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    HM II Candidate Profiles and Pre-Operative Assessment Check List

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    vamshidh
    This document contains a checklist for pre-operative assessment of patients being considered for a HeartMate II left ventricular assist device, including demographic information, medical history, risk factors, current condition, lab results, hemodynamic measurements, and other relevant health details. The risk factor section calculates a total risk score that is used to determine if a patient is at low, medium, high, or very high risk. The checklist collects comprehensive medical information to evaluate candidates for the left ventricular assist device.

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    HM II Candidate Profiles and Pre-Operative Assessment Check List

    Uploaded by

    vamshidh
    64 views3 pages
    This document contains a checklist for pre-operative assessment of patients being considered for a HeartMate II left ventricular assist device, including demographic information, medical history, risk factors, current condition, lab results, hemodynamic measurements, and other relevant health details. The risk factor section calculates a total risk score that is used to determine if a patient is at low, medium, high, or very high risk. The checklist collects comprehensive medical information to evaluate candidates for the left ventricular assist device.

    Original Description:

    HM@ evaluation

    Original Title

    HM II Evaluation -2

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    This document contains a checklist for pre-operative assessment of patients being considered for a HeartMate II left ventricular assist device, including demographic information, medical history, risk factors, current condition, lab results, hemodynamic measurements, and other relevant health details. The risk factor section calculates a total risk score that is used to determine if a patient is at low, medium, high, or very high risk. The checklist collects comprehensive medical information to evaluate candidates for the left ventricular assist device.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    64 views3 pages

    HM II Candidate Profiles and Pre-Operative Assessment Check List

    Uploaded by

    vamshidh
    This document contains a checklist for pre-operative assessment of patients being considered for a HeartMate II left ventricular assist device, including demographic information, medical history, risk factors, current condition, lab results, hemodynamic measurements, and other relevant health details. The risk factor section calculates a total risk score that is used to determine if a patient is at low, medium, high, or very high risk. The checklist collects comprehensive medical information to evaluate candidates for the left ventricular assist device.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    HM II Candidate Profiles and Pre-Operative Assessment Check List

    Age: Gender: LVEF:


    Height:__________ Weight:__________ BSA(m2):__________

    Heart Failure Etiology:


    Acute Myocardial Infarction Congenital Heart Disease Dilated Myopathy Ischemic
    Restrictive Myopathy Arrhythmia Coronary Artery Disease
    Hypertrophic Valvular Heart Disease Cancer
    Cardiomyopathy
    Dilated Myopathy Post Cardiotomy Cardiogenic Other Please describe:
    Idiopathic Shock _________________________

    Indication:
    Bridge to Transplant Destination Therapy Post Cardiotomy
    Myocardial Recovery Other Please describe: _________________________

    Risk Factors Weighted Scores: Score


    Platelet count <148 x 10/l Score : 7
    Serum albumin <3.3g/dl Score: 5
    International normalization ratio > 1.1 Score: 4
    Vasodilator therapy Score : 4
    Mean pulmonary artery pressure <25 mmHg Score: 3
    Aspartate aminotransferase > 45 U/mL Score: 2
    Hematocrit <34% - Score : 2
    Blood urea nitrogen > 51 mg/dl Score: 2
    No intravenous inotropes Score: 2
    Total Score:
    0-8: Low risk 9-16: Medium risk 17-19: High risk >19: Very high risk

    Right-Heart Function: Desirable Value Current Value


    RVSWI >300 mmHg x mL/m
    Central venous pressure <15 mmHg
    Tricuspid regurgitation Minimal to moderate
    Pulmonary vascular resistance < 4 woods units
    Transpulmonary gradient <15 mmHg
    RV Size
    RVEDV <200 ml
    RVESV <177 ml
    Need for pre-op ventilator support None
    RVSP:
    TAPSE:
    RVEF
    LV d (diastole)
    LV d (systole)
    RWMA:
    Aortic root (size)
    AR
    MR
    IVS
    IAS
    HR
    HR rhythm

    Other Remarks:
    Pacemaker/CRT-P/CRT-D/AICD Implant: Prosthetic Heart Valve Implant:

    Date of Implant: Date of Implant:

    Model of Device: Model/Type of Valve:

    Metabolic Markers: Desirable Value Current Value


    Renal
    Blood Urea Nitrogen <40 mg/dl
    Serum Creatinine <2.5 mg/dl
    Estimated GFR >50 ml/kg/min
    Serum Potassium
    Serum Sodium
    Serum Bicarbonate
    Serum Lactate
    Metabolic Markers: Desirable Value Current Value
    Hematology
    INR <1.2
    Hemoglobin >10 g/dl
    Platelets >150,000/mm

    Nutritional
    Pre-albumin >15 mg/dl
    Albumin >3 g/dl
    Transferrin >250 mg/dl

    Hepatic
    Total bilirubin <2.5 mg/dl
    ALT, AST <2 times normal

    Hemodynamic
    Right atrial pressure <15 mmHg
    PCWP <24 mmHg
    ABP
    Current Condition:
    Admitted/Non admitted:
    If yes since when:
    On ventilator: Yes/No

    If yes Since when:


    Inotropic support: Y/N
    Pl specify: Drugs & Dosages:
    On IABP: Yes/No
    If yes Since when:
    NYHA Class:
    Suffering from HF since:
    Current LVEF %:
    X- ray
    Pulmonary Function:
    PFT:
    Coronary Angiogram:
    Hb:
    TC:
    ESR
    Temp:
    Infection if any:
    Recent history of illness:
    Past history of any surgery:
    Any other disease: DM/Thyroid/any others ..Pl specify

    Current medications:
    Any specific concerns:

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