ECHOCARDIOGRAPHY DATA REPORT FORM

Transcription

1 Patient ID Patient Study ID AVM - - Date of form completion / / 20 Initials of person completing the form mm dd yyyy Study period Preoperative Postoperative Operative 6-month f/u 1-year f/u 2-year f/u 3-year f/u 5-year f/u 7-year f/u 10-year f/u Post 10-year f/u Unplanned visit or hospitalization If operative: Pre-procedure Post-procedure ECHOCARDIOGRAPHY DATA REPORT FORM A. General Information 1. Date of echocardiographic exam: BSA: cm 2 Unknown 3. Heart rate at the time of echocardiography, bpm: Unknown 4. Blood pressure at the time of echocardiography: / mm Hg Unknown 5. Imaging quality: Excellent Good Adequate Poor or inadequate 6. TEE: Yes No 7. Both B. Aortic Dimensions, mm Annulus Arch Sinus Upper descending Sino-tubular junction Mid descending Mid ascending Upper abdominal, mm Upper ascending C. 2D 2D PLAX PSAX IVSd thickness, cm PWd thickness, cm LVEDD, cm LVESD, cm EF by 2D, % Visual EF. % AVOMP Study Echocardiography Data Report Form Page 1 of 6 Document page 23

2 D. Volumes View: 4 chamber 4 chamber/apical long axis LVED biplane volume, ml LVES biplane volume, ml Biplane Sympson EF, % Single plane volumes View: 4 chamber 2 chamber Apical long axis LVED volume, ml LVES volume, ml EF by single plane volume, % E. Pulsed Wave Doppler MV E vel leaf tip, m/sec A vel leaf tip, m/sec Dt leaflet tip, ms LVOT Vel, m/sec TVI, cm Abdominal Aorta Diastolic reversal TVI, cm Descending Aorta Diastolic reversal TVI, cm F. Continuous Wave/Color Flow Doppler Aortic Valve TVI, cm Mean gradient, mm Hg AR early-diastolic velocity, m/sec AR ½ time ms Aortic Regurgitation Incomplete parameters radius, cm Alias velocity, cm/sec AVOMP Study Echocardiography Data Report Form Page 2 of 5 Document page 24

3 AR early-diastolic velocity, cm/sec AR TVI, cm ERO, cm 2 Regurgitant volume, ml Composite AR severity: Aortic valve morphology, CHECK ALL THAT APPLY: Normal Bicuspid Unicuspid Quadracuspid Flail Prolapse Repair Replacement Other, specify: Unknown Mitral Regurgitation Incomplete parameters radius, cm Alias velocity, cm/sec MR velocity, cm/sec MR TVI, cm ERO, cm 2 Regurgitant volume, ml Composite MR severity: Mitral valve morphology, CHECK ALL THAT APPLY: Normal Prolapse Flail Rheumatic AVOMP Study Echocardiography Data Report Form Page 3 of 5 Document page 25

4 Repair Replacement Other, specify: Unknown Tricuspid Regurgitation RA pressure (est), mm Hg TR severity: Pulmonary Valve PR end-diastolic velocity, m/sec PR severity: G. Comments Aortic dimensions: AVOMP Study Echocardiography Data Report Form Page 4 of 5 Document page 26

5 Abbreviations AR BSA d EF ERO IVS LA LV LVOT LVEDD LVESD MR MV PR PSAX PW RA s TEE TR TVI Aortic regurgitation Body surface area Diastolic Ejection fraction Effective regurgitant orifice Intra ventricular septum thickness Left atrium Left ventricle LV outflow tract LV end diastolic dimension LV end systolic dimension Mitral regurgitation Mitral valve Proximal isovelocity surface area Pulmonic regurgitation Parasternal short axis Posterior wall Right atrium Systolic Transesophageal echocardiogram Tricuspid regurgitation Time-velocity integral AVOMP Study Echocardiography Data Report Form Page 5 of 5 Document page 27