Patient ID __ __ __ __ __ Patient Study ID AVM - __ __ - __ __ __ __

Date of form completion ____ / ____ / 20 ____ Initials of person completing the form __ __ __
mm dd yyyy
Study period __ Preoperative __ 6-month f/u __ 3-year f/u __ 10-year f/u
__ Postoperative __ 1-year f/u __ 5-year f/u __ Post 10-year f/u
__ Operative __ 2-year f/u __ 7-year f/u __ Unplanned visit
or hospitalization
If operative: __ Pre-procedure __ Post-procedure

ECHOCARDIOGRAPHY DATA REPORT FORM

A. General Information

1. Date of echocardiographic exam: __ __ - __ __ - __ __

2. BSA: __.__ cm2 __ Unknown

3. Heart rate at the time of echocardiography, bpm: __ __ __ __ Unknown

4. Blood pressure at the time of echocardiography: __ __ __ / __ __ __ mm Hg __ Unknown

5. Imaging quality: __ Excellent __ Good __ Adequate __ Poor or inadequate

6. TEE: __ Yes __ No

7. Data source: __ Echo reading __ Report __ Both

B. Aortic Dimensions, mm

Annulus __ Arch __
Sinus __ Upper descending __
Sino-tubular junction __ Mid descending __
Mid ascending __ Upper abdominal, mm __
Upper ascending __
Data source: __ Echo reading __ Report

C. 2D

2D __ PLAX __ PSAX

IVSd thickness, cm __.__

PWd thickness, cm __.__
LVEDD, cm __.__
LVESD, cm __.__
EF by 2D, % __ __

Visual EF. % __ __
Data source: __ Echo reading __ Report

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D. Volumes

View: __ 4 chamber __ 4 chamber/Apical long axis

LVED biplane volume, ml __ __ __

LVES biplane volume, ml __ __ __
Biplane Sympson EF, % __ __

Single plane volumes

View: __ 4 chamber __ 2 chamber __ Apical long axis

LVED volume, ml __ __ __
LVES volume, ml __ __ __
EF by single plane volume, % __ __

E. Pulsed Wave Doppler

MV

E vel leaf tip, m/sec __.__

A vel leaf tip, m/sec __.__
Dt leaflet tip, ms __ __ __

LVOT

Vel, m/sec __.__

TVI, cm __ __

Abdominal Aorta

Diastolic reversal TVI, cm __ __

Descending Aorta

Diastolic reversal TVI, cm __ __

F. Continuous Wave/Color Flow Doppler

Aortic Valve

Systolic velocity, m/sec __.__

TVI, cm __ __
Mean gradient, mm Hg __.__
AR early-diastolic velocity, m/sec __.__
AR ½ time ms __ __ __

Aortic Regurgitation Incomplete PISA parameters __

PISA

PISA radius, cm __.__ __

Alias velocity, cm/sec __ __

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AR early-diastolic velocity, cm/sec __ __ __
AR TVI, cm __ __ __
ERO, cm2 __.__ __
Regurgitant volume, ml __ __

Composite AR severity:
__ None
__ Trivial
__ Grade 1
__ Grade 2
__ Grade 3
__ Grade 4
__ Indeterminate regurgitation
Data source: __ Echo reading __ Report

Aortic valve morphology, CHECK ALL THAT APPLY:

__ Normal
__ Bicuspid
__ Unicuspid
__ Quadracuspid
__ Flail
__ Prolapse
__ Repair
__ Replacement
__ Other, specify:
__ Unknown
Data source: __ Echo reading __ Report

Mitral Regurgitation Incomplete PISA parameters __

PISA

PISA radius, cm __.__ __

Alias velocity, cm/sec __ __
MR velocity, cm/sec __ __ __
MR TVI, cm __ __ __
ERO, cm2 __.__ __
Regurgitant volume, ml __ __

Composite MR severity:
__ None
__ Trivial
__ Grade 1
__ Grade 2
__ Grade 3
__ Grade 4
__ Indeterminate regurgitation
Data source: __ Echo reading __ Report

Mitral valve morphology, CHECK ALL THAT APPLY:

__ Normal
__ Prolapse
__ Flail
__ Rheumatic

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__ Repair
__ Replacement
__ Other, specify:
__ Unknown
Data source: __ Echo reading __ Report

Tricuspid Regurgitation

Systolic velocity, m/sec __.__

RA pressure (est), mm Hg __ __

TR severity:
__ None
__ Trivial
__ Grade 1
__ Grade 2
__ Grade 3
__ Grade 4
__ Indeterminate regurgitation
Data source: __ Echo reading __ Report

Pulmonary Valve

Systolic velocity, m/sec __.__

PR end-diastolic velocity, m/sec __.__

PR severity:
__ None
__ Trivial
__ Grade 1
__ Grade 2
__ Grade 3
__ Grade 4
__ Indeterminate regurgitation
Data source: __ Echo reading __ Report

G. Comments

Aortic dimensions:

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Abbreviations

AR Aortic regurgitation
BSA Body surface area
d Diastolic
EF Ejection fraction
ERO Effective regurgitant orifice
IVS Intra ventricular septum thickness
LA Left atrium
LV Left ventricle
LVOT LV outflow tract
LVEDD LV end diastolic dimension
LVESD LV end systolic dimension
MR Mitral regurgitation
MV Mitral valve
PISA Proximal isovelocity surface area
PR Pulmonic regurgitation
PSAX Parasternal short axis
PW Posterior wall
RA Right atrium
s Systolic
TEE Transesophageal echocardiogram
TR Tricuspid regurgitation
TVI Time-velocity integral

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