5a.i. Center Code. Patient Initials. Is patient under the age of 18 at the time of listing? Was informed consent and HIPAA Authorization obtained?

Transcription

1 PHTS - Screening Log Page 1 of 1 Screening Log Print this Form t Started Center Code 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. 2 Was informed consent and HIPAA Authorization obtained? /my center has a waiver 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. 4 Is this the patient s first listing for a heart transplant? 5 Is this a Japanese-American transfer patient? 5a Are they coming from Japan or rth America? Japan rth America 5a.i Enter patient ID from rth American Hospital 2017 PHTS [PHTS]

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3 PHTS - Demographics Page 1 of 3 Demographics Print this Form t Started 1 Date of Birth 2 Sex Female Male 3 Race Check all that apply. African-American or Black American Indian or Alaskan Native Asian Hawaiian or other Pacific Islander /Undisclosed White 4 Hispanic or Latino if of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture of origin, regardless of race. 5 Primary Etiology Cardiac Tumor Cardiomyopathy Congenital Heart Disease Myocarditis 5a Cardiomyopathy ARVD/C Dilated Hypertrophic MIXED Restrictive 5a.i Cardiomyopathy: Dilated Chemotherapy-Induced Conduction Defect Familial Ischemic Isolated/Idiopathic LVNC Metabolic/Syndromic/Mitochondrial Neuromuscular s/p Myocarditis

4 PHTS - Demographics Page 2 of 3 5a.i.1 Cardiomyopathy: Dilated, Ischemic ALCAPA Kawasaki 5a.ii Cardiomyopathy: Hypertrophic Familial Isolated/Idiopathic Metabolic/Syndromic/Mitochondrial Neuromuscular 5a.iii Cardiomyopathy: Restrictive Chemotherapy-Induced Isolated/Idiopathic LVNC Metabolic/Syndromic/Mitochondrial s/p Radiation 5b Congenital Heart Disease ASD/VSD Complete AV Septal Defect/AV Canal Cong. Corrected Trans. (I-TGA) (CC-TGA) Coronary Anomaly Double Inlet Left Ventricle Ebstein's Anomaly Hypoplastic Left Heart Hypoplastic Right Heart Left Heart Valve/Structural Hypoplasia Left Ventricular Outflow Tract Obstruction additional diagnosis other than Single Ventricle PAPVR Pulmonary Atresia with IVS Right Heart Valve/Structural Hypoplasia TAPVR TOF/TOF Variant/DORV/RVOTO Transposition of the Great Arteries (d-tga) Tricuspid Atresia Truncus Arteriosus

5 PHTS - Demographics Page 3 of 3 5b.i Single Ventricle 6 5b.ii If pulmonary atresia with IVS, RV dependent coronary circulation Blood Type A AB B O 6a Blood A Subtype A1 A2 7 Rh Negative Positive 2017 PHTS [PHTS]

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7 PHTS - Form 1: Listing Page 1 of 15 Patient Details Hidden Show Show/Hide Annotations Stickies: Toggle All Toggle Open Toggle Resolved Form 1: Listing Print this Form t Started 1 Listing Date Height and Weight 2 Height Centimeters Inches Calculated BSA: n/a BMI: n/a 3 Weight Kilograms Pounds 4 Main reason for listing Select only one primary reason for listing. CHD too high risk for palliative surgical options Growth failure due to the heart disease Hypercyanosis without further palliative surgical options Malignant arrhythmia Medically refractory heart failure Plastic bronchitis Progressive liver disease Progressive pulmonary hypertension Protein losing enteropathy 4a Medically refractory heart failure Both Diastolic Failure Systolic Failure Surgeries Prior to Listing 5 Did the patient have any cardiac surgery prior to listing?

8 PHTS - Form 1: Listing Page 2 of 15 Surgery Details 5 If Congenital cardiac surgery, specify surgery: AP Shunt (including BT Shunt, Modified BT Shunt, Waterson Shunt, Pott's Shunt, Central Shunt, and MEE procedure) Arterial switch operation ASD Repair Atrial switch (Senning/Mustard) CABG Complete AV Septal Defect Repair Congenitally Corrected Transposition Repair (classic) Congenitally Corrected Transposition Repair (double switch) Damus Kaye Stansel (DKS) d-transposition of the Great Vessels Repair Ebstein's Anomaly Repair Fontan Procedure Glenn Procedure Hybrid Palliation rwood Stage I: BT Shunt rwood Stage I: Sano/RV-PA conduit PA Banding TOF/DORV/RVOTO Repair Truncus Arteriosus Repair Valve Replacement VSD Repair 5 Date of Surgery 5 5 Congenital cardiac surgery, d- Transposition of the Great Vessels Repair Congenital cardiac surgery, Valve Replacement Arterial Switch Operation Atrial Switch (Senning/Mustard) Aortic Valve Replacement Mitral Valve Replacement Pulmonary Valve Replacement Tricuspid Valve Replacement 5 5 Homograft Tissue in Aortic Valve Replacement? Pulmonary valve replacement?

9 PHTS - Form 1: Listing Page 3 of 15 Status Details at Listing 6a 6a.i Status at Listing Brazil Brazil Canada United Kingdom United States n-priority Priority 6a.ii Canada S 6a.iii United Kingdom Routine Urgent 6a.iv Status at Listing, US 1 (this option is only for listings prior to 1999) 1A 1B 2 7 6b Was patient in or out of hospital at time of listing? In hospital Out of hospital 6b.i 6b.ii Was patient in the ICU at time of listing? Did the patient require continuous invasive mechanical ventilation? Did the patient require continuous 6c inotropes at time of listing? 6c.i Inotropes Dose Dose High Dose or Multiple IV Single Low Dose

10 PHTS - Form 1: Listing Page 4 of 15 6d 6e 6f Did the patient have ductal dependent pulmonary or systemic circulation, with ductal patency maintained by stent or prostaglandin infusion? Was patient listed for ABO Incompatible? Was patient on a VAD or ECMO at time of listing? VAD ECMO t on support at time of listing 6f.i Specify initiation date (VAD) Missing Reason: 6f.ii Specify initiation date (ECMO) 6g Was patient listed for DCD (Donation after Cardiac Death) organ? This is not current practice at our center t Applicable Infectious Disease Screening 7a 7b 7c 7d 7e 7f 7g 7h 7i HIV Serology AIDS testing Negative Positive CMV Serology Negative Positive CMV PCR Negative Positive EBV Serology Negative Positive EBV PCR Negative Positive IFA Toxo Toxoplasma testing HBs Ag Hepatitis B surface antigen HB core Ab Hepatitis B core antibody HBs Ab Hepatitis B surface antibody Negative Positive Negative Positive Negative Positive Negative Positive

