Screening Log Print this Form t Started Center Code DCC Patient Initials If middle initial is not known, enter a hyphen ( ) 1 2 5 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. Was informed consent and HIPAA Authorization obtained? 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. Is this the patient s first listing for a heart transplant? /my center has a waiver PTLT18 PTIC NOHLTX PRIMELS 2016 PHTS [test]
Patient Details Hidden Show Show/Hide Annotations Demographics Print this Form t Started 1 Date of Birth 2 Sex Female Male Race Check all that apply. African American or Black American Indian or Alaskan Native Asian Hawaiian or other Pacific Islander /Undisclosed White 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 5 Cardiomyopathy ARVD/C Dilated Hypertrophic MIXED Restrictive 5 Cardiomyopathy: Dilated Chemotherapy Induced Conduction Defect Familial Ischemic Isolated/Idiopathic LVNC Metabolic/Syndromic/Mitochondrial Neuromuscular s/p Myocarditis
5 Cardiomyopathy: Dilated, Ischemic ALCAPA Kawasaki 5 Cardiomyopathy: Hypertrophic Familial Isolated/Idiopathic Metabolic/Syndromic/Mitochondrial Neuromuscular 5 Cardiomyopathy: Restrictive Chemotherapy Induced Isolated/Idiopathic LVNC Metabolic/Syndromic/Mitochondrial s/p Radiation 5 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 Single Ventricle
5 If pulmonary atresia with IVS, RV dependent coronary circulation 6 Blood Type A AB B O 6 Blood A Subtype A1 A2 7 Rh Negative Positive 2016 PHTS [test]
Patient Details Hidden Show Show/Hide Annotations 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 Weight Kilograms Pounds 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 Medically refractory heart failure Both Diastolic Failure Systolic Failure Surgeries Prior to Listing 5 Did the patient have any cardiac surgery prior to listing?
Surgery Details 5 If Congenital cardiac surgery, specify surgery: AP Shunt 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?
Status Details at Listing 6 Status at Listing Brazil Canada United Kingdom United States 6a 6a Status at Listing, US 1 (this option is only for listings prior to 1999) 1A 1B 2 7 Canada 1 2.5 S 6a 6a United Kingdom Brazil Routine Urgent n Priority Priority 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? 6c Did the patient require continuous inotropes at time of listing? 6c.i Inotropes Dose Dose High Dose or Multiple IV Single Low Dose
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 Specify initiation date (VAD) Missing Reason: Specify initiation date (ECMO) Missing 6f Reason: 6g Was patient listed for DCD (Donation after Cardiac Death) organ? This is not current practice at our center Infectious Disease Screening 7 7 7 7 7 7 7 7 7 7 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
7 7 Hep C Ab Hepatitis C antibody RPR/Syphilis Syphilis testing Negative Positive Negative Positive Medical History at time of Listing 8 Medical History 8 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 8 Arrhythmia Afib/flutter Complete heart block V Fibrillation V Tachycardia 8 Cardiac arrest/cpr Date 8 Pacemaker Defibrilliator/AICD Pacemaker, CRT/biventricular pacing Pacemaker, not CRT and not ICD 8 Pacemaker, not CRT and not ICD, Date Placed
8 8 Pacemaker, CRT/biventricular pacing, Date Placed Pacemaker, Defibrillator/AICD Date Placed 8 8 8 Shock, Date of last appropriate Shock Diabetes, Date of last Hgb A1c Diabetes, Value of last Hgb A1c 8 8 Diabetes, Treating with insulin Medical History, GI/Nutrition Failure to thrive/cachexia Fontan associated liver disease Infectious hepatitis Protein losing Enteropathy 8 GI/Nutrition, Infectious hepatitis type A B C 8 Medical History, Heterotaxy/Isomerism Asplenia Polysplenia Situs Inversus Unspecified Medical History, Lymphoma, leukemia
