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DEMOGRAPHICS
CLINICAL ENROLLMENT
ENROLLMENT TESTING
VIEW FOLLOW-UPS / HOSPITALIZATIONS
Identifier:
Center:
HOSPITALIZATION
Date of Admission:
*
mm/dd/yyyy
Date of Discharge:
*
mm/dd/yyyy
Primary Reason for Hospitalization:
*
Arrhythmia (specify)
Arterial Non-CNS Thromboembolic Event
Cardiac Arrest
Elective Procedure - Cardiac Diagnosis
Elective Procedure - Cardiac Therapeutic
Elective Procedure - Non-Cardiac
Electrolyte Disturbance
Feeding/Nutrition Issues (eg. vomiting, poor weight gain)
Fever Treated With Antibiotics Without Known Cause
GI Disorder (other than bleeding)
Heart Failure for Medical Treatment
Major Bleeding
Major Infection
Myocardial Infarction
Neurologic Event, Ischemic
Pulmonary Condition
Renal Failure/Kidney Injury
Syncope
Transplant
Trauma/Accident
VAD Implant
Venous Thromboembolic Disease (DVT/PE)
Other - Cardiac
Other - Non-Cardiac
Specify:
*
Contributing Causes (check all that apply):
Arrhythmia (specify below)
Arterial Non-CNS Thromboembolic Event
Cardiac Arrest
Elective Procedure - Cardiac Diagnosis
Elective Procedure - Cardiac Therapeutic
Elective Procedure - Non-Cardiac
Electrolyte Disturbance
Feeding/Nutrition Issues (eg. vomiting, poor weight gain)
Fever Treated With Antibiotics Without Known Cause
GI Disorder (other than bleeding)
Heart Failure for Medical Treatment
Major Bleeding
Major Infection
Myocardial Infarction
Neurologic Event, Ischemic
Neurologic Event, Hemorrhagic
Pulmonary Condition
Renal Failure/Kidney Injury
Syncope
Transplant
Trauma/Accident
VAD Implant
Venous Thromboembolic Disease (DVT/PE)
Other - Cardiac
Other - Non-Cardiac
Arrhythmia Specify:
Other Cardiac:
Other Non-Cardiac:
Interventions Initiated Upon Hospital Admission (check all that apply):
*
Atrial Arrhythmia Ablation
Blood Transfusion
Cardioversion
CPR
Dialysis
Enteral Feeding Tube (NG, G, GJ)
IABP
ICD
Inotropes
IV Antibiotics
Left Heart Cath
MCSD: Durable LVAD
MCSD: BiVAD
MCSD: RVAD
MCSD: TAH
MCSD: Temporary Percutaneous LVAD
Pacemaker Without ICD
Right Heart Cath
Ventilation: Continuous Mechanical
Ventilation: Non-Invasive
Ventricular Arrhythmia Ablation
Other, Specify
None
Unknown
Specify:
*
All Subsequent Interventions During Hospitalization (check all that apply):
*
Atrial Arrhythmia Ablation
Blood Transfusion
Cardioversion
CPR
Dialysis
Enteral Feeding Tube (NG, G, GJ)
IABP
ICD
Inotropes
IV Antibiotics
Left Heart Cath
MCSD: Durable LVAD
MCSD: BiVAD
MCSD: RVAD
MCSD: TAH
MCSD: Temporary Percutaneous LVAD
Pacemaker Without ICD
Right Heart Cath
Ventilation: Continuous Mechanical
Ventilation: Non-Invasive
Ventricular Arrhythmia Ablation
Other, Specify
None
Unknown
Specify:
*
TESTING
Endomyocardial Biopsy:
*
Yes
No
Unknown
PATIENT HISTORY
Listed for Transplant:
*
Yes
No
Unknown
Date Listed:
*
mm/dd/yyyy
Listing Reported to PHTS:
*
Yes
No
Unknown
PHTS Unique Identifier:
Transplanted:
*
Yes
No
Unknown
Date Transplanted:
mm/dd/yyyy
Transplant Reported to PHTS:
*
Yes
No
Unknown
PHTS Unique Identifier:
Transplant Reported to the ISHLT Transplant Registry:
*
Yes
No
Unknown
ISHLT Transplant Registry Unique Identifier:
Did Patient Receive a MCSD:
*
Yes
No
Date:
*
mm/dd/yyyy
Type:
*
BIVAD
LVAD
RVAD
TAH
Intended Support Strategy (check all that apply):
*
Bridge to Candidacy
Bridge to Recovery
Bridge to Transplant
