NCDR AFib Ablation Registry v1.0 Atrial Fibrillation (AF) Ablation Interventional Registry

Transcription

1 A. DEMOGRAPHICS Last Name 2000 : First Name 2010 : Middle Name 2020 : SSN 2030 : - - SSN N/A 2031 Patient ID 2040 : (auto) Other ID 2045 : Birth Date 2050 : Sex 2060 : O Male O Female Patient Zip Code 2065 : Zip Code NA 2066 Race: (check all that apply) White 2070 Black/African American 2071 American Indian/Alaskan Native 2073 Asian 2072 à If Yes, Asian - Indian 2080 Chinese 2081 Filipino 2082 Japanese 2083 Korean 2084 Vietnamese 2085 Other 2086 Native Hawaiian/Pacific Islander 2074 à If Yes, Native Hawaiian 2090 Guamanian or Chamorro 2091 Samoan 2092 Other Island 2093 Hispanic or Latino Ethnicity 2076 : à If Yes, Ethnicity Type: (check all that apply) Mexican, Mexican-American, Chicano 2100 Puerto Rican 2101 Cuban 2102 Other Hispanic, Latino or Spanish Origin 2103 B. EPISODE OF CARE (ADMISSION) Arrival Date 3000 : Hospital Status 3010 : Insurance 3020 : O Outpatient O Inpatient à If Inpatient, Inpatient for AFib 3015 : à If Yes, Payor 3025 : (Select all that apply) C. HISTORY AND RISK FACTORS (PRIOR TO FIRST PROCEDURE) SPECIFIC TO HAS-BLED RISK SCORES Private Health Insurance Medicare Medicaid Military Health Care State-Specific Plan (non-medicaid) Indian Health Service Non-US Insurance HIC # 3030 : Research Study 3035 : à If Yes, Study Name 3036, Patient ID 3037 :, HAS-BLED Hypertension: Uncontrolled 4000 : HAS-BLED Bleeding 4020 : HAS-BLED Abnormal Renal Function 4005 : HAS-BLED Labile INR 4025 : O NA HAS-BLED Abnormal Liver Function 4010 : HAS-BLED Alcohol 4030 : HAS-BLED Stroke 4015 : HAS-BLED Drugs 4035 : SPECIFIC TO CHA2DS2-VASC RISK SCORES CHA2DS2-VASC Congestive Heart Failure 4050 : à If Yes, NYHA Functional Classification 4055 : O Class I O Class II O Class III O Class IV CHA2DS2-VASC LV Dysfunction 4060 : CHA2DS2-VASC Hypertension: Controlled 4065 : CHA2DS2-VASC Diabetes Mellitus 4070 : CHA2DS2-VASC Stroke 4075 : CHA2DS2-VASC TIA 4080 : CHA2DS2-VASC Thromboembolic Event 4085 : CHA2DS2-VASC Vascular Disease 4090 : à If Yes, Vascular Disease Type 4095 : ADDITIONAL HISTORY & RISK FACTORS (Select all that apply) Prior MI PAD Known Aortic Plaque Cardiomyopathy (CM) 4125 : à If Yes, CM Type 4130 : (Select all that apply) Non-Ischemic Ischemic Restrictive Hypertrophic Other Chronic Lung Disease 4140 : Sleep Apnea 4150 : Coronary Artery Disease 4145 : à If Yes, Rx Followed 4155 : 2014, American College of Cardiology Foundation 26-Mar-2015 Page 1 of 5