8 Malignancy s/p BMT s/p Chest Radiation Solid organ cancer 8 Medical History, Neurologic Anoxic brain injury Hemorrhagic and/or thromboembolic stroke 8 Neurologic, Anoxic brain injury Last Date 8 Neurologic, Hemorrhagic and/or thromboembolic stroke Date Last 8 Medical History, Peripheral myopathy/neuromuscular disease Becker MuscularDystrophy Duschenne Muscular Dystrophy Freidrich's Ataxia Unspecified 8 Medical History, Respiratory Asthma Plastic Bronchitis Tracheostomy 8 History Dialysis Dialysis, acute (within past 0 days) Dialysis, chronic (>1 month duration) Dysfunction, not dialysis 8 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 8 8 Specify Metabolic Disorder Medical History, Mitochondrial Disorder, specify Barth's Unspecified 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. Percent or Panel Reactive Antibody (closest to listing) 10a Cytotoxic PRA ie. Serum is tested against panel of lymphocytes Done 10a T Cell %
10a B Cell % 10a Date (Cytotoxic PRA) 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 10b T Cell % B Cell % 10b Date (Cytotoxic PRA, DTE/DTT) 10c Flow Cytometry or Luminex PRA Done 10c 10c Class I % Class II % 10c Date 10d 10d Listed for prospective crossmatch Prospective Crossmatch Results Donor Cells Donor Cells and Virtual Virtual 10d 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. 11a Were hemodynamics done prior to listing? 11a Date 11a Fontan Mean Pressure 11a RAm (RAP or CVP) Right Atrial Mean Pressure 11a PAm Pulmonary Artery Mean 11a PCW Mean Pulmonary Capillary Wedge Pressure 11a SVC Sat Oxygen Saturation in the SVC 11a AO Sat Aortic Saturation 11a Rp, PVRI Pulmonary resistance indexed to body surface area (BSA) Woods Units x m 2 wu x m 2 11a Rs, SVRI Systemic resistance indexed to body surface area (BSA) Woods Units x m 2 wu x m 2 11a EDP End diastolic pressure of systemic ventricle
11a C.O. Cardiac output (i.e. Qs) in L/min L/min 11a C.I. Cardiac index (i.e. C.O. divided by m 2 ) in L/min/m 2 L/min/m 2 Was patient on mechanical 11b support at time of Hemodynamics 11b Hemodynamic Agents Used 11b 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 12 12 Are they at the age appropiate level Are they in a special education class
Exercise Test 1 Was exercise test performed? 1 If exercise test not performed, specify reason Age inappropriate Too sick 1 Max VO 2% Predicted for Age Refers to predicted maximum VO 2 for patient (should be listed in exercise report; if not, exercise lab personnel should be able to provide this data) % 1 Max VO 2 Maximum oxygen consumption ml/kg/min 1 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. 1 1 Total Bilirubin mg/dl Direct Bilirubin mg/dl 1 AST Aspartate transaminase (also SGOT) U/L 1 ALT Alanine transaminase (also SGPT) U/L
1 BNP B type natriuretic peptide pg/ml or ng/l 1 Pro BNP Pro NT B type natriuretic peptide pg/ml or ng/l 1 CRP C reactive protein mg/dl 1 Creatinine mg/dl 1 BUN Blood urea nitrogen mg/dl 1 1 1 1 Cystatin C mg/l Total Protein g/dl Pre Albumin mg/dl Serum Albumin g/dl 1 Cholesterol Total Cholesterol mg/dl 1 TG Triglycerides mg/dl 1 LDL Low density lipoprotein mg/dl 1 HDL High density lipoprotein mg/dl
1 VLDL Very low density lipoprotein mg/dl NYHA and Ross' Heart Failure 15 NYHA Class 1 2 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). 15 Ross' Heart Failure Class 1 2 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. 2016 PHTS [test]
Patient Details Hidden Show Show/Hide Annotations 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 Weight Kilograms Pounds Has this patient been transplanted Indicate total number of prior transplants This includes transplants that were and were not done at your hospital. 5 Main reason for Re Listing Coronary artery disease, (infarction, arrhythmia, CHF post MI) n Specific Graft Failure (>0 days post transplant) Pulmonary Hypertension/RV Failure Rejection, acute Rejection Hyperacute (onset < 2 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) n compliance n specific graft failure (>0 days post transplant)
Pulmonary Hypertension/RV Failure Rejection, acute Rejection, hyperacute (onset < 2 hours post transplant) Sudden cardiac death, no MI documented Status Details at Re Listing 7 Status at Re Listing Brazil Canada United Kingdom United States 7a Status at Re Listing, US 1 (this option is only for listings prior to 1999) 1A 1B 2 7 7a Status at Re Listing, Canada 0 1 2.5 7a Status at Re Listing, UK Routine Urgent 7a Status at Re Listing, Brazil n Priority Priority 7b Was patient in or out of hospital at time of listing? In hospital Out of hospital 7b.i 7b.ii Was patient in the ICU at time of relisting? Did the patient require continuous invasive mechanical ventilation? 7c Did the patient require continuous 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 Specify initiation date (VAD) Missing Reason: Specify initiation date (ECMO) Missing 7f Reason: 7g Was patient listed for DCD (Donation after Cardiac Death) organ? This is not current practice at our center Infectious Disease Screening 8 8 8 8 HIV Serology AIDS testing Negative Positive CMV Serology Negative Positive CMV PCR Negative Positive EBV Serology Negative Positive 8 8 EBV PCR Negative Positive IFA Toxo Toxoplasma testing Negative Positive Negative Positive
