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Pediatric Heart Transplant Study PEDIATRIC HEART TRANSPLANT STUDY ID# P FORM 01: 2010: Initi al Pati ent Entry at Listi ng (PG 1 of 2) P Insti tuiti onal Sequenti al Pati ent Tran To be fi lled out at ti me of listi ng Code Pati ent Number Initi als # 1. Insti tuti on Code: 2. Pati ent Number: 3. Pati ent Initi als: 4. Height: in Weight: lb ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ______ cm ______ kg 5. Date of Birth: 6. Date of Listi ng: 7. Gender: Male ( MO | DAY | YR ) ( MO | DAY | YR ) Female 8a. Race: (See Manual, check all that apply) 8b. Hispanic Origin: White Pacifi c Islander Yes Black Mid-east/Arabian No American Indian/Alaskan Nati ve Indian Subconti nent Asian Other, specify: _____________ 9. Eti ology: (Choose only ONE primary eti ology) Myocarditi s (Cardiomyopathy conti nued) Congenital Heart Disease Cardiomyopathy Hypertrophic (if checked, (if checked, complete below): (if checked, complete below): complete below): Complete AV Septal Defect Dilated Isolated/idiopathic Congenitally Corrected Transpositi on Isolated/Idiopathic Metabolic/Syndromic Ebstein’s Anomaly Neuromuscular Neuromuscular Hypoplasti c Left Heart Chemotherapy-induced Familial Left Heart Valvar/Structural Hypoplasia Familial Other _________________ Pulmonary Atresia with IVS s/p Myocarditi s Restricti ve (if checked, Single Ventricle Metabolic/syndromic complete below): TOF/DORV/RVOTO Conducti on defect Isolated/idiopathic Transpositi on of the Great Arteries Ischemic, Kawasaki s/p Radiati on Truncus Arteriosus Ischemic, Other _________ Chemotherapy-induced VSD/ASD ARVD Metabolic Other ____________________ Other __________________ Other _________________ Cardiac Tumor Mixed Isomerism Other __________________ Ischemic, other __________________ Other, specify ____________________ 10a. Cardiac Surgical History: 10b. Code Date Surgical Codes: Previous Surgery: 1. AP Shunt 15. Valve Replacement or 1. ___ ___ ___ ___ 2. ASD Repair Repair for Outf low No (If no, skip to #11) 3. Complete AV Septal Obstructi on 2. ___ ___ ___ ___ Defect Repair 16. VSD Repair Yes (If yes, complete #10a-b) 4. Congenitally Corrected 17. Other, specify Total Number: ______ 3. ___ ___ ___ ___ Transpositi on Repair __________________ 5. Damus Kaye Stansel (DKS) 18. Other, specify Homograft : No Yes 4. ___ ___ ___ ___ 6. Ebstein’s Anomaly Repair __________________ Valve replacement: No Yes 7. Fontan 19. Other, specify 5. ___ ___ ___ ___ 8. Glenn, Bi-directi onal __________________ If yes, please specify: PRINT IN BLACK INK ONLY. USE THIS FORM FOR ALL PATIENTS OR EVENTS AFTER JANUARY 1, 2010 OR EVENTS AFTER JANUARY ALL PATIENTS FOR USE THIS FORM INK ONLY. PRINT IN BLACK 11. PA Banding 20. Other, specify Tissue Mechanical 6. ___ ___ ___ ___ 12. TOF/DORV/RVOTO Repair __________________ 13. Transpositi on of the 21. Stage 1 Norwood – BT Choose Surgical Codes at right. Please 7. ___ ___ ___ ___ Great Vessels Repair 22. Stage 1 Norwood – RV-PA list code and date of surgery (at least 14. Truncus Arteriosus Repair conduit year) in chronological order. 