 30 days, specify stopdate.
MM/DD/YYYY
Missing Reason: Unknown
6 Tacrolimus (Prograf, FK506) NoYesUnknown
6 Was patient on medication at30 days?
NoYesUnknown
6 If patient is no longer onmedication
at 30 days, specify stopdate.
MM/DD/YYYY
Missing Reason: Unknown
7 Everolimus NoYesUnknown
7 Was patient on medication at30 days?
NoYesUnknown
7 If patient is no longer onmedication
at 30 days, specify stopdate.
MM/DD/YYYY
Missing Reason: Unknown
8 Cyclophoshamide (Cytoxan) NoYesUnknown
8 Was patient on medication at30 days?
NoYesUnknown
8 If patient is no longer onmedication
at 30 days, specify stopdate.
MM/DD/YYYY
Missing Reason: Unknown
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
Missing Reason: Unknown
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
Missing Reason: Unknown
10 Was patient given otherimmunosuppressants?
NoYesUnknown
10 Specify date of first post opdose
MM/DD/YYYY
Missing Reason: Unknown
10 Patient on medication at 30days
NoYesUnknown
10 If patient is no longeron medication
at 30 days, specify stopdate.
MM/DD/YYYY
Missing Reason: Unknown
11 ProphylacticAntibiotics/Antivirals
started Preop through 30 dayspost op
Check all that apply
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
Check all that apply
IVPO
12 Date of Hospital Discharge MM/DD/YYYY
Missing Reason: Still In Hospital Unknown
Patient Details Hidden ShowShow/Hide Annotations
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
Check all that apply.
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)
<0.3 mm>= 0.3mmUnknown
6 If LAD, Stanford Score
01234Not DoneUnknown
6 If LCx, Maximal IntimalThickness (MIT)
<0.3 mm>= 0.3mmUnknown
6 If LCx, Stanford Score
01234Not DoneUnknown
6 If RCA, Maximal IntimalThickness (MIT)
<0.3 mm>= 0.3mmUnknown
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
Missing Reason: Not Done Unknown
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
> 1 Segment1 SegmentDiffuseUnknown
8 If Stress is New Akinesis/dyskinesis
> 1 Segment1 SegmentDiffuseUnknown
8Maximum Heart Rate Achieved Missing Reason: Unknown
8 LV Dilatation with Stress NoYesUnknown
Patient Details Hidden ShowShow/Hide Annotations
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
Missing Reason: Unknown
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
NegativePositiveUnknown
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
NegativePositiveUnknown
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
Patient Details Hidden ShowShow/Hide Annotations
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
Patient Details Hidden ShowShow/Hide Annotations
Height and Weight
Form 7: Malignancy/Lymphoproliferative Disorder Not StartedPrint this Form
1 Date of Diagnosis MM/DD/YYYY
2a Height cm in
Missing Reason: Not Done Unknown
2b Weight kg lb
Missing Reason: Not Done Unknown
3 Patient Diagnosis Initial DiagnosisRecurrence of previously diagnosed malignancythought to be "cured."Unknown
3 If recurrence, date of previousdiagnosis
MM/DD/YYYY
Missing Reason: Unknown
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
Missing Reason: Not Done Unknown
6b If EbsteinBarrSeroconversion is Yes,
Date last Positive EBV titer
Missing Reason: Not Done Unknown
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
Check all that apply.
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
Patient Details Hidden ShowShow/Hide Annotations
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.
3 Height Centimeters Inches
Missing Reason: Not Done Unknown
4 Weight Kilograms Pounds
Missing Reason: Not Done Unknown
5 Were Hemodynamics Performed? YesNoUnknown
5 Hemodynamics If done during annual surveillance biopsy (if performed)
or during coronary assessment. MM/DD/YYYY
Missing Reason: Unknown
5 AoM Aortic mean
Missing Reason: Not Done Unknown
5 RAm Right atrial mean
Missing Reason: Not Done Unknown
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
Missing Reason: Not Done Unknown
5 C.O. Cardiac output
L/min Missing Reason: Not Done Unknown
5 C.I. Cardiac Index
L/min/m2 Missing Reason: Not Done Unknown
6 Current residence ZIP code/Postal Code
Missing Reason: Unknown
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
Missing Reason: Unknown
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
10Max VO2% Predicted for Age Refers to predicted maximum VO2 for patient
(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
10 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.
Missing Reason: Not Done Unknown
11 Primary insurance at followup Charitable DonationFreeGovernmentPrivateSelf PayUnknownOther, specify
Laboratory Values closest to time of this reportNote: labs may have been collected on different dates.