8 8 8 8 8 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 Medical History at time of Re Listing 9 Medical History 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) 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 9 Arrhythmia Afib/flutter Complete heart block V Fibrilliation V Tachycardia Date of last cardiac arrest/cpr 9 9 Pacemaker Defibrillator/AICD Pacemaker, CRT/Biventricular pacing
Pacemaker, not CRT and not ICD 9 Pacemaker, not CRT and not ICD, Date placed 9 Pacemaker, CRT/Biventricular pacing Date placed 9 Defibrillator/AICD, Date Placed 9 Date of last appropriate Shock 9 9 Date of Last Hgb A1c Value of Last Hgb A1c 9 9 Treating with Insulin GI/Nutrition Failure to thrive/cachexia Fontan associated liver disease Infectious hepatitis Protein losing Enteropathy 9 Hepatitis History A B C 9 Heterotaxy/Isomerism Asplenia Polysplenia Situs inversus Unspecified
9 Malignancy Lymphoma, leukemia s/p BMT s/p Chest Radiation Solid organ cancer 9 Neurologic Anoxic brain injury Hemorrhagic and/or thromboembolic stroke 9 9 Anoxic Brain Injury Date Hemorrhagic and/or Thromboembolic Stroke, Date Last 9 Peripheral myopathy/ neuromuscular disease Becker muscular dystrophy Duschenne muscular dystrophy Freidrich's ataxia Unspecified 9 Respiratory Asthma Plastic Bronchitis Tracheostomy 9 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 Renal Insufficiency Dialysis, acute (within past 0 days)
9 Dialysis, chronic (>1 month duration) Dysfunction, not dialysis 9 Specify Metabolic Disorder 9 Medical History, Mitochondrial Disorder, specify Barth's Unspecified 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. 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 11a T Cell % B Cell %
11a Date (Cytotoxic PRA) 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 11b T Cell % B Cell % 11b Date (Cytotoxic PRA, DTE/DTT) 11c Flow Cytometry or Luminex PRA Done 11c 11c Class I % Class II % 11c Date 11d 11d Re listed for prospective crossmatch Prospective Crossmatch Type Donor Cells Donor Cells and Virtual Virtual 11d 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. 12a Were hemodynamics done prior to relisting? 12a Date 12a Fontan Mean Pressure 12a RAm (RAP or CVP) Right Atrial Mean Pressure 12a PAm Pulmonary Artery Mean 12a PCW Mean Pulmonary Capillary Wedge Pressure 12a SVC Sat Oxygen Saturation in the SVC 12a AO Sat Aortic Saturation 12a Rp, PVRI Pulmonary resistance indexed to body surface area (BSA) Woods Units x m 2 wu x m 2 12a Rs, SVRI Systemic resistance indexed to body surface area (BSA) Woods Units x m 2 wu x m 2 12a EDP End diastolic pressure of systemic ventricle 12a C.O. Cardiac output (i.e. Qs) in L/min L/min
12a C.I. L/min/m 2 Cardiac index (i.e. C.O. divided by m 2 ) in L/min/m 2 12b Was patient on mechanical support at time of Hemodynamics 12b Hemodynamic Agents 12b 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 1 Is patient in school? t Applicable 1 1 Are they at the age appropiate level Are they in a special education class Exercise Test
1 Was exercise test performed? 1 If test no, specify reason Age Inappropriate Too Sick 1 Max VO 2% Predicted for Age Refers to predicted maximum VO 2 for patient (should be listed in exercise report; if not, exercise lab personnel should be able to provide this data) % 1 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. 1 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. 15 15 Total Bilirubin mg/dl Direct Bilirubin mg/dl 15 AST Aspartate transaminase (also SGOT) U/L 15 ALT Alanine transaminase (also SGPT) U/L 15 BNP B type natriuretic peptide pg/ml or ng/l
