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SHOCK TRIAL

MITRAL VALVE SURGERY

Form S3

INSTRUCTIONS:	COMPLETE FOR   1)	PATIENTS WHO EXCLUDE DUE TO ACUTE 																	SEVERE MITRAL REGURGITATION AND 																	UNDERGO MITRAL VALVE SURGERY 
											     2)	TRIAL PATIENTS WHO UNDERGO MITRAL 
													VALVE SURGERY
		
						TO BE COMPLETED BY PERFUSIONIST OR SURGEON
			

A.	IDENTIFICATION

A1.		Clinic Site Code and Patient I.D.
ID LABEL HERE MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗   
A2.		Date Form Completed									___ ___ / ___ ___ / ___ ___
           (COMP_D is character and is COMPD numeric)	    MO		DAY		YEAR
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
A3.		Person Completing Form								___________________________________
																		(NAME - PLEASE PRINT)

A4.		Date of Surgery										___ ___ / ___ ___ / ___ ___
           (SURG_D is character and is SURGDTE numeric)	    MO		DAY		YEAR
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
B.  PROCEDURES

B1.		Mitral procedure										1.  Replacement		2.  Repair  (Q.B1.2)
	 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		B1.1  IF REPLACEMENT,

				a.  Type of Valve									__________________________(specify)
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				b.  Size of Valve									____ ____ mm
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				c.  Preservation of leaflets/chordae/
					papillary muscle								1.  No					2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		B1.2  IF REPAIR,

				a.  Anterior										1.  No					2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				b.  Posterior										1.  No					2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				c.  Annuloplasty Ring								1.  No (Q.B2)			2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
					c.1  IF YES, Size of ring						____ ____ mm
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
B2. 	Other procedures

		a.  Aneurysmectomy										1.  No					2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		b.  Repair VSD											1.  No					2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		c.  Repair LV rupture										1.  No					2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		d.  Repair RV rupture										1.  No					2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		e.  Aortic valve surgery									1.  No					2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗

C.  		CARDIAC FUNCTION

C1.		a.  Pre-Operative LV Ejection Fraction					____ ____%  			-9.  Not available (Q.C2)
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		b.  Measurement obtained by 								1.  LV gram		2.  Echo 		3.  RVG
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
C2. 	Pre-Operative RV Function 	

		a.  Ejection Fraction										____ ____% 			-9.  Not available
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		b.  Qualitative Assessment

				1.  Normal		2.  Mild dysfunction	3.  Moderate dysfunction	4.  Severe dysfunction
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		c.  Tricuspid Regurgitation					1.  0			2.  1 - 2+			3.  3 - 4+
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗








 Patient ID Number   ___ ___ - ___ ___ ___ ___ - ___


Quality of Life - OLS  9/21/92  Page page1



SHOCK TRIAL - Form S3 - Version 1.0 Date 11/30/94  Page PAGE2

SHOCK TRIAL - Form S3 - Version 1.0 Date 11/30/94  Page PAGE1






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