CoreValve

Medtronic CoreValve
1 Jenner, Suite 100
Irvine, CA 92618
949-333-2500

Trans Catheter Valve Patient Selection Form

Hospital:
City:

Contents:
Angio (with graduated pigtail
catheter)
TTE
TEE
MS CT

Country:
Physician:
E-mail:
Phone
number

Date:

Patient Informed Consent obtained yes

no

Patient Information
Name
Date Of
Birth:
Sex:
Surgical
Risk

Acceptable

Height:
NYHA:
Weight
Euro score:
:
BMI:
STS score:
High Risk
Inoperable

Clinical History / Co-morbidities

Unstable Angina?

Y/N/U

Aortic aneurysm?

Y/N/U

Atrial fibrillation?
Coronary Artery Disease?
Congestive Heart Failure?
Cardiomyopathy?
Diabetes mellitus?
If above yes: IDDM or NIDDM
Hyperlipidemia?

Y/N/U
Y/N/U
Y/N/U
Y/N/U
Y/N/U
IDDM / NIDDM
/U
Y/N/U

Hypertension?

Y/N/U

Myocardial Infarction?
If above yes: < 3 months ago?
Other? / Comments

Y/N/U
Y/N/U

Serum Creatinine:

Porcelain aorta?
Chronic Obstruct. Pulm.
Disease?
Pulmonary hypertension?
Renal failure?
If above yes: dialysis?
Stroke or TIA?
Carotid artery disease?

Y/N/U
Y/N/U
Y/N/U
Y/N/U
Y/N/U

Permanent pacemaker?

Y/N/U

Implanted defibrillator?
Coronary Artery Bypass
Surgery?
Peripheral Vascular Disease?
Valvular surgery?

Y/N/U

Y/N/U
Y/N/U

Y/N/U
Y/N/U
Y/N/U

Measurements
Coronary
Analysis:

Comments:
LM
LAD
LCX
RCA
Grafts, LIMA /RIMA

Aortic Valve Analysis

Measuremen Diameters
Angio
ts:
Annulus Diameter (mm)
Sinus of Valsalva Diameter (mm)
Sinotubular Junction Diameter
(mm)
Ascending Aorta Diameter (mm)
LVOT Diameter (mm)
LVEF (%)
Lengths
Native Leaflet to Sinutubular
Junction (mm)

Angio

Echo

MS CT

Echo

MS CT

Angles
Angio
Echo
MS CT
Annular Angulation
Aortic Arch Angulation
Femoral/Subclavian/Axillary Analysis
Measuremen
Angio
MS CT
ts:
Left
Right
Left
Right
Iliac (mm)
Femoral (mm)
Subclavian/Axillary (mm)
Comments:
Echocardiogram (TTE / TEE) Analysis
Measuremen Septal Wall Thickness
6 - 13 (mm)
14- 16 (mm)
> 17 (mm)
ts:
Posterior Wall
6 - 13 (mm)
14- 16 (mm)
> 17 (mm)
Thickness
Echocardiogr Aortic stenosis - Max gradient
Mitral stenosis- Mean gradient
am (TTE /
(mmHg)
(mmHg)
TEE)
Aortic stenosis - Mean gradient
Mitral regurgitation, grade
Analysis:
(mmHg)
Aortic Valve Area (cm2)
Tricuspid regurgitation, grade
Aortic regurgitation, grade
PAPS / PHT
Thrombus:

Sub Aortic
Stenosis:

Y/N/U

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