Patient Assessment Form 1Paper 12Paper 23Paper 34Paper 45Paper 5 Paper 1Patient Name Phone Number AgeClinical evaluationConsultation date MM slash DD slash YYYY Previous assessment for TAVI Yes No History and risk factorsPrior CABG Yes No Prior aortic valve procedure Yes No Prior other valve procedure Yes No Number of previous cardiac surgery None 1 2 Prior arrhythmia Yes No Permanent peacemaker Yes No Other historyPrevious CVA or TIA Yes No Extracardiac arteriopathy Yes No Hypertension Yes No Diabetes melitus Yes No Renal insufficiency requiring dialysis Yes No Renal insufficiency requiring renal transplant Yes No Chronic lung disease Yes No Malignancy (prior or current) Yes No Malignancy notes Paper 2Clinical evaluation continuedSyncope Yes No CCS Yes No NYHA I II III IV Clinical dataHeight (cm) Weight (kg) Body mass index (BMI) Automatically calculatedHemoglobin (g/dl) Creatinine (mg/dl) Creatinine clearance Automatically calculatedPre-operative special investigationsECGRhythm PR Interval (ms) QRS Duration (ms) ECHO (TTE or TOE)Mean gradient across aortic valve (mm Hg) Aortic valve area (cm2) Aortic valve peak velocity (m/s) Aortic valve annulus diameter (mm) Ejection fraction (%) LVED (ml) Pulmonary artery pressure (mm Hg) Associated valvular lesionsAortic insufficiency None Mild Moderate Severe Mitral insufficiency None Mild Moderate Severe Mitral stenosis None Mild Moderate Severe Tricuspid insufficiency None Mild Moderate Severe Tricuspid stenosis None Mild Moderate Severe Pulmonary insufficiency None Mild Moderate Severe Pulmonary stenosis None Mild Moderate Severe Paper 3TAVI evaluationRisk profilePredicted operative risk Log euroscore (%) STS score (%) Euroscore II (%) Contra-indication to surgery Yes No OtherReason for contra-indication to surgeryFrailty Yes No Porcelain aorta Yes No Patent LIMA graft Yes No Hostile thorax Yes No Further investigationsLung function tests Yes No Angiogram Yes No Number of diseased vessels 1 2 3 PCI or revascularization indicated Yes No CT coronary angiogram Yes No Pre TAVI CT AssessmentAortic AnnulusPerimeter (mm) Perimeter derived (mm) AREA (mm2) Area derived (mm) LVOTPerimeter (mm) Perimeter derived (mm) AREA (mm2) Area derived (mm) Sinus of ValsalvaSOV Perimeter derived Left Right Non MAX Ascending Aorta Angle STJ Angle MeasurementsAortic AnnulusMin Aortic Annulus Diameter (mm) Max Aortic Annulus Diameter (mm) Average Aortic Annulus Diameter LVOTMin LVOT diameter Max LVOT diameter Average Aortic Annulus Diameter STJ angleMin Max Average LCA Height RCA Height Aortic Valve Calcification Aortic Root Angulation Paper 4TAVI procedureProcedure date MM slash DD slash YYYY Procedural location Type of anesthesia Local General TOE used intra-operatively Yes No Valve in valve procedure Yes No VIV procedure planningProcedural success Yes No Reason procedural not successfulDuration of procedure (mins) Procedural complications (VARC < 72 hours)Intra-procedural mortality Yes No Consequent mortality < 72 hr post-procedure Yes No Myocardial infarction Yes No Stroke or TIA Yes No New PML Yes No Bleeding complications Yes No Vascular complication Yes No Valve dysfunction Yes No Other thrombotic or embolic complications Yes No Cardiopulmonary bypass required Yes No Other procedural complications Yes No Conversion to open heart surgery Yes No Device informationAccess site Access method Number of valves implanted None 1 2 3 Pre-dilatation Ballon Yes No Note Size Post-dilatation Ballon Yes No Note Size Valve 1Type implanted Medtronic Boston Medtronic dataModel implanted Evolut R Evolut R PRO Evolut R PRO+ FX Size implanted 23 26 29 34 Valve result PVL-trace Not-detectable Boston dataModel implanted ACURATE neo2 Size implanted S M L XL Valve result PVL-trace not-detectable Hospital stayDays in ICU Days in high care Days in ward Paper 5Follow up informationGeneral follow upStroke / TIA since TAVI Yes No NotePPM since TAVI Yes No PPM – timeframe Intraprocedural Post-procedural NoteReason of PPM Hospital admission Yes No Number of admission 1 2 3 Follow up 30 daysFollow up date MM slash DD slash YYYY Patient status NYHA class I II III IV Stroke / TIA since TAVI Yes No PPM since TAVI Yes No ComplicationsFollow up notes