15 Pro BNP Pro NT B type natriuretic peptide pg/ml or ng/l 15 CRP C reactive protein mg/dl 15 Creatinine mg/dl 15 BUN Blood urea nitrogen mg/dl 15 15 15 15 Cystatin C mg/l Total Protein g/dl Pre Albumin mg/dl Serum Albumin g/dl 15 Cholesterol Total Cholesterol mg/dl 15 TG Triglycerides mg/dl 15 LDL Low density lipoprotein mg/dl 15 HDL High density lipoprotein mg/dl 15 VLDL Very low density lipoprotein mg/dl
NYHA and Ross' Heart Failure 16 NYHA Class 1 2 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 1 2 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. 2016 PHTS [test]
Patient Details Hidden Show Show/Hide Annotations Form 1T: Transplant Print this Form t Started 1 Date of Transplant 2 Simultaneous organ Check all that apply. Kidney Liver ne 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 Height Centimeters Inches Calculated BSA: n/a BMI: n/a 5 Weight Kilograms Pounds Status Details at Transplant 6 Status at Transplant Brazil Canada United Kingdom United States 6a United States 1 (this option is only for listings prior to 1999) 1A 1B
2 7 6a Brazil n Priority Priority 2 6a Canada 1 2.5 S 6a 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? 6c Did the patient require continuous inotropes at time of transplant? 6c.i Inotropes Dose High Dose or Multiple IV Single Low Dose 6d 6e 6f Did the patient have ductal dependent pulmonary or systemic circulation, with ductal patency maintained by stent or prostaglandin infusion? Was the patient transplanted with an ABO incompatible transplant? Was patient on a VAD or ECMO at time of transplant? VAD ECMO
t on support at time of Transplant 6f Specify initiation date (VAD) Missing Reason: Specify initiation date (ECMO) Missing 6f Reason: 6g Was patient listed for DCD (Donation after Cardiac Death) organ? This is not current practice at our center Percent or Panel Antibody (closest to Transplant) 7a Cytotoxic PRA Done 7a 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. Date % % 7b Cytotoxic PRA DTE/DTT Done 7b 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. Date % % 7c Flow Cytometry or Luminex PRA Done
7c 7c 7c Class I Values above 10 will require section 10: Per operative management for PRA to be completed. Class II Values above 10 will require section 10: Per operative management for PRA to be completed. Date 8 Did this patient have a virtual crossmatch? 8 Crossmatch Results Negative Positive 9 Donor Specific or Retrospective Crossmatch performed? 9 Crossmatch Results Negative Positive Was the crossmatch performed 9 prior to the decision to accept the donor? Pre Transplant Interventions for Elevated PRA 10a Did the patient receive treatment to lower or manage an elevated PRA while awaiting transplantation? 10a.1 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.2 How long was therapy administered? Check all that apply. Only for a pre specified time/number of treatments: specify 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 Peri operative management for PRA 10b.i. Was prophylactic plasmapheresis/ exchange performed in the peri operative period 10b.i.1 10b.i.2 Was this performed during cardiopulmonary bypass? Was this performed during the immediate postoperative period? 10b.i.2 How many cycles? 10b.ii Were there additional therapies, not routinely administered to post transplant patients in your center, given to this patient? Therapies administered 10b.ii 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 11b 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) 12 Donor Specific Antigens (DSA) Results Class I Class II Was DSA compliment fixing? 12 (i.e. positive C1q assay) Labaratory Values (closest to time of transplant) te: labs may have been collected on different dates. 1 Total Bilirubin mg/dl 1 Direct Bilirubin mg/dl 1 AST Aspartate transaminase (also SGOT) U/L 1 ALT Alanine transaminase (also SGPT) U/L
1 BNP B type natriuretic peptide pg/ml or ng/l 1 Pro BNP Pro NT B type natriuretic peptide pg/ml or ng/l 1 CRP C reactive protein mg/dl 1 Creatinine mg/dl 1 BUN Blood urea nitrogen mg/dl 1 1 1 1 Cystatin C mg/l Total Protein g/dl Pre Albumin mg/dl Serum Albumin g/dl 1 Cholesterol Total Cholesterol mg/dl 1 TG Triglycerides mg/dl 1 LDL Low density lipoprotein mg/dl 1 HDL High density lipoprotein mg/dl
