Instructions for use: Ikus - Berlin Heart

13.4 EXCOR standard forms implantation record
EXCOR standard forms implantation record
Please fill out the implantation record form (a total of 2 pages) and fax or send a copy of it to the Berlin Heart
GmbH immediately after implantation.
After explanting the system or replacing a pump resp., please fill out the “Follow up” or the “Pump Replacement”section
resp. Fax or send a copy of the completed form to the Berlin Heart GmbH.
Berlin Heart GmbH, Wiesenweg 10, 12247 Berlin, Germany
Tel.: +49(0)30. 8187 2600, Fax: +49(0)30. 81872737, service@berlinheart.de
Hospital: City/ Country:
Patient data (for Berlin Heart registry)
Patient’s initials:
Implantation
Followup
Pump replacement
Sex m O / f O Date of birth:
Body size:
[cm]
Weight:
[kg]
Id.No.: IABP pre-op n O y O ECMO pre-op n O y O , since ___ days
On transplantation list n O y O, since _______ months
Ischemic CMP O Idiopathic CMP O Acute Myocarditis O Postcardiotomy O
Acute Myocardial Infarction O Congenital: O ____________________ Other: O ______________________
PAP mean
[mmHg]
CVP
[mmHg]
Cl
[l/min/m²] NYHA
Creatinine
[mg/dl]
Total Bilirubin
[mg/dl]
Date: Surgeon:
MAP
[mmHg]
LVEDP
[mmHg]
Platelet count
[ /μl]
LVEF %
FS %
LVEDD
[mm]
Leukocytes
[ /μl]
Type: BVAD O LVAD O RVAD O Access: medial O lateral O Left sided cannulation:atrial O apical O
LVAD Pump type: PU valve O Tilting-disk valve O
Pump size: 10 ml O 25ml O 30 ml O 50 ml O 60ml O 80ml O
RVAD Pump type: PU valve O Tilting-disk valve O
Pump size: 10 ml O 25ml O 30 ml O 50 ml O 60ml O 80ml O
Ikus no.:__________ Ikus hours of operation: ____________________________________
Date: Signature
Date: Weaning O Out of hospital O TX O Expired O
Left pump O Reason for replacement: _________________________________________
Date: Location of deposit: inflow O outflow O pump chamber O
Right pump O Reason for replacement: _________________________________________
Date: Location of deposit: inflow O outflow O pump chamber O
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