2 HISTORY RHYTHM HISTORY Symptoms Experienced During AFib/AFlutter 4160 : O Asymptomatic O Symptomatic Atrial Fibrillation Classification (prompting ablation) 4165 : O Paroxysmal O Long standing persistent t Documented O Persistent O Permanent Valvular Atrial Fibrillation 4170 : à If Yes, Hx of Mitral Valve Replacement (MVR) 4175 : à If Yes, Mechanical Valve in Mitral Position 4180 : à If Yes, Hx of Mitral Valve Repair (Surgical Leaflet or Annuloplasty) 4185 : Previous Attempt at Atrial Fibrillation Termination 4190 : à If Yes, Pharmacologic Cardioversion 4195 : à If Yes, DC Cardioversion 4200 : à If Yes, Catheter Ablation 4205 : à If Yes, Date of Most Recent 4210 : à If Yes, Prior Ablation Strategy(s) 4215 :,,, à If Yes, Surgical Ablation 4220 : à If Yes, Date of Most Recent 4225 : Atrial Flutter 4250 : à If Yes, Atrial Flutter Type 4255 : O Typical/Cavotricuspid Isthumus (CTI) Dependent O Atypical à If Yes, Previous Attempt at Atrial Flutter Termination 4260 : à If Yes, Pharmacologic Cardioversion 4265 : à If Yes, DC Cardioversion 4270 : à If Yes, Catheter Ablation 4275 : à If Yes, Date of Most Recent 4280 : D. DIAGNOSTIC STUDIES (MOST RECENT VALUES PRIOR TO THE START OF THE FIRST PROCEDURE) Atrial Rhythm 5050 : (Select all that apply) Sinus Afib Atrial tach Aflutter Sinus arrest Atrial paced Not Documented Transthoracic Echo (TTE) Performed 5060 : à If Yes, Date of TTE 5065 : à If Yes, LVEF Assessed 5066 : à If Yes, LVEF 5070 : % à If Yes, LV Hypertrophy 5075 : à If Yes, LA Size 5080 : ne O Mild O Moderate O Severe rmal O Mild enlargement O Moderate enlargement O Severe enlargement à If Yes, RA Size 5085 : à If Yes, Mitral Regurgitation 5090 : rmal O Mild enlargement O Moderate enlargement O Severe enlargement (highest) ne O 1+ (Mild) O 3+ (Moderate-Severe) O Trace/Trivial O 2+ (Moderate) O 4+ (Severe) à If Yes, Mitral Stenosis 5095 : Transesophageal Echo Performed (TEE) 5100 : à If Yes, Date of Most Recent 5105 : à If Yes, Atrial Thrombus Detected 5110 : Baseline Imaging Performed 5115 : à If Yes, CT Performed 5120 : à If Yes, Date of Most Recent 5125 : à If Yes, MR Performed 5130 : à If Yes, Date of Most Recent 5135 : 2014, American College of Cardiology Foundation 26-Mar-2015 Page 2 of 5

3 E. PHYSICAL EXAM AND LABS Height 6000 : cm PT 6025 : sec Not Drawn 6026 Bilirubin 6040 : mg/dl Not Drawn 6041 Weight 6005 : kg INR 6030 : Not Drawn 6031 AST 6045 : U/dL Not Drawn 6046 Pulse 6010 : bpm Creatinine 6035 : mg/dl Not Drawn 6036 ALT 6050 : U/dL Not Drawn 6051 Blood Pressure 6015/6020 : / mmhg Alk Phos 6055 : IU/dL Not Drawn 6056 F. MEDICATIONS Medications prescribed at discharge are not required for patients who expired, discharged to Other acute care Hospital, AMA, or are receiving Hospice Care. PRE-PROC MEDICATION ADMINISTERED PRESCRIBED AT DISCHARGE MEDICATION 7000,10200 PAST CURRENT HELD NEVER YES NO - NO NO - MEDICAL NO - PT. NO - SYSTEM RATE CONTROL RHYTHM CONTROL ANTIPLATELET ANTICOAGULANT NON-VITAMIN K DEPENDENT ORAL ANTICOAGULANT BRIDGING WITH HEPARIN OR HEPARIN DERIVATIVE OTHERS Beta Blockers (Any) Diltiazem Verapamil Digoxin Amiodarone (Cordarone, Pacerone) Dofetilide (Tikosyn) Dronedarone (Multaq) Flecainide (Tambocor) Propafenone (Rythmol) Sotalol (Betapace) Other Rhythm Control Therapy Aspirin Clopidogrel (Plavix) Warfarin (Coumadin) Apixaban Dabigatran Rivaroxaban Edoxaban Unfractionated Heparin Fondaparinux Low Molecular Wt Heparin Heparin / Derivative (Other) ACE Inhibitors (any) ARB (Any) Statin therapy 2014, American College of Cardiology Foundation 26-Mar-2015 Page 3 of 5

