STS Tricuspid/Pulmonic Valve Surgeon Worksheet V2.9 Valve ↓Tricuspid Procedure↓ Tricuspid Stenosis: □Yes □No Tricuspid Insufficiency: □None □Trace/Trivial □Mild □Moderate □Severe Tricuspid Disease Etiology: □Functional/secondary □Endocarditis □Rheumatic etiology □Carcinoid □Congenital □Mixed □Degenerative □Tumor □Trauma failure of previous TV repair/replacement □Reoperation – □Pacing wire/catheter induced dysfunction Procedure Performed Repair (If Repair↓) □Annuloplasty □Pericardium □Suture □Prosthetic Ring □Prosthetic Band □Other □Leaflet resection Replacement (If Replacement↓) Replacement Approach: □Surgical □Transcatheter □Valvectomy (If valve valve □Implant Yes→) Implant type: □Mechanical □Bioprosthetic □Annuloplasty device □Homograft □Transcatheter □Other Implant Model:_____________________________ Implant Size:___________________ Aortic Assessment (epiaortic ultrasound or echo): Concentric Calcification Normal Aorta Extensive Intimal Thickening Protruding Atheroma < 5mm Protruding Atheroma ≥ 5m Mobile Plaques Did Aortic Assessment Alter Operative Plan? Yes No Valve ↓Pulmonic Procedure↓ (If Highest mead gradient: ___________mmHg Pulmonic Stenosis: □Yes □No Yes→) Pulmonic Insufficiency: □None □Trace/Trivial □Mild □Moderate □Severe Pulmonic Disease Etiology: of Tetralogy of Fallot (TOF) repair no prior Tetralogy of Fallot (TOF) □Acquired □Congenital, history □Congenital, repair - failure of previous PV repair or replacement Etiology □Reoperation □Mixed Procedure Performed □Repair/Leaflet Reconstruction (If Approach: □Replacement Replacement→) □Surgical □Transcatheter □Valvectomy (If □Surgeon Fashioned Yes→) □Material PTFE (Gore-Tex) □Pericardium □Other (If device □Commercially Supplied Yes→) □Mechanical □Transcatheter □Bioprosthetic □Homograft Device □Annuloplasty □Other Implant (If □ Yes→) Implant Model:_____________________________ Implant Size:___________________ Aortic Assessment (epiaortic ultrasound or echo): Concentric Calcification Normal Aorta Extensive Intimal Thickening Protruding Atheroma < 5mm Protruding Atheroma ≥ 5m Mobile Plaques Did Aortic Assessment Alter Operative Plan? Yes No
STS Tricuspid/Pulmonic Valve Surgeon Worksheet V2.9 ↓Tricuspid Valve Procedure↓ Tricuspid Stenosis: □Yes □No Tricuspid Insufficiency: □None □Trace/Trivial □Mild □Moderate □Severe Tricuspid Disease Etiology: □Functional/secondary □Endocarditis □Rheumatic □Carcinoid □Congenital □Mixed etiology □Degenerative □Tumor □Trauma □Reoperation – failure of previous TV repair/replacement □Pacing wire/catheter induced dysfunction Procedure Performed Repair (If Repair↓) □Annuloplasty □Pericardium □Suture □Prosthetic Ring □Prosthetic Band □Other □Leaflet resection Replacement (If Replacement↓) Replacement Approach: □Surgical □Transcatheter □Valvectomy □Implant (If Yes→) Implant type: □Mechanical valve □Bioprosthetic valve □Annuloplasty □Homograft □Transcatheter device □Other Implant Model:_____________________________ Implant Size:___________________ Aortic Assessment (epiaortic ultrasound or echo): Concentric Calcification Normal Aorta Extensive Intimal Thickening Protruding Atheroma < 5mm Protruding Atheroma ≥ 5m Mobile Plaques Did Aortic Assessment Alter Operative Plan? Yes No ↓Pulmonic Valve Procedure↓ Pulmonic Stenosis: □Yes □No (If Yes→) Highest mead gradient: ___________mmHg Pulmonic Insufficiency: □None □Trace/Trivial □Mild □Moderate □Severe Pulmonic Disease Etiology: □Acquired □Congenital, history of Tetralogy of Fallot (TOF) repair □Congenital, no prior Tetralogy of Fallot (TOF) repair □Reoperation - failure of previous PV repair or replacement □Mixed Etiology Procedure Performed □Repair/Leaflet Reconstruction □Replacement (If Replacement→) Approach: □Surgical □Transcatheter □Valvectomy □ Implant (If Yes→) □Surgeon Fashioned (If Yes→) □Material PTFE (Gore-Tex) □Pericardium □Other □Commercially Supplied (If Yes→) □Mechanical □Transcatheter device □Bioprosthetic □Homograft □Annuloplasty Device □Other Implant Model:_____________________________ Implant Size:___________________ Aortic Assessment (epiaortic ultrasound or echo): Concentric Calcification Normal Aorta Extensive Intimal Thickening Protruding Atheroma < 5mm Protruding Atheroma ≥ 5m Mobile Plaques Did Aortic Assessment Alter Operative Plan? Yes No
ACSD_TricuspidPulmonic_Worksheet_Final.docx