12 Total Bilirubin mg/dL Missing Reason: Not Done Unknown
12 Direct Bilirubin mg/dL Missing Reason: Not Done Unknown
12 AST Aspartate transaminase (also SGOT)
U/L Missing Reason: Not Done Unknown
12 ALT Alanine transaminase (also SGPT)
U/L Missing Reason: Not Done Unknown
12 BNP Btype natriuretic peptide
pg/mL or ng/L Missing Reason: Not Done Unknown
12 Pro BNP Pro NT Btype natriuretic peptide
pg/mL or ng/L Missing Reason: Not Done Unknown
12 CRP C reactive protein
mg/dL Missing Reason: Not Done Unknown
12Creatinine mg/dL Missing Reason:
Not Done Unknown
12 BUN Blood urea nitrogen
mg/dL Missing Reason: Not Done Unknown
12 Cystatin C mg/L Missing Reason: Not Done Unknown
12 Total Protein g/dL Missing Reason: Not Done Unknown
12 Pre Albumin mg/dL Missing Reason: Not Done Unknown
Glomular Filtritation Rate (GFR)
Viral Studies
12 Serum Albumin g/dL Missing Reason: Not Done Unknown
12 Cholesterol Total Cholesterol
mg/dL Missing Reason: Not Done Unknown
12 TG Triglycerides
mg/dL Missing Reason: Not Done Unknown
12 LDL Low density lipoprotein
mg/dL Missing Reason: Not Done Unknown
12HDL
High density lipoprotein
mg/dL Missing Reason: Not Done Unknown
12 VLDL Very low density lipoprotein
mg/dL Missing Reason: Not Done Unknown
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:
Patient Details Hidden ShowShow/Hide Annotations
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)
<0.3 mm>= 0.3mmUnknown
3 If LAD, Standford Score
01234Not DoneUnknown
3 If LCx, Median Intimal Thickness
(MIT)
<0.3 mm>= 0.3mmUnknown
3 If LCx, Standford Score 01234Not DoneUnknown
3 If Left Main, Median Intimal Thickness
(MIT)
<0.3 mm>= 0.3mmUnknown
3 If Left Main, Standford Score
01234Not DoneUnknown
3 If RCA, Median Intimal Thickness
<0.3 mm>= 0.3mm
Percutaneous Procedures
Procedure Details
(MIT) Unknown
3 If RCA, Standford Score
01234Not DoneUnknown
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
Patient Details Hidden ShowShow/Hide Annotations
*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
Patient Details Hidden ShowShow/Hide Annotations
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
Missing Reason: Not Done Unknown
3 Weight Indicate weight at time of followup. Kilograms
Pounds
Missing Reason: Not Done Unknown
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
Patient Details Hidden ShowShow/Hide Annotations
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
Missing Reason: Unknown
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
Missing Reason: Unknown
2c Date of last dialysis related to this event
Missing Reason: Unknown
2d Type of dialysis BothHemodialysisPeritonealUnknown
3 Total Bilirubin mg/dL Missing Reason: Not Done Unknown
3 Direct Bilirubin mg/dL Missing Reason: Not Done Unknown
3 AST Aspartate transaminase (also SGOT)
U/L Missing Reason: Not Done Unknown
3 ALT Alanine transaminase (also SGPT)
U/L Missing Reason: Not Done Unknown
3 BNP Btype natriuretic peptide
pg/mL or ng/L Missing Reason: Not Done Unknown
3 Pro BNP Pro NT Btype natriuretic peptide
pg/mL or ng/L Missing Reason: Not Done Unknown
3 CRP C reactive protein
mg/dL Missing Reason: Not Done Unknown
3 Creatinine mg/dL Missing Reason: Not Done Unknown
3 BUN Blood urea nitrogen
mg/dL Missing Reason: Not Done Unknown
3 Cystatin C mg/L Missing Reason: Not Done Unknown
3 Total Protein g/dL Missing Reason: Not Done Unknown
3 Pre Albumin mg/dL Missing Reason: Not Done Unknown
3 Serum Albumin g/dL Missing Reason: Not Done Unknown
© 2016 PHTS [test]
Calculated
BSA: n/a BMI: n/a
Height and Weight
3 Cholesterol Total Cholesterol
mg/dL Missing Reason: Not Done Unknown
3 TG Triglycerides
mg/dL Missing Reason: Not Done Unknown
3 LDL Low density lipoprotein
mg/dL Missing Reason: Not Done Unknown
3 HDL High density lipoprotein
mg/dL Missing Reason: Not Done Unknown
3 VLDL Very low density lipoprotein
mg/dL Missing Reason: Not Done Unknown
4 Height Centimeters Inches
Missing Reason: Not Done Unknown
4 Weight Kilograms Pounds
Missing Reason: Not Done Unknown
Patient Details Hidden ShowShow/Hide Annotations
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