8. ___ ___ ___ ___ 23. Hybrid 11. Status at Listi ng: Check All Status Details That Apply Per UNOS Policy 3.7 on 11/17/2009: US 1A 1B 2 Status 1A, life expect <14 days <6 mon old, pulmonary hypertension Other _________________ In Hospital >50% systemic pressure Canada _____________________ Out Hospital <6 mon old, pulmonary hypertension UK _____________________ ICU <50% systemic pressure IV Inotropes, high Other _____________________ Growth failure due to acquired IV Inotropes, low or congenital heart disease ABO incompati ble: No Yes Hemo Monitoring If IABP VAD ECMO TAH, complete Mechanical Venti lator Support Form (Form 15) PEDIATRIC HEART TRANSPLANT STUDY ID# P FORM 01: 2010: Initi al Pati ent Entry at Listi ng (PG 2 of 2) P Insti tuiti onal Sequenti al Pati ent Tran To be fi lled out at ti me of listi ng Code Pati ent Number Initi als # 12. Infecti ous HIV: Pos Neg NA IFA Toxo: Pos Neg NA RPR: Pos Neg NA Disease CMVSerology: Pos Neg NA CMV PCR: Pos Neg NA Quant _________ DNA copies/mL Screening GENERAL EBV Serology: Pos Neg NA EBV PCR: Pos Neg NA Quant _________ DNA copies/mL HBs Ag: Pos Neg NA HBs Ab: Pos Neg NA HEPAT HB core Ab: Pos Neg NA Hep C Ab: Pos Neg NA 13a. Blood Type, Pati ent: A (If known: A1 A2) B AB O 13b. Rh: Pos Neg 14. Med Hx: (check all that apply) None Arrhythmia (check below) Dialysis – Acute Peripheral Myopathy Afi b/fl utt er V Tach VFib Dialysis – Chronic Plasti c Bronchiti s Complete Ht Block Failure to thrive Prenatal Diagnosis Other, specify: ____________ Hepati ti s: Dt dx: ___ ___ (MO|YR) Prior Transfusions Asthma Hypertension: Dt dx: ___ ___ Protein Losing Enteropathy CPR: Date Last ___ ___ (MO|YR) Malignancy, type: __________ Renal Insuffi ciency CVA: Date Last ___ ___ Pacemaker: BIV/CRT AICD Shock: Date Last ___ ___ Diabetes Date First Placed ___ ___ Other: ________________ 15. Primary Insurance: (check one) Medicaid ( State HMO) Other Gov Private Self Donati on Free Other _______________ 16. Percent or Panel Reacti ve Anti body (closest to listi ng): PRA, AHG_Enhanced: Yes No Unknown 16a. Cytotoxic PRA: Not Done T Cell _____ % B Cell _____ % Date: ___ ___ ___ 16b. Cytotoxic PRA, DTE/DTT: Not Done T Cell _____ % B Cell _____ % Date: ___ ___ ___ 16c. Flow PRA/Luminex: Not Done Class I _____ % Class II _____ % Date: ___ ___ ___ 16d. ELISA: Not Done Class I _____ % Class II _____ % Date: ___ ___ ___ 16e. Other: Specify Results, Not Done Methods and Units ____________________________________________ Date: ___ ___ ___ 16f. Specifi citi es: Not Done A ____________________ B ____________________ DR _____________________ Method used for specifi citi es: Cytotoxic PRA Single Anti gen Beads Date: ___ ___ ___ 16g. Listed for prospecti ve crossmatch: No Yes If yes, specify: donor cells virtual 17a. Hemodynamics closest to listi ng (Date ___ ___ ___ ): 17b. Indicate agents for best hemodynamics BEST HEMODYNAMICS BEST HEMODYNAMICS None Nesiriti de 100% O2 Nitroglycerine Ram _______ Rp _______ Dopamine Nitroprusside (Nipride) PAm _______ Rs _______ Dobutamine Nitric Oxide PCW _______ AO Sat _______ Milrinone (Primacor) Others, specify: C.O. _______ EDP _______ Isoproterenol (Isuprel) ___________________ C.I. _______ SVC Sat _______ PGE (Alprostadil) ___________________ PRINT IN BLACK INK ONLY. USE THIS FORM FOR ALL PATIENTS OR EVENTS AFTER JANUARY 1, 2010 OR EVENTS AFTER JANUARY ALL PATIENTS FOR USE THIS FORM INK ONLY. PRINT IN BLACK ___________________ Qp/Qs _______ Not Done PGI (Flolan) 18. Schooling: Within one grade level Delayed grade level Special educati on Not applicable, < 6 years Status unknown 19. Exercise Test: 20. Laboratory Values: Date Performed (closest to listi ng) ___ ___ ___ Not done (Print “NA” in spaces if not done) Resti ng BP: ___ / ___ Bili Total Bili Direct AST ALT BNP CRP Creat. BUN/urea HR: ___ Max. durati on: ___ min T Protein S Album Cholesterol TG LDL HDL VLDL Max. BP: ___ / ___ HR: ___ % Predicted for Age: ___ 21. NYHA or Ross’ Heart Failure: Not Done Max. VO2 _______ ml/kg/mi NYHA Class: I II III IV Ross’ Heart Failure Class: I II III IV Person completi ng this form: _____________________________ Date original form mailed (do not send copy) ___________ PEDIATRIC HEART TRANSPLANT STUDY ID# P FORM 01T: 2010: Transplant Informati on (PG 1 of 1) P Insti tuiti onal Sequenti al Pati ent Tran To be fi lled out at ti me of transplant Code Pati ent Number Initi als # 1. Date of Transplant: 3. Simultaneous organ: None ( MO | DAY | YR ) kidney liver other, specify ___________________ 2. Type of Transplant: Orthotopic Heterotopic 4. Height ______ in cm Weight ______ lb kg 5. Status at Transplant: Check All Status Details That Apply Per UNOS Policy 3.7 on 11/17/2009: US 1A 1B 2 Status 1A, life expect <14 days <6 mon old, pulmonary hypertension Other _________________ In Hospital >50% systemic pressure Canada _____________________ Out Hospital <6 mon old, pulmonary hypertension UK _____________________ ICU <50% systemic pressure IV Inotropes, high Other _____________________ Growth failure due to acquired IV Inotropes, low or congenital heart disease ABO incompati ble: No Yes Hemo Monitoring If IABP VAD ECMO TAH, complete Mechanical Venti lator Support Form (Form 15) 6. HLA Allotype: NA A A B B DR DR 7a. Donor Specifi c Crossmatch: Not Done Negati ve Positi ve (if positi ve, please fi ll out Form 16: Anti -HLA Anti bodies) 7b. Prospecti ve Crossmatch: No Yes 7c. B-Cell Method _____ Not Done T-Cell Method _____ Not Done 8. Percent or Panel Reacti ve Anti body (closest to transplant): PRA, AHG_Enhanced: Yes No Unknown 8a. Cytotoxic PRA: Not Done T Cell _____ % B Cell _____ % Date: ___ ___ ___ 8b. Cytotoxic PRA, DTE/DTT: Not Done T Cell _____ % B Cell _____ % Date: ___ ___ ___ 8c. Flow PRA/Luminex: Not Done Class I _____ % Class II _____ % Date: ___ ___ ___ 8d. ELISA: Not Done Class I _____ % Class II _____ % Date: ___ ___ ___ 8e. Other: Specify Results, Not Done Methods and Units _____________________________________________ Date: ___ ___ ___ 8f. Specifi citi es: Not Done A ____________________ B ____________________ DR _____________________ Method used for specifi citi es: Cytotoxic PRA Single Anti gen Beads Date: ___ ___ ___ 8g. DSA: No Yes If yes, specify _________________________________________ 9. Laboratory Values: Date Performed (closest to transplant) ___ ___ ___ (Print “NA” in spaces if not done) Bili Total Bili Direct AST ALT BNP CRP Creat. BUN/urea T Protein S Album Cholesterol TG LDL HDL VLDL 10a. Best Hemodynamics closest to transplant (Date ___ ___ ___ ): 10b. Indicate agents for best hemodynamics Ram _______ Rp _______ None PGI (Flolan) PAm _______ 100% O2 Nesiriti de Rs _______ Dopamine Nitroglycerine PRINT IN BLACK INK ONLY.
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