IMACS Implant Printable Form

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Implant Device Information Additional indication for VAD: Failure to wean from CPB Post Cardiac Surgery None Enter cardiac operation: Device Type: LVAD RVAD Both (in the same OR visit) Total Artificial Heart Implant Date: Device Type (LVAD) Device Brand: Berlin Heart EXCOR Adult Berlin Heart EXCOR Pediatric Berlin Heart INCOR Circulite Synergy EvaHeart LVAS Heartmate II LVAS Heartmate IP Heartmate VE Heartmate XVE Heartware HVAD Jarvik 2000 Levacor LVAD Medos VAD Micromed Debakey VAD – Child Micromed HeartAssist 5 Novacor PC Novacor PCq Terumo Duraheart Thoratec IVAD Thoratec PVAD Device Type (RVAD) Device Brand: Berlin Heart EXCOR Adult Berlin Heart EXCOR Pediatric Berlin Heart INCOR Heartware HVAD Jarvik 2000 Medos VAD Thoratec IVAD Thoratec PVAD 1 of 3 Device Type – Total Artificial Heart Device Brand: SynCardia CardioWest AbioCor TAH Associated Findings (Surgical PFO/ASD observations or Intraoperative TEE): Aortic Insufficiency Tricuspid Insufficiency None Aortic Insufficiency: Mild Moderate Severe Tricuspid Insufficiency: Mild Moderate Severe Antibiotic Prophylaxis at time of Yes implant: No Unknown If yes, Select antibiotics/antifungals Amikacin days: ____________ given as prophylaxis at the Amphotericin days: ____________ time of Implant: Anidulafungin days: ____________ Aztreonam days: ____________ Caspafungin days: ____________ Cefazolin days: ____________ Cefuroxime days: ____________ Ceftazidime days: ____________ Ceftriaxone days: ____________ Cefepime days: ____________ Ceftaroline days: ____________ Ciprofloxacin days: ____________ Co-amox/Clavulanate days: ____________ Daptomycin days: ____________ Ertapenem days: ____________ Flucloxacillin days: ____________ Fluconazole days: ____________ Gentamicin days: ____________ Levofloxacin days: ____________ Linezolid days: ____________ Meropenem days: ____________ Micafungin days: ____________ Pip/Tazobactam days: ____________ Rifampicin days: ____________ Teicoplanin days: ____________ Ticarcillin/Clavulanate days: ____________ Tigecycline days: ____________ TMP/SMX days: ____________ Vancomycin days: ____________ Voriconazole days: ____________ Other specify: _________________ 2 of 3 Device Details Concomitant surgery: None ASD closure PFO closure RVAD implant ECMO decannulation CABG VSD closure Congenital cardiac surgery Valve Surgery: Aortic Repair Valve Surgery: Mitral Repair Valve Surgery: Tricuspid Repair Valve Surgery: Pulmonary Repair Valve Surgery: Aortic Replacement - Mechanical Valve Surgery: Aortic Replacement - Biological Valve Surgery: Mitral Replacement - Mechanical Valve Surgery: Mitral Replacement - Biological Valve Surgery: Tricuspid Replacement - Mechanical Valve Surgery: Tricuspid Replacement - Biological Valve Surgery: Pulmonary Replacement - Mechanical Valve Surgery: Pulmonary Replacement - Biological Other, specify specify: _________________ 3 of 3.

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Heartmate II® LVAS LEFT VENTRICULAR ASSIST SYSTEM
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