Destination Therapy
Other, specify
Specify:
*
Reported to VAD registry:
*
Yes
No
Unknown
VAD Registry:
*
PediMACS
IMACS
INTERMACS
EUROMACS
OTHER
Specify:
*
VAD Registry Unique Identifier:
Has there been a change in function on Echo or MRI since last reported:
*
Improved
Similar
Worsended
MEDICATIONS AT THE TIME OF HOSPITAL DISCHARGE
ACEI:
*
Currently Using
Currently Not Using: Known Previous Use
Currently Not Using: Intolerant
Currently Not Using: No Known Previous Use
Current Use Unknown
Medications (check all that apply):
*
Captopril
Enalapril
Fosinopril
Lisinopril
Perindopril
Ramipril
Other, Specify
Specify:
*
Beta Blocker:
*
Currently Using
Currently Not Using: Known Previous Use
Currently Not Using: Intolerant
Currently Not Using: No Known Previous Use
Current Use Unknown
Medications (check all that apply):
*
Atenolol
Bisoprolol
Carvedilol
Metoprolol
Nadolol
Propranolol
Other, Specify
Specify:
*
Aldosterone Antagonist:
*
Currently Using
Currently Not Using: Known Previous Use
Currently Not Using: Intolerant
Currently Not Using: No Known Previous Use
Current Use Unknown
Medications (check all that apply):
*
Eplerenone
Spironolactone
Other, Specify
Specify:
*
Antiarrhythmic:
*
Currently Using
Currently Not Using: Known Previous Use
Currently Not Using: Intolerant
Currently Not Using: No Known Previous Use
Current Use Unknown
Medications (check all that apply):
*
Amiodarone
Flecainide
Ivabradine
Procainamide
Sotalol
Other, Specify
Specify:
*
Calcium Channel Blockers:
*
Currently Using
Currently Not Using: Known Previous Use
Currently Not Using: Intolerant
Currently Not Using: No Known Previous Use
Current Use Unknown
Medications (check all that apply):
*
Amlodipine
Diltiazem
Israpidine
Nifedipine
Verapamil
Other, Specify
Specify:
*
Phosphodiesterase Inhibitors:
*
Currently Using
Currently Not Using: Known Previous Use
Currently Not Using: Intolerant
Currently Not Using: No Known Previous Use
Current Use Unknown
Medications (check all that apply):
*
Sildenafil
Tadalafil
Other, Specify
Specify:
*
Angiotensin Receptor Blocker Drug:
*
Currently Using
Currently Not Using: Known Previous Use
Currently Not Using: Intolerant
Currently Not Using: No Known Previous Use
Current Use Unknown
Medications (check all that apply):
*
Candesartan
Losartan
Valsartan
Other, Specify
Specify:
*
Digoxin:
*
Currently Using
Currently Not Using: Known Previous Use
Currently Not Using: Intolerant
Currently Not Using: No Known Previous Use
Current Use Unknown
Anticoagulants (check all that apply):
*
Argatroban
Aspirin (ASA)
Bivalirudin
Clopidogrel
Dipyridamole
Fondaparinux
Heparin Low Molecular Weight
Heparin Standard
Lepirudin
Ticlopidine
Warfarin
Ximetagatran
Other, Specify
None
Specify:
*
Diuretics:
*
Yes
No
Unknown
Method of Administration:
*
Enteral
IV Bolus
IV Continuous
Medications (check all that apply):
*
Bumetanide
Ethacrynic Acid
Furosemide
Metolazone
Thiazide
Torsemide
Other, Specify
Specify:
*
Other Medications:
*
Yes
No
Unknown
Medications (check all that apply):
*
Ivabradine
Entresto (LCZ696)
Serelaxin
Levosimendan
Other, Specify
Specify:
*
Nutrition:
*
Fully Orally Fed
NG/J Tube - Partial
NG/J Tube - Fall
G/GJ Tube - Partial
G/GJ Tube - Full
TPN - Partial
TPN - Full
ISHLT PEDIATRIC HEART FAILURE REGISTRY
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