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: ______

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