11 PHTS - Form 1: Listing Page 5 of 15 7j 7k Hep C Ab Hepatitis C antibody RPR/Syphilis Syphilis testing Negative Positive Negative Positive Medical History at time of Listing 8 Medical History 8a Type of medical history at Listing Arrythmia Cardiac Arrest/CPR Diabetes GI/Nutrition Heterotaxy/Isomerism Malignancy Metabolic/Disorder Mitochondrial Disorder Neurologic Pacemaker Peripheral Myopathy/Neuromuscular disease Prenatal Diagnosis Prior Transfusions Renal Insufficiency Respiratory Shock Syndrome 8a.i Arrhythmia Afib/flutter Complete heart block V Fibrillation V Tachycardia 8a.ii 8a.iii 8a.iii Cardiac arrest/cpr Date Diabetes, Date of last Hgb A1c Diabetes, Value of last Hgb

12 PHTS - Form 1: Listing Page 6 of 15 A1c 8a.iii 8a.iv Diabetes, Treating with insulin Medical History, GI/Nutrition Failure to thrive/cachexia Fontan associated liver disease Infectious hepatitis Protein losing Enteropathy 8a.iv.1 GI/Nutrition, Infectious hepatitis type A B C 8a.v Medical History, Heterotaxy/Isomerism Asplenia Polysplenia Unspecified 8a.vi Medical History, Malignancy Lymphoma, leukemia s/p BMT s/p Chest Radiation Solid organ cancer 8a.vii Specify Metabolic Disorder 8a.viii Medical History, Mitochondrial Disorder, specify Barth's Unspecified 8a.ix Medical History, Neurologic Anoxic brain injury Hemorrhagic and/or thromboembolic stroke

13 PHTS - Form 1: Listing Page 7 of 15 8a.ix.1 Neurologic, Anoxic brain injury Last Date 8a.ix.2 Neurologic, Hemorrhagic and/or thromboembolic stroke Date Last 8a.x Pacemaker Defibrilliator/AICD Pacemaker, CRT/biventricular pacing Pacemaker, not CRT and not ICD 8a.x.1 Pacemaker, Defibrillator/AICD Date Placed 8a.x.2 Pacemaker, CRT/biventricular pacing, Date Placed 8a.x.3 Pacemaker, not CRT and not ICD, Date Placed 8a.xi Medical History, Peripheral myopathy/neuromuscular disease Becker MuscularDystrophy Duschenne Muscular Dystrophy Freidrich's Ataxia Unspecified 8a.xii History Dialysis Dialysis, acute (within past 30 days) Dialysis, chronic (>1 month duration) Dysfunction, not dialysis 8a.xiii Medical History, Respiratory Asthma Plastic Bronchitis

14 PHTS - Form 1: Listing Page 8 of 15 Tracheostomy 8a.xiv Shock, Date of last appropriate Shock 8a.xv Medical History, Syndrome Cardiofaciocutaneous Syndrome Costello Syndrome Digeorge (22q11 deletion) Down's/Trisomy 21 Ehlers-Danlos Syndrome LEOPARD/Multiple Lentigenes Loeys-Dietz Syndrome Marfan Syndrome onan Syndrome Other Marfan-like Syndrome Turner Syndrome Unspecified Williams Syndrome Insurance 9 Primary Insurance Charitable Donation Free Government Private Self Pay Other, Specify 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 cost of the hospitalization Government Other US or state government insurance. For Example, Medicaid, Medicare, CHIP (Children s Health Insurance Program), Department of 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 cost of the hospitalization. Other For example, funds from a foreign government. Specify foreign country in the space provided.

15 PHTS - Form 1: Listing Page 9 of 15 Percent or Panel Reactive Antibody (closest to listing) 10a Cytotoxic PRA ie. Serum is tested against panel of lymphocytes Done 10a.i 10a.ii T Cell % B Cell % 10a.iii Date (Cytotoxic PRA) Missing Reason: 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. Done 10b.i 10b.ii T Cell % B Cell % 10b.iii Date (Cytotoxic PRA, DTE/DTT) 10c Flow Cytometry or Luminex PRA Done 10c.i 10c.ii Class I % Class II % 10c.iii Date 10d Listed for prospective crossmatch Prospective Crossmatch 10d.i Results Donor Cells Donor Cells and Virtual

16 PHTS - Form 1: Listing Page 10 of 15 Virtual 10d.i.1 Virtual Crossmatch Avoidance of donor antigens to all antibodies present Avoidance of donor antigens to antibodies above pre-specified threshold Avoidance of donor antigens to C1q fixing antibodies only Hemodynamics Prior to Listing Indicate the hemodynamics even if the patient is on pressors or inotropes. Best hemodynamics are those performed during the administration of agents given specifically to lower the pulmonary arterial pressure or the pulmonary vascular resistance. All pressures should be listed in mmhg. If unclear, please consult with your PI. 11 Were hemodynamics done prior to listing? 11a Date 11b Fontan Mean Pressure 11c RAm (RAP or CVP) Right Atrial Mean Pressure 11d PAm Pulmonary Artery Mean 11e PCW Mean Pulmonary Capillary Wedge Pressure 11f SVC Sat Oxygen Saturation in the SVC 11g AO Sat Aortic Saturation 11h Rp, PVRI Pulmonary resistance indexed to body surface area (BSA) Woods Units x m 2 wu x m 2 wu x m 2

17 PHTS - Form 1: Listing Page 11 of 15 11i Rs, SVRI Systemic resistance indexed to body surface area (BSA) Woods Units x m 2 11j EDP End diastolic pressure of systemic ventricle 11k C.O. Cardiac output (i.e. Qs) in L/min L/min 11l C.I. L/min/m 2 Cardiac index (i.e. C.O. divided by m 2 ) in L/min/m 2 11m Was patient on mechanical support at time of Hemodynamics 11n Hemodynamic Agents Used 11n.i Indicate agent for best hemodynamics 100% O2 Dobutamine Dopamine Epinephrine Isoproterenol (Isuprel) Milrinone (Primacor) Nesiritide Nitric Oxide Nitroglycerin Nitroprusside (Nipride) repinephrine PGE (Alprostadil) PGI (Flolan) Phenylephrine/ Neosynephrine Sildenafil Vasopressin Schooling 12 Is the patient in school? t Applicable, <6 years

18 PHTS - Form 1: Listing Page 12 of 15 12a 12b Are they at the age appropiate level Are they in a special education class Exercise Test 13 Was exercise test performed? t Routinely Done 13a If exercise test not performed, specify reason Age inappropriate Too sick 13b Max VO 2% 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) % 13c Max VO 2 Maximum oxygen consumption ml/kg/min 13d 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. Laboratory Values closest to time of this report te: labs may have been collected on different dates. 14a 14b Total Bilirubin mg/dl Direct Bilirubin mg/dl

