CoreValve

Medtronic CoreValve1 Jenner, Suite 100Irvine, CA 92618

949-333-2500

Trans Catheter Valve Patient Selection FormHospital:Contents:Date:

City:( Angio (with graduated pigtail catheter)

Country:( TTE ( TEE

Physician:( MS CT

E-mail:

Phone numberPatient Informed Consent obtained ( yes ( no

Patient InformationNameHeight:NYHA:

Date Of Birth:Weight:Euro score:

Sex:BMI:STS score:

Surgical Risk( Acceptable ( High Risk ( Inoperable

Clinical History / Co-morbidities

Unstable Angina?

Y / N / UPorcelain aorta?

Y / N / U

Aortic aneurysm?

Y / N / UChronic Obstruct. Pulm. Disease?

Y / N / U

Atrial fibrillation?

Y / N / UPulmonary hypertension?

Y / N / U

Coronary Artery Disease?

Y / N / URenal failure?

Y / N / U

Congestive Heart Failure?

Y / N / UIf above yes: dialysis?

Y / N / U

Cardiomyopathy?

Y / N / UStroke or TIA?

Y / N / U

Diabetes mellitus?

Y / N / UCarotid artery disease?

Y / N / U

If above yes: IDDM or NIDDM

IDDM / NIDDM / UPermanent pacemaker?

Y / N / U

Hyperlipidemia?

Y / N / UImplanted defibrillator?

Y / N / U

Hypertension?

Y / N / UCoronary Artery Bypass Surgery?

Y / N / U

Myocardial Infarction?

Y / N / UPeripheral Vascular Disease?

Y / N / U

If above yes: < 3 months ago?Y / N / UValvular surgery?

Y / N / U

Other? / CommentsSerum Creatinine:

Measurements

Coronary Analysis: Comments:

LMLAD

LCX

RCA

Grafts, LIMA /RIMA

Aortic Valve Analysis

Measurements: Diameters

AngioEchoMS CTAnnulus Diameter (mm)Sinus of Valsalva Diameter (mm)Sinotubular Junction Diameter (mm)Ascending Aorta Diameter (mm)LVOT Diameter (mm)LVEF (%)

Lengths

AngioEchoMS CTNative Leaflet to Sinutubular Junction (mm)

Angles

AngioEchoMS CTAnnular Angulation

Aortic Arch Angulation

Femoral/Subclavian/Axillary Analysis

Measurements: AngioMS CTLeft

Right

Left

Right

Iliac (mm)Femoral (mm)Subclavian/Axillary (mm)

Comments:

Echocardiogram (TTE / TEE) Analysis

Measurements:Septal Wall Thickness

(6 - 13 (mm)(14- 16 (mm)

(> 17 (mm)Posterior Wall Thickness(6 - 13 (mm)(14- 16 (mm)

(> 17 (mm)

Echocardiogram (TTE / TEE) Analysis: Aortic stenosis - Max gradient (mmHg)

Mitral stenosis- Mean gradient (mmHg)

Aortic stenosis - Mean gradient (mmHg)

Mitral regurgitation, grade

Aortic Valve Area (cm2)

Tricuspid regurgitation, grade

Aortic regurgitation, grade

PAPS / PHT

Thrombus:Y / N / USub Aortic Stenosis:Y / N / U

Comments:

General Instructions

Please enclose DICOM-compatible images of all screening exams with this form.

All patient information (including DICOM disks) must be received at least 3 weeks before the scheduled

procedure date. Otherwise, reserved dates for your center cannot be guaranteed

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