1 Week / 1 Month Follow-Up

1 Week / 1 Month Follow-Up

Follow-up date:* Facility Type:*

State reason why you are unable to obtain follow-up information:*

General Hemodynamics - during report interval

Peripheral edema* YES NO UNK

Ascites:* YES NO UNK

ECG rhythm (cardiac rhythm):* Specify:*

Height:* in cm ST=

Weight:* _{lbs kg ST=}

Invasive Hemodynamics - during report interval

Date of Measurement:* mm/dd/yyyy ST=

Pulmonary artery systolic

pressure:* mm Hg ST=

Mean Pulmonary artery diastolic

pressure:* mm Hg ST=

Mean RA Pressure:* _{mm Hg ST=}

PVRI:* wood units ST=

Pulmonary artery wedge

pressure:* mm Hg ST=

Cardiac Index:* _L/min/m2 _ST=

Please answer the following questions regarding patient status as of the day of follow-up Is the patient intubated?:* _{YES NO UNK}

Is the patient on dialysis?:* _{YES NO UNK} Medications

Is the patient currently on IV

therapy at time of follow-up?:* YES NO UNK If yes, IV therapy agents:* _Dopamine

Unknown Vasopressin Nitroprusside Fenoldopam Neseritide Prostacyclin If yes, was the patient sent

home with an IV?:* YES NO UNK

ACE inhibitors:* YES NO UNK

Aldosterone antagonist:* _{YES NO UNK}

Amiodarone:* _{YES NO UNK}

Angiotensin receptor blocker

drug:* YES NO UNK

Antiplatelet therapy drug:* YES NO UNK

Select drug(s)* Aspirin

Dexpran Dipyridamole Clopidogrel Ticlopidine Unknown Other, specify Specify:*

Beta-blockers:* YES NO UNK

Calcium channel

blockers:* YES NO UNK

Digoxin:* _{YES NO UNK}

Hydralazine:*

YES NO UNK

Loop Diuretics:* YES NO UNK

If yes, enter dosage:* ST=:

If dose is entered, then check type of loop diuretic (check all that apply):*

Furosemide Torsemide Bumetanide Other

Lovenox:* YES NO UNK

Nesiritide:* YES NO UNK

Nitric oxide:* YES NO UNK

Sildenafil/Bosentan:* YES NO UNK

UFH: Unfractionated Heparin:* _{YES NO UNK}

Warfarin (coumadin):* _{YES NO UNK}

Pump Change

Please answer the following questions regarding patient status considering all time since previous visit and current follow-up date.

Was there a pump change?* _{YES NO UNK}

If yes, please select one of the following:*

Please select appropriate reason:*

The Device Malfunction Form needs to be completed. Transfusions

Was there a transfusion?* YES NO

If yes, enter number of PRBC:* ml/kg ST=

Laboratory

Sodium:* mmol/L ST=

Potassium:* _{mEq/L ST=}

Blood urea nitrogen:* mg/dL ST=

Creatinine:* mg/dL ST= SGPT/ALT (alanine aminotransferase/ALT):* u/L ST= SGOT/AST (aspartate aminotransferase/AST):* u/L ST= LDH:* U/L ST= Total bilirubin:* mg/dL ST= Bilirubin direct:* mg/dL ST= Bilirubin indirect:* _{mg/dL ST=} Albumin:* g/dL ST= Pre-albumin:* mg/dL ST= Total Cholesterol:* mg/dL ST=

If value is outside given range please see 'status' drop down field

Brain natriuretic peptide BNP:* pg/ml ST=

If value is outside given range please see 'status' drop down field

NT pro brain natriuretic peptide

Pro-BNP:* pg/ml ST=

White blood cell count:* K/uL ST=

Reticulocyte count:* % ST=

Hemoglobin:* g/dl ST=

Platelets:* _{K/uL ST=}

INR:* international units ST=

Plasma-free hemoglobin:* mg/dL ST=

Positive antiheparin/platelet

antibody (HIT):* YES NO UNK

Is Patient on Direct Thrombin

Inhibitors?* YES NO UNK

Enter drugs:

Heparin Coumadin

Direct thrombin inhibitors (ex: arg, lip, val�) ThrombElastoGraph Hemostasis

System (TEG) profile, MA k:* max amplitude in kaolin ST=

ThrombElastoGraph Hemostasis

System (TEG) profile, R k:* reaction time in kaolin ST=

ThrombElastoGraph Hemostasis

System (TEG) profile, R h:* reaction time w/heparinase ST=

Sensitivity CRP(C Reactive

Protein):* mg/L ST=

Does the patient have a history

of lupus anticoagulant?:* YES NO UNK Medical Condition

NYHA class:* Class I: No limitation of physical activity; physical activity does not cause fatigue, palpitation or shortness of breath.

Class II: Slight limitation of physical activity; comfortable at rest, but ordinary physical activity results in fatigue, palpitations or shortness of breath.

Class III: Marked limitation of physical activity; comfortable at rest, but less than ordinary activity causes fatigue, palpitation or shortness of breath.

Class IV: Unable to carry on minimal physical activity without discomfort; symptoms may be present at rest.

Unknown Ross Classification of Congestive

Heart Failure (patient < 2 yrs of age):*

Ross class II:* Mild tachypnea with feeds in infant Mild diaphoresis with feeds in infant Dyspnea on exercise in older children Unknown

Ross class III:* _{Marked tachypnea with exertion or with feeding} Marked diaphoresis with exertion or with feeding Unknown

Ross class IV:* _Tachypnea

Retractions Grunting Diaphoresis Unknown

Functional Capacity - for follow-up time period (answer yes or no)

Sedated:* YES NO Paralyzed:* YES NO Intubated:* YES NO Ambulating:* YES NO Primary Nutrition:* Excursions

Has the patient had any non-medically required excursions off the unit?*

YES NO UNK

If so, where (please select all

that apply):* Playroom _Cafeteria Walk outside Sitting room General rehab None Specify:*

Adverse Events

Note: Please check that you have entered all Adverse Events since the last follow-up. These events are usually entered during a rehospitalization (or during the index hospitalization). To enter an adverse event click on the button located at the top of the patient overview screen.

Rehospitalization

Explant due to Transplant Explant due to Recovery Explant due to Exchange Death

Device Malfunction (if suspected device thrombosis, then enter here) Major Infection

Neurological Dysfunction Major Bleeding

Cardiac Arrhythmia

Pericardial Fluid Collection Myocardial Infarction Psychiatric Episode Respiratory Failure

Venous Thromboembolic Event Wound Dehiscence

Arterial Non-CNS Thromboembolism Other SAE

Hemolysis