19 PHTS - Form 1: Listing Page 13 of 15 14c AST Aspartate transaminase (also SGOT) U/L 14d ALT Alanine transaminase (also SGPT) U/L 14e BNP B-type natriuretic peptide pg/ml or ng/l 14f Pro BNP Pro NT B-type natriuretic peptide pg/ml or ng/l 14g CRP C reactive protein mg/dl 14h Creatinine mg/dl 14i BUN Blood urea nitrogen mg/dl 14j 14k 14l 14m Cystatin C mg/l Total Protein g/dl Pre Albumin mg/dl Serum Albumin g/dl 14n Cholesterol Total Cholesterol mg/dl 14o TG Triglycerides mg/dl

20 PHTS - Form 1: Listing Page 14 of 15 14p LDL Low density lipoprotein mg/dl 14q HDL High density lipoprotein mg/dl 14r VLDL Very low density lipoprotein mg/dl NYHA and Ross' Heart Failure 15 NYHA Class NYHA Classes Class I: symptoms at any level of exertion and no limitation in ordinary physical activity. Class II: Mild symptoms and slight limitation during regular activity. Comfortable at rest. Class III: ticeable limitation due to symptoms, even during minimal activity. Comfortable only at rest. Class IV: Severe limitations. Experience symptoms even while at rest (sitting in a recliner or watching TV). 16 Ross' Heart Failure Class Ross Heart Failure Classes Class I: limitations or symptoms Class II: Mild tachypnea and/or diaphoresis with feeds in infants; dyspnea on exercise in older children. growth failure. Class III: Marked tachypnea and/or diaphoresis with feeds or exertion and prolonged feeding time with growth failure. Class IV: Symptomatic at rest with tachypnea, retractions, grunting or diaphoresis.

21 PHTS - Form 1: Listing Page 15 of 15 3/1/ PHTS [PHTS]

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23 PHTS - Form 1RL: Relisting Page 1 of 14 Show trials/registries Patient Details Hidden Show Show/Hide Annotations Stickies: Toggle All Toggle Open Toggle Resolved Form 1RL: Relisting Print this Form t Started 1 Date of Relisting Height and Weight 2 Height Centimeters Inches Calculated BSA: n/a BMI: n/a 3 Weight Kilograms Pounds 4 Has this patient been transplanted 4a Indicate total number of prior transplants This includes transplants that were and were not done at your hospital. 4b Date of most recent transplant 5 Main reason for Re-Listing Coronary artery disease, (infarction, arrhythmia, CHF post MI) Graft dysfunction <30 days in the absence of rejection, pulmonary hypertension or surgical complications n-specific Graft Failure (>30 days post transplant) Pulmonary Hypertension/RV Failure Rejection, acute Rejection Hyperacute (onset < 24 hours post transplant) Rejection, Acute Sudden Cardiac Death, no MI documented 6 Contributing reason for Re-Listing Coronary artery disease, (infarction, arrhythmia, CHF post MI)

24 PHTS - Form 1RL: Relisting Page 2 of 14 Graft dysfunction <30 days in the absence of rejection, pulmonary hypertension or surgical complications n-compliance n-specific graft failure (>30 days post transplant) contributing cause Pulmonary Hypertension/RV Failure Rejection, acute Rejection, hyperacute (onset < 24 hours post transplant) Sudden cardiac death, no MI documented Status Details at Re-Listing 7a 7a.i Status at Re-Listing Status at Re-Listing, Brazil n-priority Brazil Canada United Kingdom United States Priority 7a.ii 7a.iii Status at Re-Listing, Canada Status at Re-Listing, UK Routine Urgent 7a.iv Status at Re-Listing, US 1 (this option is only for listings prior to 1999) 1A 1B 2 7 7b Was patient in or out of hospital at time of listing? In hospital Out of hospital 7b.i Was patient in the ICU at time of relisting?

25 PHTS - Form 1RL: Relisting Page 3 of 14 7b.ii Did the patient require continuous invasive mechanical ventilation? Did the patient require continuous 7c inotropes at time of listing? 7c.i Inotropes does Dose High Dose or Multiple IV Single Low Dose 7d 7e 7f Did the patient have ductal dependent pulmonary or systemic circulation, with ductal patency maintained by stent or prostaglandin infusion? ABO incompatible Was patient on a VAD or ECMO at time of relisting? VAD ECMO t on support at time of Relisting 7f.i Specify initiation date (VAD) Missing Reason: 7f.ii Specify initiation date (ECMO) 7g Was patient listed for DCD (Donation after Cardiac Death) organ? This is not current practice at our center t Applicable Infectious Disease Screening 8a 8b 8c HIV Serology AIDS testing Negative Positive CMV Serology Negative Positive CMV PCR Negative Positive

26 PHTS - Form 1RL: Relisting Page 4 of 14 8d 8e 8f 8g 8h 8i 8j 8k EBV Serology Negative Positive EBV PCR Negative Positive IFA Toxo Toxoplasma testing HBs Ag Hepatitis B surface antigen HB core Ab Hepatitis B core antibody HBs Ab Hepatitis B surface antibody Hep C Ab Hepatitis C antibody RPR/Syphilis Syphilis testing Negative Positive Negative Positive Negative Positive Negative Positive Negative Positive Negative Positive Medical History at time of Re-Listing 9 9a Medical History Medical History Details Select all medical history the patient had at the time of listing. Arrhythmia (current heart only) Cardiac arrest/cpr (current heart) Diabetes GI/Nutrition Heterotaxy/Isomerism Malignancy Metabolic Disorder Mitochondrial Disorder Neurological Pacemaker (current heart) Peripheral myopathy/neuromuscular disease Prenatal Diagnosis Prior transfusions Renal insufficency Respiratory Shock (current heart) Syndrome 9a.i Arrhythmia Afib/flutter Complete heart block V Fibrilliation V Tachycardia

27 PHTS - Form 1RL: Relisting Page 5 of 14 9a.ii 9a.iii 9a.iv Date of last cardiac arrest/cpr Date of Last Hgb A1c Value of Last Hgb A1c Missing Reason: 9a.v 9a.vi Treating with Insulin GI/Nutrition Failure to thrive/cachexia Fontan associated liver disease Infectious hepatitis Protein losing Enteropathy 9a.vi.1 Hepatitis History A B C 9a.vii Heterotaxy/Isomerism Asplenia Polysplenia Situs inversus Unspecified 9a.viii Malignancy Lymphoma, leukemia s/p BMT s/p Chest Radiation Solid organ cancer 9a.ix Specify Metabolic Disorder