1 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. 1a Hemodynamics 1a Date 1a Fontan Mean Pressure 1a RAm (RAP or CVP) Right atrial mean pressure 1a PAm Pulmonary artery mean 1a PCW Mean pulmonary capillary wedge pressure 1a SVC Sat Oxygen saturation in the SVC 1a AO Sat Aortic saturation 1a Rp, PVRI Pulmonary resistance indexed to body surface area (BSA) Woods Units x m 2 1a Rs, SVRI Systemic resistance indexed to body surface area (BSA) Woods Units x m 2 EDP End diastolic pressure of systemic ventricle
1a 1a C.O. Cardiac output (i.e. Qs) in L/min L/min 1a C.I. L/min/m 2 Cardiac index (i.e. C.O. divided by m 2 ) in L/min/m 2 1b Hemodynamic Agents 1b Indicate agent for best hemodynamics Check all that apply. 100% O2 Dobutamine Dopamine Epinephrine Isoproterenol (Isuprel) Milrinone Nesiritide Nitric Oxide Nitroglycerine Nitroprusside (Nipride) repinephrine PGE (Alprostadil) PGI (Flolan) Phenylephrine/Neosynephrine Sildenafil Vasopressin 1b Was patient on mechanical support at time of Hemodynamics? Inotropes, Pressors, and Thyroid Hormones 15 Was recipient on inotropes, pressors, or thyroid hormones at time of transplant? 15 Inotropes, Pressors, or Thyroid 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 T (Tri iodothyronine) T (Levothyroxine) Vasopressin 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 2016 PHTS [test]
Patient Details Hidden Show Show/Hide Annotations 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 Donor Height Centimeters Inches Calculated BSA: n/a BMI: n/a 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 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". 9 Duration of Donor Downtime Previously called "Duration of Cardiac Arrest". Enter duration in minutes. 10 Chest Compressions (CPR)
10 If yes, CPR Time Enter duration in minutes minutes 11 Donor Blood Type A AB B O 11 Blood type A subtype A1 A2 12 Donor Rh Negative Positive 1 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 1 If donor had diabetes, was patient on insulin? 1 Did the donor have an increased risk for HIV, HBV, HCV? 1 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 1 If at risk social history, specify. Check all that apply Incarceration Injected Drug Use Mother with HIV Sexual exposure
Pre transplant Donor Echocardiogram 15 Pre Transplant Donor Echocardiogram (closest to time of procurement) 15 Result of Donor Echocardiogram Abnormal rmal 15 If abnormal, please specify Check all that apply. Abnormal Septal Motion Diffuse Wall Motion Abnormality Focal Wall Motion Abnormality Mitral Regurgitation Tricuspid Regurgitation 15 Donor Fractional Shortening 15 Donor Estimated LV Eject Fraction Pre transplant Donor Angiogram 16 Pre transplant Donor Angiogram 16 Angiogram results Abnormal, Specify rmal Donor Serologies 17 17 17 17 HIV Serology AIDS testing CMV IgG Cytomegalovirus testing IFA Toxo Toxoplasma testing EBV IgG Epstein Barr Virus Negative Positive Negative Positive Negative Positive Negative Positive Negative Positive
17 17 17 17 17 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 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) T T Epinephrine Adrenaline (Inotrope, pressor) Dopamine (Inotrope) Dobutamine Dobutrex (Inotrope) Vasopressin Pitressin (Pituitary hormone) Levophed repinephrine (Inotrope, Pressor) Milrinone Primacor (Inotrope) Neosynephrine Phenylephrine (Pressor) Other 2016 PHTS [test]
Patient Details Hidden Show Show/Hide Annotations Form : 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 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 Induction Immunosuppression Agent Alemtuzumab (Campath) Basiliximab (Simulect) Bortezomib (Velcade) Daclizumab (Zenapax) OKT Rituximab (Rituxan) Thymoglobulin (ATG) Start Date End Date 2 Azathioprine (Imuran)
2 Was patient on medication at 0 days? 2 If patient is no longer on medication at 0 days, specify stop date. Cyclosporine Was patient on medication at 0 days? If patient is no longer on medication at 0 days, specify stop date. Mycophenolate (Cellcept, Myfortic) Was patient on medication at 0 days? If patient is no longer on medication at 0 days, specify stop date. 5 Sirolimus (Rapamycin) 5 Was patient on medication at 0 days? 5 If patient is no longer on medication at 0 days, specify stop date.
