Explant reason: Select one of the following as the reason for explant. If Device is removed (turned off) for reasons than recovery, transplant, or death, type in the specification in the block provided. Explant - Fill out death form – If Yes, Evidence of Pump Thrombosis? Yes, No, or Unknown Explant - Transplanted - Enter Transplant Date and Waitlist ID below If Yes, Evidence of Pump Thrombosis? Yes, No, or Unknown Transplant date: Enter the transplant date in MMDDYYYY format. ST= Unknown UNOS waitlist identifier. Waitlist ID: (May enter when ID is unknown) “99999” Explant - Exchange Explant Reasons all that apply): Device Malfunction: Elective Device Malfunction: Emergent Device Thrombosis: Elective Device Thrombosis: Emergent Infection: Elective Infection: Emergent Specify If Specify: please complete text box Yes, No, or Unknown New device part of an FDA IDE trial? If Yes, enter name of FDA IDE in the text box provided. Explant - No New Device Explant Reasons (Check all that apply): Recovery Withdrawal of Support Device Malfunction: Elective Device Malfunction: Emergent Device Thrombosis: Elective Device Thrombosis: Emergent Infection: Elective Infection: Emergent Other, Specify If Specify: please complete text box Turned Off (Decommissioned) Reasons (Check all that apply): Recovery Withdrawal of Support Device Malfunction: Elective Device Malfunction: Emergent Device Thrombosis: Elective Device Thrombosis: Emergent Infection: Elective Infection: Emergent Other, Specify If Specify: please complete text box Note: If patient is transplanted, that patient will no longer be followed in the STS Intermacs® Registry, but will be followed in the UNOS web-based data entry for transplant system. Note: If the explanted device was not functioning normally (malfunction or thrombosis) then complete the Device Malfunction Form.
Explant reason: Select one of the following as the reason for explant. If Device is removed (turned off) for reasons than recovery, transplant, or death, type in the specification in the block provided. Explant - – Fill out death form If Yes, Evidence of Pump Thrombosis? Yes, No, or Unknown Explant - Transplanted - Enter Transplant Date and Waitlist ID below If Yes, Evidence of Pump Thrombosis? Yes, No, or Unknown Transplant date: Enter the transplant date in MMDDYYYY format. ST= Unknown Waitlist ID: UNOS waitlist identifier. (May enter “99999” when ID is unknown) Explant - Exchange Explant Reasons all that apply): Device Malfunction: Elective Device Malfunction: Emergent Device Thrombosis: Elective Device Thrombosis: Emergent Infection: Elective Infection: Emergent Specify If Specify: please complete text box New device part of an FDA IDE trial? Yes, No, or Unknown If Yes, enter name of FDA IDE in the text box provided. Explant - No New Device Explant Reasons (Check all that apply): Recovery Withdrawal of Support Device Malfunction: Elective Device Malfunction: Emergent Device Thrombosis: Elective Device Thrombosis: Emergent Infection: Elective Infection: Emergent Other, Specify If Specify: please complete text box Turned Off (Decommissioned) Reasons (Check all that apply): Recovery Withdrawal of Support Device Malfunction: Elective Device Malfunction: Emergent Device Thrombosis: Elective Device Thrombosis: Emergent Infection: Elective Infection: Emergent Other, Specify If Specify: please complete text box Note: If patient is transplanted, that patient will no longer be followed in the STS Intermacs® Registry, but will be followed in the UNOS web-based data entry for transplant system. Note: If the explanted device was not functioning normally (malfunction or thrombosis) then complete the Device Malfunction Form.