28 PHTS - Form 1RL: Relisting Page 6 of 14 9a.x Medical History, Mitochondrial Disorder, specify Barth's Unspecified 9a.xi Neurologic Anoxic brain injury Hemorrhagic and/or thromboembolic stroke 9a.xi.1 Anoxic Brain Injury Date 9a.xi.2 Hemorrhagic and/or Thromboembolic Stroke, Date Last 9a.xii Pacemaker Defibrillator/AICD Pacemaker, CRT/Biventricular pacing Pacemaker, not CRT and not ICD 9a.xii.1 Defibrillator/AICD, Date Placed 9a.xii.2 Pacemaker, CRT/Biventricular pacing Date placed 9a.xii.3 Pacemaker, not CRT and not ICD, Date placed 9a.xiii Peripheral myopathy/ neuromuscular disease Becker muscular dystrophy Duschenne muscular dystrophy Freidrich's ataxia Unspecified 9a.xiv Renal Insufficiency Dialysis, acute (within past 30 days) Dialysis, chronic (>1 month duration) Dysfunction, not dialysis

29 PHTS - Form 1RL: Relisting Page 7 of 14 9a.xv Respiratory Asthma Plastic Bronchitis Tracheostomy 9a.xvi Date of last appropriate Shock 9a.xvii Syndrome Cardiofaciocutaneous syndrome Costello syndrome DiGeorge (22q11 deletion) Down's/Trisomy 21 Ehlers-Danlos Syndrome LEOPARD/Multiple Lentigenes Loeys-Dietz Syndrome Marfan Syndrome onan syndrome Other Marfan-like syndrome Turner Syndrome Unspecified Williams syndrome Insurance 10 Primary Insurance Charitable Donation Free Government Private Self Pay 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 cost of the hospitalization Government Other US or state government insurance. For Example, Medicaid, Medicare, CHIP (Children s Health Insurance Program), Department of VA refers to funds from the Veterans Administration or others. Private Refers to funds from agencies such as Blue Cross/Blue Shield, etc.

30 PHTS - Form 1RL: Relisting Page 8 of 14 Self Pay Indicates that the recipient will pay for the largest portion of the cost of the hospitalization. Other For example, funds from a foreign government. Specify foreign country in the space provided. Percent or Panel Reactive Antibody (closest to relisting) 11a Cytotoxic PRA ie. Serum is tested against panel of lymphocytes Done 11a.i 11a.ii T Cell % B Cell % 11a.iii Date (Cytotoxic PRA) Missing Reason: 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. Done 11b.i 11b.ii T Cell % B Cell % 11b.iii Date (Cytotoxic PRA, DTE/DTT) 11c Flow Cytometry or Luminex PRA Done 11c.i 11c.ii Class I % Class II % 11c.iii Date

31 PHTS - Form 1RL: Relisting Page 9 of 14 11d Re-listed for prospective crossmatch Prospective Crossmatch 11d.i Type Donor Cells Donor Cells and Virtual Virtual 11d.i.1 Virtual Crossmatch Avoidance of donor antigens to all antibodies present Avoidance of donor antigens to antibodies above pre-specified threshold Avoidance of donor antigens to C1q fixing antibodies only Hemodynamics Prior to Re-Listing Indicate the hemodynamics even if the patient is on pressors or inotropes. Best hemodynamics are those performed during the administration of agents given specifically to lower the pulmonary arterial pressure or the pulmonary vascular resistance. All pressures should be listed in mmhg. If unclear, please consult with your PI. 12 Were hemodynamics done prior to relisting? 12a 12b 12c 12d 12e 12f 12g Date Fontan Mean Pressure RAm (RAP or CVP) Right Atrial Mean Pressure PAm Pulmonary Artery Mean PCW Mean Pulmonary Capillary Wedge Pressure SVC Sat Oxygen Saturation in the SVC AO Sat Aortic Saturation

32 PHTS - Form 1RL: Relisting Page 10 of 14 12h Rp, PVRI Pulmonary resistance indexed to body surface area (BSA) Woods Units x m 2 wu x m 2 12i Rs, SVRI Systemic resistance indexed to body surface area (BSA) Woods Units x m 2 wu x m 2 12j EDP End diastolic pressure of systemic ventricle 12k C.O. Cardiac output (i.e. Qs) in L/min L/min 12l C.I. L/min/m 2 Cardiac index (i.e. C.O. divided by m 2 ) in L/min/m 2 12m Was patient on mechanical support at time of Hemodynamics 12n Hemodynamic Agents 12n.i Indicate agent for best hemodynamics 100% O2 Dobutamine Dopamine Epinephrine Isuproterenol (Isuprel) Milrinone (Primacor) Nesiritide Nitric Oxide Nitroglycerin Nitroprusside (Nipride) repinephrine PGE (Alprostadil) PGI (Flolan) Phenylephrine/ Neosynephrine Sildenafil Vasopressin Schooling

33 PHTS - Form 1RL: Relisting Page 11 of a 13b Is patient in school? Are they at the age appropiate level Are they in a special education class t Applicable Exercise Test 14 Was exercise test performed? t Routinely Done 14a If test no, specify reason Age Inappropriate Too Sick 14b Max VO 2% 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) % 14c 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. 14d Max VO 2 Maximum oxygen consumption ml/kg/min Laboratory Values closest to time of this report te: labs may have been collected on different dates. Total Bilirubin mg/dl

34 PHTS - Form 1RL: Relisting Page 12 of 14 15a 15b Direct Bilirubin mg/dl 15c AST Aspartate transaminase (also SGOT) U/L 15d ALT Alanine transaminase (also SGPT) U/L 15e BNP B-type natriuretic peptide pg/ml or ng/l 15f Pro BNP Pro NT B-type natriuretic peptide pg/ml or ng/l 15g CRP C reactive protein mg/dl 15h Creatinine mg/dl 15i BUN Blood urea nitrogen mg/dl 15j 15k 15l 15m Cystatin C mg/l Total Protein g/dl Pre Albumin mg/dl Serum Albumin g/dl

35 PHTS - Form 1RL: Relisting Page 13 of 14 15n Cholesterol Total Cholesterol mg/dl 15o TG Triglycerides mg/dl 15p LDL Low density lipoprotein mg/dl 15q HDL High density lipoprotein mg/dl 15r VLDL Very low density lipoprotein mg/dl NYHA and Ross' Heart Failure 16 NYHA Class NYHA Classes Class I: symptoms at any level of exertion and no limitation in ordinary physical activity. Class II: Mild symptoms and slight limitation during regular activity. Comfortable at rest. Class III: ticeable limitation due to symptoms, even during minimal activity. Comfortable only at rest. Class IV: Severe limitations. Experience symptoms even while at rest (sitting in a recliner or watching TV). 17 Ross Heart Failure Class Ross Heart Failure Classes Class I: limitations or symptoms Class II: Mild tachypnea and/or diaphoresis with feeds in infants; dyspnea on exercise in older children. growth failure. Class III: Marked tachypnea and/or diaphoresis with feeds or exertion and prolonged feeding time with growth failure. Class IV: Symptomatic at rest with tachypnea, retractions, grunting or diaphoresis.

