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Transcript
Cardiac Surgery Report, Adult (age 18 and over) NEW YORK STATE DEPARTMENT OF HEALTH State Cardiac Advisory Committee Facility Name PFI Number Sequence Number I. Patient Information Patient Name (last) (first) Medical Record Number (m.i.) Social Security Number Age in Years Date of Birth m Sex 1 Male Ethnicity 1 Hispanic Race 1 White 2 2 2 8 Female Non-Hispanic Residence (see instructions) Code State or Country d y Hospital Admission Date Black Other m d y d y II. Procedural Information Hospital That Performed Diagnostic Cath Hospital Name PFI Primary Physician Performing Operation Name License Number Date of Primary Surgery m Primary Cardiac Procedure SCAC Code (see instructions) Other Cardiac Procedure SCAC Code (see instructions) LIMA to LAD Minimally Invasive VATS 0 No 0 No 0 No 1 2 With no other arterial grafts With other arterial grafts 1 Yes 1 Yes Converted to Standard Incision Cardioplegia IV Heparin within 48 hours Pre-op 0 None 0 Not Used 1 2 Cold Warm 1 2 Antegrade Retrograde 1 2 Discontinued < 3 hours Pre-op Discontinued 3-48 hours Pre-op 3 Both 3 Both 1 Intermittent 1 Crystalloid 2 Continuous 2 Blood 3 Both Global Myocardial Ischemic Time minutes Cardiopulmonary Bypass Time minutes Converted from off pump to on pump III. Major Events Following Operation (check all that apply) 0 None 5 Bleeding Requiring Reoperation 1 Stroke (new neurological deficit) Intra-Op to 24 hrs 8 Sepsis or Endocarditis 1A 2 4 Stroke (new neurological deficit) over 24 hrs Transmural MI (new Q waves) 9 10 G-I Bleeding, Perforation or Infarction Renal Failure, dialysis Deep Sternal Wound Infection (bone-related) 13 Respiratory Failure IV. Discharge Information Discharged to: 11 Home Died in: 2 30 Day Status: Operating Room 6 In Transit to Other Facility 1 Live Elsewhere in Hospital (specify) 2 9 Dead Unknown 12 13 Hospice Acute Care Fac (Rehab) 3 4 Recovery Room Critical Care Unit 8 14 19 Skilled NH Other (specify) 5 Medical/Surgical Floor Hospital Discharge Date m DOH-2254a (2/99) page 1 of 2 d y V. Pre-Op Surgical Risk Factors (answer all that apply) Surgical Priority 1 2 Elective Urgent 3 Emergency Ejection Fraction Height cm Measure % Weight kg 1 2 Calculated Estimated 9 Unknown Angina: CCS Functional Class (all CABG patients) see instructions Stress Test Results 1 LV Angiogram 1 Positive 2 3 Echocardiogram Radionuclide Studies 2 3 Negative Not Done 4 8 TEE including Intra-Op Other 9 Unknown 9 Unknown 1 Class I 2 3 Class II Class III 4 Class IV Vessels Diseased (check all that apply) LMT Prox LAD or Major Diag Mid/Dist LAD or Major Diag RCA or PDA LCX or Larger Marg 1 50 - 69% 4 50 - 69% 6 50 - 69% 8 50 - 69% 10 50 - 69% 2 3 70 - 89% 90 - 100% 5 70 - 100% 7 70 - 100% 9 70 - 100% 11 70 - 100% Valvular Stenosis and Incompetence(valve patients only) Stenosis: Incompetence: None Mild Aortic Mitral 0 0 1 1 2 2 3 3 Tricuspid Aortic 0 0 1 1 2 2 3 3 Mitral 0 1 2 3 Tricuspid 0 1 2 3 Pulmonary Artery Pressure (valve patients only) Systolic Cardiac Index (valve patients only) liters/min/m2 0 Moderate mm Hg Severe Mean Wedge mm Hg None of the pre-op risk factors listed below were present Previous Open Heart Operations Peripheral Vascular Disease Previous MI (most recent) 1 One 4 <6 hours 2 3 Two Three or more 5 6 6-23 hours days (use 21 for 21 or more) 7 Stroke Hemodynamic Instability at time of procedure 9 10 Carotid/Cerebrovascular Aortoiliac 12 13 Unstable Shock 11 Femoral/Popliteal 37 CPR 8 Check here if Transmural MI 14 More than one Previous MI 28 Immune System Deficiency 15 Hypertension History 29 IABP Pre-op 16 17 IV NTG within 24 hours before operation ECG Evidence of Left Ventricular Hypertrophy 30 31 Emergency Transfer to OR after Dx Cath Emergency Transfer to OR after PTCA 18 19 Congestive Heart Failure, this admission Congestive Heart Failure, before this admission 32 33 Previous PTCA, this admission PTCA before this admission 20 Malignant Ventricular Arrhythmia 34 Thrombolytic Therapy within 7 days 21 22 Chronic Obstructive Pulmonary Disease Myocardial Rupture 35 36 Smoking history, in past 2 weeks Smoking history, in past year 23 24 Extensively Calcified Ascending Aorta Diabetes requiring medication 38 Stent Thrombosis 25 Hepatic Failure Report the following risk factors for Valve surgery only 26 27 Renal Failure, creatinine > 2.5 mg/dl Renal Failure, dialysis 61 62 Cardiomegaly (>50% C-T ratio) Active Endocarditis VI. Person Completing Report Name Referring Physician Date m d y DOH-2254a (2/99) page 2 of 2