6 Tacrolimus (Prograf, FK506) 6 Was patient on medication at 0 days? 6 If patient is no longer on medication at 0 days, specify stop date. 7 Everolimus 7 Was patient on medication at 0 days? 7 If patient is no longer on medication at 0 days, specify stop date. 8 Cyclophoshamide (Cytoxan) 8 Was patient on medication at 0 days? 8 If patient is no longer on medication at 0 days, specify stop date. 9a Was patient given pre operative steroids? 9b Was patient given intra operative steroids?
9c Was patient given post operative steroids? 9c Date of first post op dose 9c Daily dose at 0 days mg Steroids at 0 days 9d Planned Maintenance Steroids 9d If no, please specify End Date of steroid use 10 Was patient given other immunosuppressants? 10 Specify date of first post op dose 10 Patient on medication at 0 days 10 If patient is no longer on medication at 0 days, specify stop date. Prophylactic Antibiotics/Antivirals started Pre op through 0 days post op Infection Prophylaxis: Started during the first 0 days post transplant (not used to treat known infection). 11 Prophylactic Antibiotics/Antivirals started Pre op through 0 days post op Check all that apply Acyclovir Antifungal CMV Immunoglobulin (Cytogam) Dapsone Ganciclovir or Valganciclovir Immunoglobulin (IV Ig) Pentamidine
Trimethaprim Sulfamethoxazole Valacyclovir 11 If antifungal, please specify Check all that apply Fluconazole Nystatin Unspecified 11 If ganciclovir or valganciclovir, please specify Check all that apply IV PO 12 Date of Hospital Discharge Still In Hospital 2016 PHTS [test]
Patient Details Hidden Show Show/Hide Annotations Form : 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) 2 n invasive test prior to this date indicated coronary disease, specify test Check only one. Cardiac CT Dobutamine Stress Echo Exercise Test MRI Radionuclide Angiogram (MUGA) Resting Echo Stress Perfusion 2 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
a b c 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 a Angiography Results Abnormal rmal a If abnormal, indicate ISHLT CAV score (J Heart Lung Transplant July 2010;29(7):717 27) 0 1 2 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 (Severe): Angiographic LM >50%, or two or more primary vessels >70% stenosis, or isolated branch stenosis >70% in all systems; or ISHLT CAV 1 or CAV 2 with allograft dysfunction (defined as LVEF <5% usually in the presence of regional wall motion abnormalities) b 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%) Ectasia L Main = Left Main Coronary Artery LAD = Left Anterior Descending LCx = Left Circumflex RCA = Right Coronary Artery PDA = Posterior Descending
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 5a 5a Fractional Flow Reserve Performed Vessels Studied Check all that apply. LAD LCx Left Main RCA 5a FFR Abnormal for Left Main Coronary Artery (L Main) 5a 5a FFR Abnormal for Left Anterior Descending (LAD) FFR Abnormal for Left Circumflex (LCx) 5a FFR Abnormal for Right Coronary Artery (RCA) 5b Coronary Flow Reserve (CFR) Performed 5b If CFR Performed, CFR abnormal (Abnormal is defined as: 2.0 Maximal Flow: Resting Flow) Intravascular Ultrasound 6 Intravascular Ultrasound Performed
6 Vessels Studied LAD LCx Left Main RCA 6 6 6 6 6 6 6 6 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) If RCA, Stanford Score <0. mm >= 0.mm 0 1 2 <0. mm >= 0.mm 0 1 2 <0. mm >= 0.mm 0 1 2 <0. mm >= 0.mm 0 1 2
Left Ventricular Function Evaluation Left Ventricular Function Evaluation 7 Nearest to coronary angiogram 7a Date of study 7b Method of Interpretation Contrast ventriculogram Echocardiogram MRI Radionuclide angiogram (MUGA) 7c 7c Left Ventricular Ejection Fraction Echo Shortening Fraction Missing Reason: 7d Wall Motion Akinesis Dyskinesis Hypokinesis rmal t interpreted for wall motion abnormalities 7d 7d 7d Hypokinesis Akinesis Dyskinesis > 1 Segment 1 Segment Diffuse > 1 Segment 1 Segment Diffuse > 1 Segment 1 Segment Diffuse