36 PHTS - Form 1RL: Relisting Page 14 of PHTS [PHTS]

37 PHTS - Form 1T: Transplant Page 1 of 10 10/24/2017 Patient Details Hidden Show Show/Hide Annotations Stickies: Toggle All Toggle Open Toggle Resolved Form 1T: Transplant Print this Form t Started 1 Date of Transplant 2 Simultaneous organ Check all that apply. Kidney Liver ne 3 Type of Transplant Orthotopic: recipient heart is replaced by donor heart. Heterotopic: donor heart is transplant into recipient without the removal of the recipient s heart (also called piggy-back transplant) Heterotopic Orthotopic Height and Weight 4 Height Centimeters Inches Calculated BSA: n/a BMI: n/a 5 Weight Kilograms Pounds Status Details at Transplant 6a Status at Transplant Brazil Canada United Kingdom United States 6a.iv United States 1 (this option is only for listings prior to 1999) 1A 1B 2 7 6a.i Brazil n Priority Priority

38 PHTS - Form 1T: Transplant Page 2 of 10 10/24/2017 6a.ii Canada S 6a.iii United Kingdon Routine Urgent 6b Was patient in or out of hospital at time of transplant? In hospital Out of hospital 6b.i 6b.ii Was patient in the ICU at time of transplant? Did the patient require continuous invasive mechanical ventilation? Did the patient require continuous 6c inotropes at time of transplant? 6c.i Inotropes Dose High Dose or Multiple IV Single Low Dose 6d Did the patient have ductal dependent pulmonary or systemic circulation, with ductal patency maintained by stent or prostaglandin infusion? 6e Was the patient transplanted with an ABO incompatible transplant? 6f Was patient on a VAD or ECMO at time of transplant? VAD ECMO t on support at time of Transplant 6f.i Specify initiation date (VAD) Missing Reason:

39 PHTS - Form 1T: Transplant Page 3 of 10 10/24/2017 6f.ii Specify initiation date (ECMO) 6g Was patient listed for DCD (Donation after Cardiac Death) organ? This is not current practice at our center t Applicable Percent or Panel Antibody (closest to Transplant) 7a Cytotoxic PRA Done 7a 7a T Cell Values above 10 will require section 10: Per-operative management for PRA to be completed. B Cell Values above 10 will require section 10: Per-operative management for PRA to be completed. % % 7a.iii Date 7b Cytotoxic PRA DTE/DTT Done 7b 7b T Cell Values above 10 will require section 10: Per-operative management for PRA to be completed. B Cell Values above 10 will require section 10: Per-operative management for PRA to be completed. % % 7b.iii Date 7c Flow Cytometry or Luminex PRA Done 7c 7c Class I Values above 10 will require section 10: Per-operative management for PRA to be completed.

40 PHTS - Form 1T: Transplant Page 4 of 10 10/24/2017 Class II Values above 10 will require section 10: Per-operative management for PRA to be completed. 7c.ii Date 8 Did this patient have a virtual crossmatch? 8a Crossmatch Results Negative Positive 9 Donor Specific or Retrospective Crossmatch performed? 9a 9b Crossmatch Results Was the crossmatch performed prior to the decision to accept the donor? Negative Positive 10a Did the patient receive treatment to lower or manage an elevated PRA while awaiting transplantation? 10a.i Which therapy was administered? Check all that apply. Azathioprine (Imuran) Bortezomib (Velcade) Cytoxan (cyclophosphamide) Immunoglobulin (IVIG, IV IgG) Mycophenylate, MMF (Cellcept, Myfortic) Plasmapheresis/plasma exchange Rituximab (Rituxan) 10a.ii How long was therapy administered? Check all that apply. Only for a pre-specified time/number of treatments: specify

41 PHTS - Form 1T: Transplant Page 5 of 10 10/24/2017 Until Heart transplantation, regardless of subsequent PRA levels/sensitization profile Until PRA level reduced to 0%/patient no longer sensitized Until PRA/sensitization profile diminished to a prespecified goal 10b Was prophylactic plasmapheresis/ exchange performed in the peri-operative period 10b.i 10b.ii Was this performed during cardiopulmonary bypass? Was this performed during the immediate postoperative period? 10b.ii.1 How many cycles? Were there additional therapies, 10c not routinely administered to post transplant patients in your center, given to this patient? 10c.i Therapies administered Check all that apply. Alemtuzumab (Campath) Azathioprine (Imuran) Basiliximab (Simulect) Bortezomib (Velcade) Cytoxan (cyclophosphamide) Eculizumab (Soliris) Immunoglobulin (IVIG, IV IgG) MMF (Cellcept, Myfortic) Plasmapheresis/plasma exchange Rituximab (Rituxan) Steroids (methylprednisone, prednisone, orapred, prednisolone, solumederol, Medrol, etc.) B Cell and T Cell Results 11a B cell flow DSXM Negative Positive

42 PHTS - Form 1T: Transplant Page 6 of 10 10/24/ b B cell CDC/cytotoxicity DSXM Negative Positive 11c T cell flow DSXM Negative Positive 11d T cell CDC/cytotoxicity DSXM Negative Positive 12 Donor Specific Antigens (DSA) 12a 12b Donor Specific Antigens (DSA) Results Was DSA compliment fixing? (i.e. positive C1q assay) Class I Class II Labaratory Values (closest to time of transplant) te: labs may have been collected on different dates. 13a 13b Total Bilirubin mg/dl Direct Bilirubin mg/dl 13c AST Aspartate transaminase (also SGOT) U/L 13d ALT Alanine transaminase (also SGPT) U/L 13e BNP B-type natriuretic peptide pg/ml or ng/l 13f Pro BNP Pro NT B-type natriuretic peptide pg/ml or ng/l 13g CRP C reactive protein mg/dl

43 PHTS - Form 1T: Transplant Page 7 of 10 10/24/ h Creatinine mg/dl 13i BUN Blood urea nitrogen mg/dl 13j 13k 13l 13m Cystatin C mg/l Total Protein g/dl Pre Albumin mg/dl Serum Albumin g/dl 13n Cholesterol Total Cholesterol mg/dl 13o TG Triglycerides mg/dl 13p LDL Low density lipoprotein mg/dl 13q HDL High density lipoprotein mg/dl 13r VLDL Very low density lipoprotein mg/dl Hemodynamics (closest to transplant) Indicate the hemodynamics even if the patient is on pressors or inotropes. Best hemodynamics are those performed during the administration of agents given specifically to lower the pulmonary arterial pressure or the pulmonary vascular resistance. All pressures should be listed in mm Hg. If unclear, please confirm with your PI. 14 Hemodynamics

