the RVAD from the provided drop down boxes. Please refer to Appendix K (Device Brand Table available at for reference purposes). Durable Devices Temporary Devices (include only in conjunction LVAD, BiVAD, TAH with a durable device listed above) HeartMate II LVAS Abiomed AB5000 HeartMate 3 Abiomed BVS 5000 HeartMate IP Biomedicus HeartMate VE Thoratec Centrimag (Levitronix) HeartMate XVE Sorin Revolution HeartWare HVAD TandemHeart Micromed DeBakey VAD Child Abiomed Impella 2.5 – Novacor PC Abiomed Impella 5.0 Novacor PCq Abiomed Impella CP Thoratec IVAD Abiomed Impella RP Thoratec PVAD Other, Specify Abiocor TAH Syncardia Cardiowest TAH 70cc – Berlin Heart EXCOR (paracorporeal) Other, Specify Exclusion: Any exclusion will disqualify the patient for entry into STS Intermacs®: If patient meets ANY exclusion criteria then check any of the appropriate exclusion reasons below: Select all that apply: Patient receives a durable (MCSD) which is not FDA approved Yes or No Patient is incarcerated (prisoner) Yes or No If the patient meets all of the STS Intermacs criteria and none of the exclusion criteria then this patient is enrolled in STS Intermacs® and you will be directed to the Patient Demographics Form. If Patient is EXCLUDED, please complete STS Intermacs® required screening information below: Implant date: Enter the implant date in MMDDYYYY format. patient’s Device Type: Enter the appropriate device side for this implant
the RVAD from the provided drop down boxes. Please refer to Appendix K (Device Brand Table available at for reference purposes). Durable Devices Temporary Devices (include only in conjunction LVAD, BiVAD, TAH with a durable device listed above) HeartMate II LVAS Abiomed AB5000 HeartMate 3 Abiomed BVS 5000 HeartMate IP Biomedicus HeartMate VE Thoratec Centrimag (Levitronix) HeartMate XVE Sorin Revolution HeartWare HVAD TandemHeart Micromed DeBakey VAD – Child Abiomed Impella 2.5 Novacor PC Abiomed Impella 5.0 Novacor PCq Abiomed Impella CP Thoratec IVAD Abiomed Impella RP Thoratec PVAD Other, Specify Abiocor TAH Syncardia Cardiowest TAH – 70cc Berlin Heart EXCOR (paracorporeal) Other, Specify Exclusion: Any exclusion will disqualify the patient for entry into STS Intermacs®: If patient meets ANY exclusion criteria then check any of the appropriate exclusion reasons below: Select all that apply: Patient receives a durable (MCSD) which is not FDA approved Yes or No Patient is incarcerated (prisoner) Yes or No If the patient meets all of the STS Intermacs criteria and none of the exclusion criteria then this patient is enrolled in STS Intermacs® and you will be directed to the Patient Demographics Form. If Patient is EXCLUDED, please complete STS Intermacs® required screening information below: Implant date: Enter the patient’s implant date in MMDDYYYY format. Device Type: Enter the appropriate device side for this implant
STS_Intermacs.docx