Dobutamine or Exercise Stress Echo 8 Was Dobutamine or Exercise Stress Echo performed? 8 Date 8 Maximum Dobutamine Dose mcg/kg/min 8 Baseline Akinesis/dyskinesis Hypokinesis rmal 8 8 Is there segmental hypokinesis and if so, how many segments? Is there segmental Akinesis/dyskinesis and if so, how many segments? > 1 Segment 1 Segment Diffuse > 1 Segment 1 Segment Diffuse less than 1 8 Stress New Akinesis/dyskinesis New Hypokinesis rmal 8 If Stress is New Hypokinesis > 1 Segment 1 Segment Diffuse 8 If Stress is New Akinesis/dyskinesis > 1 Segment 1 Segment Diffuse 8 Maximum Heart Rate Achieved 8 LV Dilatation with Stress
Patient Details Hidden Show Show/Hide Annotations Form 5: Rejection Print this Form t Started 2 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 Event If performed prior to this rejection diagnosis, indicate the score of the most recent biopsy performed that did not lead to rejection treatment. Biopsy Date Prior to Rejection ACR Score 200 revised ISHLT scoring system for ACR: (J Heart Lung Transplant. 2005 v;2(11):1710 20.) ACR: acute cellular rejection (0, 1R, 2R, R) 0 1R 2R R AMR Score 201 revised ISHLT scoring system for pamr: J Heart Lung Transplant 201 Dec 2(12):117 62.) pamr: pathologic antibody mediated rejection (0, 1h, 1i, 2, ) AMR Findings If only accessed histology/ did not perform immunofluorescene or immunohistochemistry (ie. Cd or Cd Both histology and immunofluorescence/immunohistochemistry performed (ie. Cd or Cd) Did not assess biopsy for evidence of AMR Only assessed histology/ did not perform immunofluorescence/immunohistochemistry (ie. Cd or Cd) histologic features AMR Positive histologic features AMR (ie. Vasculitis/ pericapillaritis)
pamr score 201 revised ISHLT scoring system for pamr: J Heart Lung Transplant 201 Dec 2(12):117 62.) pamr: pathologic antibody mediated rejection (0, 1h, 1i, 2, ) 0 (negative) 1h 1i 2 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. 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 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 HLA Class I and/or II DSA Result Negative Positive HLA class I and/or II DSA Result, Positive Complement fixing (C1q positive) Increased from last date tested New Present but stable (no new abs and not increased from baseline) n HLA Ab Result n HLA antibody (e.g. MICA, MICB, antiendothelial, vimentin, anti myosin, angiotensin receptor (AR1T), or other non HLA Results Negative Positive n HLA Ab Result, Positive n HLA antibody (e.g. MICA, MICB, anti endothelial, vimentin, anti myosin, 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) Isoagglutinin (A or B Ab) to ABO i graft Positive is defined as titer of 1:16 or higher Negative Positive Rejection Event
Date of rejection event Any episode leading to an increase in immunotherapy to treat a biopsy or clinically diagnosed episode of rejection 5a 5b Basis for Diagnosis of Current Rejection Event Was biopsy performed? Biopsy Clinical ECHO New or increased Abs 5b Indication for biopsy Check all that apply. Objective Evidence of Graft Dysfunction Research Routine (scheduled as part of protocol surveillance) Symptoms 5b 5b ACR Grading 200 revised ISHLT scoring system for ACR: (J Heart Lung Transplant. 2005 v;2(11):1710 20.) ACR: acute cellular rejection (0, 1R, 2R, R) AMR Grading 201 revised ISHLT scoring system for pamr: J Heart Lung Transplant 201 Dec 2(12):117 62.) pamr: pathologic antibody mediated rejection (0, 1h, 1i, 2, ) 0 1R 2R R Both histology and immunofluorescence/immunohistochemistry performed (ie. Cd or Cd) Did not assess biopsy for evidence of AMR Only assessed histology/ did not perform immunofluorescence/immunohistochemistry (ie. Cd or Cd) 5b Histology results histologic features AMR Positive histologic features AMR 5b If both histology and immunofluorescence/ immunohistochemistry performed, indicate pamr score 201 revised ISHLT scoring system for pamr: J Heart Lung Transplant 201 Dec 2(12):117 62.) pamr: pathologic antibody mediated rejection (0, 1h, 1i, 2, ) 0 1h 1i 2 Positive with Score 5c Was there therapy used to treat this rejection episode? If no rejection therapy was used, no more rejection episodes should be entered for this event. 5c Select the therapy used ATG or ATGAM Bortezomib