44 PHTS - Form 1T: Transplant Page 8 of 10 10/24/ a Date 14b Fontan Mean Pressure 14c RAm (RAP or CVP) Right atrial mean pressure 14d PAm Pulmonary artery mean 14e PCW Mean pulmonary capillary wedge pressure 14f SVC Sat Oxygen saturation in the SVC 14g AO Sat Aortic saturation 14h Rp, PVRI Pulmonary resistance indexed to body surface area (BSA) Woods Units x m 2 14i Rs, SVRI Systemic resistance indexed to body surface area (BSA) Woods Units x m 2 14j EDP End diastolic pressure of systemic ventricle 14k C.O. Cardiac output (i.e. Qs) in L/min L/min 14l C.I. L/min/m 2 Cardiac index (i.e. C.O. divided by m 2 ) in L/min/m 2 14m Hemodynamic Agents 100% O2

45 PHTS - Form 1T: Transplant Page 9 of 10 10/24/ m.i Indicate agent for best hemodynamics Check all that apply. Dobutamine Dopamine Epinephrine Isoproterenol (Isuprel) Milrinone Nesiritide Nitric Oxide Nitroglycerine Nitroprusside (Nipride) repinephrine PGE (Alprostadil) PGI (Flolan) Phenylephrine/Neosynephrine Sildenafil Vasopressin Was patient on mechanical 14n support at time of Hemodynamics? Inotropes, Pressors, and Thyroid Hormones 15 Was recipient on inotropes, pressors, or thyroid hormones at time of transplant? Inotropes, Pressors, or Thyroid 15a Hormones 100% O2 Dobutamine Dopamine Epinephrine Isoproterenol (Isuprel) Milrinone Neosynephrine Nesiritide Nitric Oxide Nitroglycerine Nitroprusside (Nipride) repinephrine (Levophed) PGE (Alprostadil) PGI (Flolan) Phenylephrine/Neosynephrine Sildenafil T3 (Tri-iodothyronine) T4 (Levothyroxine) Vasopressin

46 PHTS - Form 1T: Transplant Page 10 of 10 10/24/2017 Cardiopulmonary bypass, donor ischemic, and technique of transplant 16 Cardiopulmonary bypass time Report total number in minutes minutes 17 Total donor ischemic time Report minutes from recovery crossclamp to removal of crosscramp after transplant minutes 18 Technique of transplant Atrial Bicaval 2017 PHTS [PHTS]

47 PHTS - Form 2: Donor Page 1 of 5 10/25/2017 Patient Details Hidden Show Show/Hide Annotations Stickies: Toggle All Toggle Open Toggle Resolved Form 2: Donor Print this Form t Started Transplant Date 1 Donor Age Indicate age in months, days, or years Days Months Years 2 Donor Date of Birth Height and Weight 3 Donor Height Centimeters Inches Calculated BSA: n/a BMI: n/a 4 Donor Weight Kilograms Pounds 5 Donor Sex Female Male 6 Donor Race Check all that apply. American Indian or Alaskan Native Asian Black Pacific Islander White 7 Hispanic or Latino if of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture of origin, regardless of race. 8a Donor Date of Death

48 PHTS - Form 2: Donor Page 2 of 5 10/25/2017 8b Donor Cause of Death Check only one. Anoxia Cerebrovascular CNS Tumor Head Trauma 8c Donor Mechanism of death Check only one. Asphyxiation Blunt Injury Cardiovascular CNS Infection Drowning Drug Intoxication Electrical Gunshot Wound Seizure Stab Sudden Infant Death 8d Donor Circumstances of death Alleged Child Abuse Alleged Homicide Alleged Suicide Motor Vehicle Accident n-motor Vehicle Accident 9 Donor Downtime Previously called "Duration of Cardiac Arrest". 9a Duration of Donor Downtime Previously called "Duration of Cardiac Arrest". Enter duration in minutes. 10 Chest Compressions (CPR) 10a If yes, CPR Time Enter duration in minutes minutes 11 Donor Blood Type A AB

49 PHTS - Form 2: Donor Page 3 of 5 10/25/2017 B O 11a Blood type A subtype A1 A2 12 Donor Rh Negative Positive 13 Donor Past Medical History Check all that are known. Cancer at time of procurement Diabetes History of Cancer Hypertension Infection, specify Mitral Valve Prolapse ne 13a If donor had diabetes, was patient on insulin? Cancer at Time of Procurement, Location Cancer Type/Location 14 Did the donor have an increased risk for HIV, HBV, HCV? 14a If yes, specify increased risk. At risk medical history (i.e. hemodialysis, new diagnosis of or treatment for STD in past 12 months) At risk social history (specify) Hemodiluted sample 14a.i If at risk social history, specify. Check all that apply Incarceration Injected Drug Use Mother with HIV Sexual exposure

50 PHTS - Form 2: Donor Page 4 of 5 10/25/2017 Pre-transplant Donor Echocardiogram 15 Pre-Transplant Donor Echocardiogram (closest to time of procurement) 15a Result of Donor Echocardiogram Abnormal rmal 15a.i If abnormal, please specify Check all that apply. Abnormal Septal Motion Diffuse Wall Motion Abnormality Focal Wall Motion Abnormality Mitral Regurgitation Tricuspid Regurgitation 15b 15c Donor Fractional Shortening Missing Donor Estimated LV Eject Fraction Reason: Pre-transplant Donor Angiogram 16 Pre-transplant Donor Angiogram 16a Angiogram results Abnormal, Specify rmal Donor Serologies 17a 17b 17c HIV Serology AIDS testing CMV IgG Cytomegalovirus testing IFA Toxo Toxoplasma testing Negative Positive Negative Positive Negative Positive

51 PHTS - Form 2: Donor Page 5 of 5 10/25/ d 17e 17f 17g 17h 17i EBV IgG Epstein Barr Virus RPR/Syphilis Syphillis testing HBs Ag Hepatitis B surface antigen HB core Ab Hepatitis B core antibody HBs Ab Hepatitis B surface antibody Hep C ab Hepatitis C antibody Negative Positive Negative Positive Negative Positive Negative Positive Negative Positive Negative Positive Donor on Inotropes, Pressors, or Thyroid Hormones at time of recovery/harvest? 18a 18b 18c 18d 18e 18f 18g 18h 18i 18j Tri-iodothyronine (Thyroid hormone) Levothyroxine (Thyroid hormone) T3 T4 Epinephrine Adrenaline (Inotrope, pressor) Dopamine (Inotrope) Dobutamine Dobutrex (Inotrope) Vasopressin Pitressin (Pituitary hormone) Levophed repinephrine (Inotrope, Pressor) Milrinone Primacor (Inotrope) Neosynephrine Phenylephrine (Pressor) Other 18j Please specify 2017 PHTS [PHTS]

