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All Forms Combined Not Started Institutional Practice Details Print this Form Date of Completion DD/MM/YYYY 1. Indicate the day, month, and year the form is being completed. Previous year’s hospital case Less than or equal to 100 per year 2. volume of congenital cardiac 101-250 per year surgeries 251-500 per year Indicate the case volume of Tier 1 AND Tier 2 surgeries for the previous Greater than 500 per year calendar year. (This is the total number of surgeries, not the number of patients.) Active congenital heart surgeons active congenital heart 3. Indicate the number of active congenital heart surgeons currently surgeons practicing at your hospital. How is a congenital heart 3a surgeon certified in your country? Cardioplegia Type Buckberg 4. Check all cardioplegia types that your hospital uses. If there are Custodiol/Bretschneider (HTK) multiple cardioplegia types that your hospital uses that are not Del Nido options in the list provided, enter all of them in the "other, specify" box Microplegia with Adenocaine seperating them by commas (,). 0 option(s) selected Microplegia with Potassium Plegisol/St. Thomas Roe's Solution University of Wisconsin Other, specify Geographic Region Served Local: one city or metro area 5. Regional: geographically larger than a metro area National: one country International: multiple countries Estimated Population Served Less than 10 million 6. Based on answer to the previous question. 10-30 million 31-50 million Greater than 51 million Unknown Total number of institutions Missing Reason: 7. providing pediatric cardiac Clear Unknown services in the region. Based on answer to question 5. Specify the total number including your institution. If your institution is the only institution providing pediatric cardiac services in the region, specify one. Does your institution have an Yes 8. established pediatric cardiology No practice? Number of pediatric cardiac 9. operating rooms at your institution Does your institution have an Yes 10. exclusive pediatric cardiac No intensive care unit? Does your institution have a Yes 11. pediatric cardiac intensivist? No Does your institution have an Yes 12. ECMO program? No ECMO (Extracorporeal Membrane Oxygenation) Does your hospital provide Yes 12a. extracorporeal No cardiopulmonary resuscitation (ECPR)? ECPR: ability to establish emergency ECMO within 30 minutes Does your institution have a Yes 13. pediatric cardiac catheterization No laboratory? Does your institution have an Yes 14. electrophysiology service? No Does your hospital have an Yes 15. Electronic Medical Records No system (EMR)? 15a. Software Vendor Does your hospital participate in Yes 16. a National Congenital Heart No Surgery Database? 16a. Enter Name of Database Does your center have a routine Yes 17. preoperative planning No conference? Does your hospital have Yes 18. intraoperative Trans esophageal No ECHO? Does your hospital have Yes 19. intraoperative Epicardial ECHO? No Who performs the Pre-operative Cardiologist 20. Trans Thoracic ECHO? Cardiac Surgeon Trained ECHO Technologist Usual Patient follow up post Cardiologist 21. discharge; Surgeon Referring Physician Other, Specify © 2020 World Database for Pediatric and Congenital Heart Surgery Not Started Add Surgery Form Print this Form First Three Letters of Patient Last 1. Name If this information cannot be provided, select a unique patient identifier. Gender Female 2. Male Unknown Date of Birth DD/MM/YYYY 3. Indicate patient's birthdate. Local Hospital Patient ID Date of Surgery DD/MM/YYYY 5. This is the date the patient enters the operating room. (Day/Month/Year) Primary Cardiac Procedure 6. Select the patient's primary surgical procedure. If the patient has multiple operating room visits, these should be reported on additional "New Surgery Forms". Anomalous systemic venous connection Mitral Valve (MV) Repair (Left Atrioventricular Valve) Anomalous systemic venous connection repair Mitral Valve Replacement (Left Atrioventricular Valve) Aortic Aneurysm Mitral Valve (MV) Replacement, Mechanical Mitral Valve (MV) Replacement, Bioprosthetic Aortic aneurysm repair Mitral Valve (MV) Replacement, Homograft Aortic Dissection Palliative Procedures Aortic Dissection repair Shunt, Ligation and Takedown Aortic Root Replacement Shunt, Systemic to pulmonary, Modified Blalock-Taussig Shunt (MBTS) Aortic Root Replacement, Bioprosthetic Shunt, Systemic to pulmonary, Central (shunt from aorta) Aortic Root Replacement, Mechanical Shunt, Systemic to pulmonary, Other Aortic Root Replacement, Homograft Pulmonary Artery banding (PAB) Aortic Root Replacement, Valve sparing Pulmonary Artery debanding Aortic Valve Disease Damus-Kaye-Stansel procedure (DKS) (creation of Aorto-pulmonary anastomosis without arch reconstruction) Ross procedure Bidirectional