Surgical Data Collection Form

Unbalanced AVSD – A congenital Heart Surgeons’ Society Inception Cohort: Surgical Data Collection Form

Study Number: ______

Procedure Date (MM/DD/YY) ☐☐/☐☐/☐☐

Procedure Number ☐☐

If not first procedure, done within same admission as first?☐Yes ☐ No

Intended treatment strategy ______

AVSD Repair ☐Yes (Complete section 1)☐No (skip to next section)

SECTION 1

PA band performed☐Yes☐No

Date of PA band: // (yyyy/mm/dd)

Univentricular repair performed☐Yes☐No

Norwood Procedure performed☐Yes☐No

Date of Norwood: // (yyyy/mm/dd)

Glenn procedure performed☐Yes☐No

Date of Glenn : // (yyyy/mm/dd)

Fontan procedure performed☐Yes☐No

Date of Fontan : // (yyyy/mm/dd)

Specify type: ☐ECC☐Lateral tunnel☐Transcatheter

One and a half ventricle repair performed☐Yes☐No

Date of 1 ½ V repair : // (yyyy/mm/dd)

Heart transplant performed☐Yes☐No

Date of Heart Transplant : // (yyyy/mm/dd)

AVSD Repair ☐Yes☐No

Date of BVR : // (yyyy/mm/dd)

☐Complete ☐Partial (residual VSD?)

Concomitant Procedures

☐RVOT procedure (including TOF repair)

☐Coarctation repair

☐Ligation PDA

☐PA plasty

☐LVOT procedure

☐ Other procedure (please specify)

Was there a 2nd bypass to repair residual lesions?☐Yes☐No

Indication?MIMSTITS VSDASDFenestration

Total Bypass Time ______

Total cross clamp Time ______

Total Ischemic Time ______

Circulatory Arrest Time ______

PREOPERATIVE FACTORS (select all that apply)

10 = No preoperative factors identified

200 = Cardio-pulmonary resuscitation

210 = Preoperative complete AV block

220 = Preoperative/Preprocedural mechanical circulatory support (IABP, VAD, ECMO, or CPS)

230 = Shock, Persistent at time of surgery

240 = Shock, Resolved at time of surgery

250 = Diabetes mellitus, Insulin dependent

260 = Diabetes mellitus, Non-insulin dependent

270 = Hypothyroidism

280 = Currently taking steroids as treatment for adrenal insufficiency

290 = Currently taking steroids for any reason other than treatment of adrenal insufficiency

295 = Colostomy present

300 = Enterostomy of small intestine present

305 = Esophagostomy present

307 = Gastrostomy present

310 = Hepatic dysfunction

320 = Necrotizing entero-colitis, Treated medically

330 = Necrotizing entero-colitis, Treated surgically

340 = Coagulation disorder, Hypercoagulable state

350 = Coagulation disorder, Hypocoagulable state not secondary to medication (intrinsic hypocoagulable state)

360 = Coagulation disorder, Hypocoagulable state secondary to medication

370 = Endocarditis

380 = Sepsis

390 = Sepsis with positive blood culture

400 = Preoperative neurological deficit

410 = Seizure during lifetime

420 = Seizure within 48 hours prior to surgery

430 = Stroke, CVA, or Intracranial hemorrhage > Grade 2 during lifetime

440 = Stroke, CVA, or Intracranial hemorrhage > Grade 2 within 48 hours prior to surgery

450 = Renal dysfunction

460 = Renal failure requiring dialysis

470 = Mechanical ventilation to treat cardiorespiratory failure

480 = Respiratory Syncytial Virus

490 = Single lung

500 = Tracheostomy present

777 = Other preoperative factors

Section 2 (FOR AVSD REPAIR ONLY)

Septal Defect Closure

AVSD Patch

☐Single☐Modified single patch☐2-Patch☐No-Patch (Nunn)

Single PatchASD Patch

☐Gore-tex☐Gore-tex

☐Dacron☐Dacron

☐Bovine pericardium☐Bovine pericardium

☐Autologous pericardium☐Autologous pericardium

☐Allograft☐Allograft

☐Other ______☐Other ______

Suture ☐Continuous ☐InterruptedSuture ☐Continuous ☐Interrupted

VSD Patch

☐Gore-tex

☐Dacron

☐Bovine pericardium

☐Autologous pericardium

☐Allograft

☐Other

☐None

Suture ☐Continuous ☐Interrupted

Fenestration ☐Yes ☐ No

If Yes, Atrial☐Yes ☐ No

VSD ☐Yes ☐ No

AV Valve Procedure

☐Cleft Closure

☐Annuloplasty

☐Chordal Resuspension

☐Leaflet Repair

☐Valve Replacement

☐Single Valve☐Right ☐Left

☐Size: ______

☐Tissue☐Mechanical

☐Double ValveSize: ______

Valve 1☐Tissue☐Mechanical

Valve 2☐Tissue☐Mechanical

Comments: ______

Version Date: 15 August 2011 Page 1 of 3