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53 PHTS - Form 3: Initial Immunosuppression Page 1 of 6 10/25/2017 Patient Details Hidden Show Show/Hide Annotations Stickies: Toggle All Toggle Open Toggle Resolved Form 3: Initial Immunosuppression Print this Form t Started Transplant Date Induction Therapy Induction Therapy is defined as the prescribed use of lymphocyte cytolytic antibody or IL2-R antagonist therapy (e.g., ATGAM, Thymoglobulin, Basiliximab, Daclizumab) given soon after transplant (started within 3 days), not used to specifically treat a known or suspected rejection episode). The use of non-cytolytic agents pre or intraoperatively is not considered to be induction therapy. 1 Is Patient on Induction Therapy Induction Agents Induction Agent Details 1a Induction Immunosuppression Agent Alemtuzumab (Campath) Basiliximab (Simulect) Bortezomib (Velcade) Daclizumab (Zenapax) OKT3 Rituximab (Rituxan) Thymoglobulin (ATG) 1b 1c Start Date End Date 2 Azathioprine (Imuran)

54 PHTS - Form 3: Initial Immunosuppression Page 2 of 6 10/25/2017 2a Specify date of first post-op dose 2b Was patient on medication at 30 days? 2b.i If patient is no longer on medication at 30 days, specify stop date. 3 Cyclosporine 3a Specify date of first post-op dose 3b Was patient on medication at 30 days? 3b.i If patient is no longer on medication at 30 days, specify stop date. 4 Mycophenolate (Cellcept, Myfortic) 4a Specify date of first post-op dose 4b Was patient on medication at 30 days? 4b.i If patient is no longer on medication at 30 days, specify stop date.

55 PHTS - Form 3: Initial Immunosuppression Page 3 of 6 10/25/ Sirolimus (Rapamycin) 5a Specify date of first post-op dose 5b Was patient on medication at 30 days? 5b.i If patient is no longer on medication at 30 days, specify stop date. 6 Tacrolimus (Prograf, FK506) 6a Specify date of first post-op dose 6b Was patient on medication at 30 days? 6b.i If patient is no longer on medication at 30 days, specify stop date. 7 Everolimus 7a Specify date of first post-op dose 7b Was patient on medication at 30 days? 7b.i If patient is no longer on medication

56 PHTS - Form 3: Initial Immunosuppression Page 4 of 6 10/25/2017 at 30 days, specify stop date. 8 Cyclophoshamide (Cytoxan) 8a Specify date of first post-op dose 8b Was patient on medication at 30 days? 8b.i If patient is no longer on medication at 30 days, specify stop date. 9a 9b 9c Was patient given pre-operative steroids? Was patient given intra-operative steroids? Was patient given post-operative steroids? 9c.i Date of first post-op dose 9c.ii Daily dose at 30 days mg Steroids at 30 days 9d Planned Maintenance Steroids 9d.i If no, please specify End Date of steroid use

57 PHTS - Form 3: Initial Immunosuppression Page 5 of 6 10/25/ Was patient given other immunosuppressants? Other immunosuppressant details Other immunosuppressant details 10a 10b Specify other immunosuppressant Specify date of first post op dose 10c Patient on medication at 30 days If patient is no longer on 10c.i medication at 30 days, specify stop date. Prophylactic Antibiotics/Antivirals started Pre-op through 30 days post op Infection Prophylaxis: Started during the first 30 days post-transplant (not used to treat known infection). 11 Prophylactic Antibiotics/Antivirals started Pre-op through 30 days post op Check all that apply Acyclovir Antifungal CMV Immunoglobulin (Cytogam) Dapsone Ganciclovir or Valganciclovir Immunoglobulin (IV Ig) Pentamidine Trimethaprim-Sulfamethoxazole Valacyclovir 11a If antifungal, please specify Check all that apply Fluconazole Nystatin Unspecified

58 PHTS - Form 3: Initial Immunosuppression Page 6 of 6 10/25/ b If ganciclovir or valganciclovir, please specify Check all that apply IV PO 12 Date of Hospital Discharge Still In Hospital 2017 PHTS [PHTS]

59 PHTS - Form 4: Coronary Evaluation Page 1 of 7 10/25/2017 Patient Details Hidden Show Show/Hide Annotations Stickies: Toggle All Toggle Open Toggle Resolved Form 4: Coronary Evaluation Print this Form t Started 1 Date of Coronary Evaluation Coronary Evaluation 2 Indication for Coronary Evaluation Check only one. Angio NOT DONE: n-invasive test performed Followup from PTCA / Revascularization (to check patency) n-invasive test prior to this date indicated coronary disease Objective evidence of graft dysfunction/cad Research Protocol Routine, per established protocol (i.e. yearly evaluation) Symptoms (suggesting CHF or angina equivalent) n-invasive test prior to this 2b date indicated coronary disease, specify test Check only one. Cardiac CT Dobutamine Stress Echo Exercise Test MRI Radionuclide Angiogram (MUGA) Resting Echo Stress Perfusion 2a Angio NOT DONE: ninvasive test performed Cardiac CT Dobutamine Stress Echo Exercise Stress Echo Exercise Test MRI Radionuclide Angiogram (MUGA) Resting Echo Stress Perfusion Angiography

60 PHTS - Form 4: Coronary Evaluation Page 2 of 7 10/25/2017 3a 3b 3c Injection sites Check all that apply. Method of Interpretation (Pertains to the angiogram) Check only one. Pre-angiogram nitroglycerin Aorta Left Ventricle Selective Left Coronary Selective Right Coronary Caliper Computer Assisted Visual Estimate Angiography Results 4 Angiography Results Abnormal rmal 4a If abnormal, indicate ISHLT CAV score (J Heart Lung Transplant July 2010;29(7):717-27) t Graded ISHLT CAV 0 (t significant): detectable angiographic lesion ISHLT CAV 1 (Mild): Angiographic left main (LM) <50%, or primary vessel with maximum lesion of <70%, or any branch stenosis <70% (including diffuse narrowing) without allograft dysfunction ISHLT CAV 2 (Moderate): Angiographic LM <50%; a single primary vessel >70%, or isolated branch stenosis >70% in branches of 2 systems, without allograft dysfunction ISHLT CAV 3 (Severe): Angiographic LM >50%, or two or more primary vessels >70% stenosis, or isolated branch stenosis >70% in all 3 systems; or ISHLT CAV 1 or CAV 2 with allograft dysfunction (defined as LVEF <45% usually in the presence of regional wall motion abnormalities) 4b L Main LAD LCx RCA PDA rmal t Visualized Absent (congenital) Mild Stenosis (0% to 50%) Moderate Stenosis (51% to 70%) Severe Stenosis (71% to 100%) L Main = Left Main Coronary Artery LAD = Left Anterior Descending LCx = Left Circumflex RCA = Right Coronary Artery PDA = Posterior Descending