cavopulmonary anastomosis (BDCPA) (bidirectional Glenn) Konno procedure (with and without aortic valve replacement) Glenn (unidirectional cavopulmonary anastomosis) (unidirectional Glenn) Ross Konno Procedure Bilateral bidirectional cavopulmonary anastomosis (BBDCPA) (bilateral Repair of Supraaortic Stenosis bidirectional Glenn) Other aortic annular enlargement procedure Hemi-Fontan Aortic Valve Repair Hepatic vein to azygous vein connection, Direct or with Interposition Graft Aortic Valve Replacement Kawashima operation (superior cavopulmonary connection in setting of Aortic Valve Replacement (AVR), Mechanical interrupted IVC with azygous continuation) Aortic Valve Replacement (AVR), Bioprosthetic Bidirectional cavopulmonary anastomosis (BDCPA) (bidirectional Glenn) Re- repair (within 90 days) Aortic Valve Replacement (AVR), Homograft Partial Anomalous Pulmonary Venous Connection AP Window Partial Anomalous Pulmonary Venous Connection (PAPVC) repair Aorto-pulmonary (AP) window repair Partial Anomalous Pulmonary Venous Connection (PAPVC), Scimitar, Repair Pulmonary artery origin from ascending aorta (hemitruncus) repair PAPVC repair, Baffle redirection to left atrium with systemic vein translocation ASD (Warden) (SVC sewn to right atrial appendage) Patent Foramen Ovale (PFO), Primary closure Partial Anomalous Pulmonary Venous Connection (PAPVC) Re-repair (within 90 Atrial Septal Defect (ASD) repair, Primary closure days) Atrial Septal Defect (ASD) repair, Patch Patent Ductus Arteriosus Atrial Septal Defect (ASD) repair, Partial closure Patent Ductus Arteriosus (PDA) closure, Device Atrial Septal Defect (ASD) repair, Device Atrial Septal Defect (ASD) repair, Patch + Partial anomalous pulmonary venous Patent Ductus Arteriosus (PDA) closure, Surgical connection repair Pericardial Disease Atrial Septal Defect (ASD), Common atrium (single atrium), Septation Pericardial drainage procedure Atrial Septal Defect (ASD) creation/enlargement Pericardiectomy Atrial Septal Fenestration Pericardial procedure, Other Atrial fenestration closure Pulmonary Atresia/VSD AV Canal Pulmonary atresia - VSD (including TOF, PA) repair Atrioventricular (AV, AVSD) Septal Repair, Complete Pulmonary atresia - VSD – MAPCA repair, Complete single stage repair (1 stage Atrioventricular (AV, AVSD) Septal Repair , Intermediate (Transitional) that includes pulmonary unifocalization + VSD closure + RV to PA connection [with or Atrioventricular (AV, AVSD) Septal Repair , Partial (Incomplete) (PAVSD) without conduit]) Common atrioventricular (AV) valve Repair Pulmonary atresia - VSD – MAPCA repair, Status post prior complete Common atrioventricular (AV) valve Replacement unifocalization (includes VSD closure + RV to PA connection [with or without conduit]) Atrioventricular (AV, AVSD) Septal Defect Re-repair (within 90 days) Pulmonary atresia - VSD – MAPCA repair, Status post prior incomplete unifocalization (includes completion of pulmonary unifocalization + VSD closure + RV Cardiomyopathy to PA connection [with or without conduit]) Transplant, Heart Unifocalization MAPCA(s), Bilateral pulmonary unifocalization Transplant, Heart and lung Unifocalization MAPCA(s), Unilateral pulmonary unifocalization Coartaction of Aorta and Aortic arch hypoplasia Pulmonary Valve Disease Coarctation repair, End to end Pulmonary Valve (PV) Replacement, Mechanical Coarctation repair, End to end, Extended Pulmonary Valve (PV) Replacement, Bioprosthetic Coarctation repair, Subclavian flap Pulmonary Valve (PV) Replacement, Homograft Coarctation repair, Patch aortoplasty Pulmonary Valve (PV) Replacement, Other Coarctation repair, Interposition graft Pulmonary Valve (PV) Repair Coarctation repair, Other Pulmonary venous stenosis Coarctation repair + Ventricular Septal Defect repair Pulmonary venous stenosis repair Aortic arch repair Aortic arch repair + Ventricular Septal Defect repair Repair of Subaortic Stenosis Coarctation repair, Extra-anatomic Bypass Membrane Resection Coarctation Re-repair (within 90 days) Myomectomy Extended Myomectomy Conduit Operations Conduit placement, Right Ventricle (RV) to Pulmonary Artery (PA) (primary or RVOT Obstruction, IVS Pulmonary Stenosis reoperation) Right ventricular Outflow Tract (RVOT) procedure and/or Transannular patch Conduit placement, Left Ventricle (LV) to Pulmonary Artery (PA) 1 1/2 ventricular repair Conduit placement, Ventricle to aorta Pulmonary Artery (PA), reconstruction, Main Congenitally Corrected TGA Pulmonary Artery (PA), reconstruction, Central Pulmonary Artery (PA), reconstruction, Peripheral Congenitally corrected Transposition of the Great Arteries (TGA) repair, Atrial switch and ASO (double switch) Double Chamber Right Ventricle (DCRV) Congenitally corrected Transposition of the Great Arteries (TGA) repair, Atrial Single Ventricle
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