4 G. PROCEDURE INFORMATION Procedure Start Date Time 8000,8001 : mm/dd/yyyy / hh:mm Operator Name 8010,8015,8020 : Phrenic Nerve Evaluation 8030 : Esophagus Monitoring Performed 8040 : Operator NPI 8025 : à If Yes, Pacing Maneuver 8035 : à If Yes, Anatomic Location Performed 8050 : à If Yes, Temperature Probe 8045 : Sedation 8060 : O Minimal Sedation/Anxiolysis O Moderate Sedation/Analgesia (Conscious Sedation) Current Ablation Strategy(s) 8100 :,,,, O Deep Sedation/Analgesia O General Anesthesia à If Current Ablation Strategy 8100 is PVI Ablation Strategy : Assessed with circumferential vein catheter 8120 : Number of veins present 8125 : O One O Two O Three O Four O Five O Six Number of veins targeted 8130 : O One O Two O Three O Four O Five O Six Number of veins isolated 8135 : O One O Two O Three O Four O Five O Six Isolation Confirmation 8140 : O Entrance Block O Exit Block O Bidirectional Block Adjunctive Ablation Lesions 8150 : à If Yes, Location 8155 : (Select all that apply) SVC Coronary Sinus Ligament/Vein of Marshall CTI Atypical Atrial Flutter Other Transseptal Catheterization 8170 : O Single O Double Cardioversion (CV) Performed during Procedure 8175 :, pharmacologic cardioversion, DC cardioversion Atrial Flutter/Tachycardia Present 8180 : Guidance Method(s) 8200 :,,,, RADIATION EXPOSURE Cumulative Air Kerma 8300 : Dose Area Product 8310 : O mgy O Gy O Gy-cm 2 O cgy-cm 2 O dgy-cm 2 O mgy-cm 2 O µgy-m 2 INTRAPROCEDURE ANTICOAGULATION STRATEGY Intraprocedure Anticoagulation 8400 : à If Yes, Uninterrupted Warfarin Therapy 8405 : à If Yes, Heparin 8410 : à If Yes, Initial Administration 8415 : O Pre-transseptal O Post-transseptal à If Yes, Bivalirudin 8420 : à If Yes, Other 8425 : Catheter Manipulation 8450 :(Select all that apply) Manual Magnetic Robotic DEVICE(S) USED Device ID 8465, UDI 8470 :, 2014, American College of Cardiology Foundation 26-Mar-2015 Page 4 of 5

5 H. INTRA OR POST-PROCEDURE EVENTS (COMPLETE FOR EACH LAB VISIT) CARDIOVASCULAR EVENTS NEUROLOGIC EVENTS Air Embolism 9000 : Phrenic Nerve Damage 9085 : Bradycardia Adverse Events 9005 : à If Yes, Confirmed By 9090 : O Chest X-ray O Fluoroscopy à If Yes, Req Permanent Pacemaker 9010 : Peripheral Nerve Injury 9095 : Cardiac Arrest 9015 : Cardiac Thromboembolic Event 9020 : Heart Failure 9025 : Heart Valve Damage 9030 : LA Thrombus 9035 : Stroke 9100 : à If Yes, Modified Rankin Score 9105 : Not Administered 9110 O 0: No symptoms at all O 1: No sig disability despite symptoms O 2: Slight disability O 3: Moderate disability O 4: Mod severe disability O 5: Severe disability O 6: Death Myocardial Infarction 9040 : TIA 9115 : Pericardial Effusion Resulting in Cardiac Tamponade 9045 : PERIPHERAL VASCULAR EVENTS Pericardial Effusion Req Intervention 9050 : Access Site Bleeding Req Transfusion 9120 : GENERAL EVENTS Arterial Thrombosis 9125 : Anaphylaxis 9055 : A-V Fistula Requiring Intervention 9130 : Hemorrhage 9060 : (non access site) Deep Vein Thrombosis 9135 : Sepsis 9065 : Hematoma (Req re-op, evacuation or transfusion) 9140 : GENITOURINARY EVENTS Pseudoaneurysm Requiring Intervention 9145 : Acute Renal Failure 9070 : GASTROINTESTINAL EVENTS Urinary Bleeding 9075 : GI Hypomotility 9080 : PULMONARY EVENTS Hemothorax 9150 : Pneumothorax 9170 : à If Yes, Req Drainage 9155 : à If Yes, Req Drainage 9175 : Respiratory Failure 9160 : (post-procedure) Pneumonia 9180 : Pleural Effusion 9165 : Pulmonary Embolism 9185 : Pulmonary Vein Damage/Dissection 9190 : I. DISCHARGE Atrial Rhythm : (Select all that apply) Discharge Date : Discharge Status : O Alive O Deceased à If Alive, Discharge Location : O Home O Skilled Nursing facility O Extended care/tcu/rehab O Other O Other acute care hospital O Left against medical advice (AMA) à If Alive, Hospice Care : Sinus Afib Atrial tach Aflutter Sinus arrest Atrial paced Not Documented à If Deceased, Death During the Procedure : à If Deceased, Cause of Death : O Acute myocardial infarction O Pulmonary O Hemorrhage O Sudden cardiac death O Renal n-cardiovascular procedure or surgery O Heart failure O Gastrointestinal O Trauma O Stroke O Hepatobiliary O Suicide O Cardiovascular procedure O Pancreatic O Neurological O Cardiovascular hemorrhage O Infection O Malignancy O Other cardiovascular reason O Inflammatory/Immunologic O Other non-cardiovascular reason 2014, American College of Cardiology Foundation 26-Mar-2015 Page 5 of 5