61 PHTS - Form 4: Coronary Evaluation Page 3 of 7 10/25/2017 Ectasia Severe Distal Pruning Coronary Flow Functional assessment of coronary flow performed using catheter-based 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 5 Fractional Flow Reserve Performed 5a 5a.iii 5a.i 5a.ii Vessels Studied Check all that apply. FFR Abnormal for Left Main Coronary Artery (L Main) FFR Abnormal for Left Anterior Descending (LAD) FFR Abnormal for Left Circumflex (LCx) LAD LCx Left Main RCA 5a.iv FFR Abnormal for Right Coronary Artery (RCA) 6 Coronary Flow Reserve (CFR) Performed 6a If CFR Performed, CFR abnormal (Abnormal is defined as: 2.0 Maximal Flow: Resting Flow) Intravascular Ultrasound

62 PHTS - Form 4: Coronary Evaluation Page 4 of 7 10/25/ Intravascular Ultrasound Performed 7a Vessels Studied LAD LCx Left Main RCA 7a.v 7a.vi 7a.i 7a.ii 7a.iii 7a.iv 7a.vii If Left Main, Maximal Intimal Thickness (MIT) If Left Main, Stanford Score If LAD, Maximal Intimal Thickness (MIT) If LAD, Stanford Score If LCx, Maximal Intimal Thickness (MIT) If LCx, Stanford Score If RCA, Maximal Intimal Thickness (MIT) <0.3 mm >= 0.3mm <0.3 mm >= 0.3mm <0.3 mm >= 0.3mm <0.3 mm >= 0.3mm

63 PHTS - Form 4: Coronary Evaluation Page 5 of 7 10/25/2017 7a.viii If RCA, Stanford Score Left Ventricular Function Evaluation Left Ventricular Function Evaluation 8 Nearest to coronary angiogram 8a Date of study 8b Method of Interpretation Contrast ventriculogram Echocardiogram MRI Radionuclide angiogram (MUGA) 8c 8d Left Ventricular Ejection Fraction Echo Shortening Fraction 8e Wall Motion Akinesis Dyskinesis Hypokinesis rmal t interpreted for wall motion abnormalities 8e.iii 8e.i Hypokinesis Akinesis > 1 Segment 1 Segment Diffuse > 1 Segment 1 Segment Diffuse

64 PHTS - Form 4: Coronary Evaluation Page 6 of 7 10/25/2017 8e.ii Dyskinesis > 1 Segment 1 Segment Diffuse Dobutamine or Exercise Stress Echo 9 Was Dobutamine or Exercise Stress Echo performed? 9a Date 9b Maximum Dobutamine Dose mcg/kg/min 9c 9c.ii Baseline Is there segmental hypokinesis and if so, how many segments? Akinesis/dyskinesis Hypokinesis rmal > 1 Segment 1 Segment Diffuse 9c.i Is there segmental Akinesis/dyskinesis and if so, how many segments? > 1 Segment 1 Segment Diffuse less than 1 9d Stress New Akinesis/dyskinesis New Hypokinesis rmal 9d.ii 9d.i If Stress is New Hypokinesis If Stress is New Akinesis/dyskinesis > 1 Segment 1 Segment Diffuse > 1 Segment 1 Segment Diffuse

65 PHTS - Form 4: Coronary Evaluation Page 7 of 7 10/25/2017 9e Maximum Heart Rate Achieved 9f LV Dilatation with Stress 2017 PHTS [PHTS]

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67 PHTS - Form 5: Rejection Page 1 of 5 10/25/2017 Patient Details Hidden Show Show/Hide Annotations Stickies: Toggle All Toggle Open Toggle Resolved Form 5: Rejection Print this Form t Started 1 Select the baseline immunosuppressive therapy at time of rejection Azathioprine Cyclosporine Everolimus Immune globulin Methotrexate Mycophenolate Plasmapheresis Prednisone Rituximab Sirolimus Tacrolimus Cytoxan (cyclophosphamide) Biopsy Prior to Rejection Event Biopsy Performed Prior to Rejection 2 Event If performed prior to this rejection diagnosis, indicate the score of the most recent biopsy performed that did not lead to rejection treatment. 2a Biopsy Date Prior to Rejection 2b 2c ACR Grading 2004 revised ISHLT grading system for ACR: (J Heart Lung Transplant v;24(11): ) ACR: acute cellular rejection (0, 1R, 2R, 3R) AMR Grading 2013 revised ISHLT grading system for pamr: J Heart Lung Transplant 2013 Dec 32(12): ) pamr: pathologic antibody mediated rejection (0, 1h, 1i, 2, 3) 2c.ii AMR Findings If only accessed histology/ did not perform immunofluorescene or immunohistochemistry (ie. C4d or C3d 0R 1R 2R 3R Both histology and immunofluorescence/immunohistochemistry performed (ie. C4d or C3d) Did not assess biopsy for evidence of AMR Only assessed histology/ did not perform immunofluorescence/immunohistochemistry (ie. C4d or C3d) histologic features AMR Positive histologic features AMR (ie. Vasculitis/ pericapillaritis)

68 PHTS - Form 5: Rejection Page 2 of 5 10/25/2017 2c.i pamr Grading 2013 revised ISHLT grading system for pamr: J Heart Lung Transplant 2013 Dec 32(12): ) pamr: pathologic antibody mediated rejection (0, 1h, 1i, 2, 3) 0 (negative) 1h 1i 2 3 Positive for AMR but pamr score not known Rejection Events Start with newly diagnosed rejection by biopsy (convert to ISHLT score) or other criteria leading to bolus immunotherapy. List all follow-up biopsies or changes in therapy. The last entry should be the first biopsy or echo not prompting additional therapy. Enter each subsequent rejection event until episode is resolved. 3 Was donor specific Ab testing performed at the time of the rejection event, Did not send testing for any circulating antibodies Which antibodies were tested 3a and what were the results HLA class I and/or class II DSA Isoagglutinin (A or B Ab) to ABO-i graft n-hla antibody (e.g. MICA, MICB, antiendothelial, vimentin, anti-myosin, angiotensin receptor (AR1T), or other non-hla 3a.i HLA Class I and/or II DSA Result Negative Positive 3a.ii 3a.i.1 HLA class I and/or II DSA Result, Positive n-hla Ab Result n-hla antibody (e.g. MICA, MICB, anti-endothelial, vimentin, anti-myosin, angiotensin receptor (AR1T), or other non-hla Results Complement fixing (C1q positive) Increased from last date tested New Present but stable (no new abs and not increased from baseline) Negative Positive 3a.ii.1 n-hla Ab Result, Positive n-hla antibody (e.g. MICA, MICB, anti-endothelial, vimentin, antimyosin, angiotensin receptor (AR1T), or other non-hla Results Increased from last date tested New Present but stable (no new abs and not increased from baseline) 3a.iii Isoagglutinin (A or B Ab) to ABO-i graft Positive is defined as titer of 1:16 or higher Negative Positive