Eculizumab Immune Adsorption Immunoglobulin Methotrexate Photopheresis Plasmapheresis Rituximab Steroid Taper Steroids, IV Steroids, Oral Tacrolimus Cytoxan (cyclophosphamide) 5d Was episode of rejection associated with hemodynamic compromise? ne 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 Support Mild ne 6 Indicate date of the end of the rejection episode 7 7 Was there baseline immunosuppressive therapy at time of resolution of rejection event Baseline immunosuppressive therapy at time of resolution of rejection event Azathioprine (Imuran) Cyclosporine (Sandimmune, Neoral, Gengraf, CSA, CyA) Everolimus Immune globulin Methotrexate Mycophenolate (Cellcept, Myfortic) Prednisone Rituximab Sirolimus (Rapamycin, Rapamune) Tacrolimus (Prograf, FK506) Cytoxan (Cyclophosphamide) Other, Specify
Patient Details Hidden Show Show/Hide Annotations Form 6: Infection Print this Form t Started 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. Life Threatening Infection Requiring Oral Therapy 1 Date of Infection Date of diagnosis or clinical presentation, whichever date is earliest. 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 posttransplant). 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 long term prophylaxis. Do not include therapy for the current infection to be included under section 6. Drug Therapy Drug Therapy Details 2 Specify drug therapy at time of infection. Acyclovir Alemtuzumab (Campath) ATGAM Azathioprine Basiliximab (Simulect) Bortezomib (Velcade) CMV Immunoglobulin, Cytogam Cyclosporine Cytoxan (cyclophosphamide) Dapsone Everolimus (Certican) Fluconazole Ganciclovir or Valganciclovir Immunoglobulin, IV Ig Methotrexate Mycophenolate Nystatin Oseltamivir Pentamidine
Prednisone Rituximab (Rituxan) Sirolimus (Rapamycin) Tacrolimus (Prograf, FK506) Thymoglobulin/ATG Trimethaprim sulfamethoxazole, Septra Valacyclovir 2 Ganciclovir or Valganciclovir IV PO a Type of infection Use a separate form for each episode and/or type of infection. Bacterial Fungal Organism Identified Protozoan Viral Type of Organism(s) Indicate all organisms associated with the type of infection. b Organism Location of infection Check all that apply Blood: Culture positive Blood: PCR positive Bone: Osteomyelitis Central nervous system/ brain (ie. Meningitis /Encephalitis) Chest tube site infection Gastrointestinal infection (ie. Gastritis, colitis, infectious diarrhea) Heart (includes endocarditis) Hepatic/ liver: Infectious hepatitis Intrabdominal/ Peritoneal: Peritonitis Pericardium/ pericarditis Renal/ kidney/urinary tract Respiratory (includes Pneumonia/ Bronchiolitis/Tracheitis/ Pleuritis) Skin or soft tissue: Cellulitis/fasciitis VAD infection Wound infection within 0 days, deep sternal: Deep sternal wound infection with positive culture or treated with prolonged antibiotics beyond
perioperative prophylaxis when culture not obtained or pre treated involving muscle, bone, and/or mediastinum requiring operative intervention Wound infection within 0 days, superficial sternal: Superficial, soft tissue Was the blood infection directly attributed to the presence of a central line (ie. organism cultured from blood is not related to an infection at another site)? VAD Infection Location Check all that apply Cannulae Driveline 5 Location of patient Emergency care, no admit In Hospital Out of Hospital 6 Intervention Check all that apply Drug therapy : Oral Drug therapy: IV or IM Mechanical Ventilation Surgical therapy, specify 7 Outcome at 0 days post date of infection Check only one. Significant long term sequelae means any residual medical problem persisting for > 0 days after the onset of the infection (e.g.) renal failure, respiratory failure. Death Resolution Significant Long Term Sequelae Unresolved at 0 days 7 If death occurred, did the infection contribute to cause of death?