Test Form – INMENZO

PROFORMA

24.10 – Clinical Proforma

Step 1 of 6

16%

1.1 – Patient Initials

Patient Intials

1.2 – Hospital ID

1.2.1 – Date of Admission

DD slash MM slash YYYY

1.3 – Age

1.4 – Sex

Male

Female

1.5 – HTN

Yes

1.6 – Diabetes

Yes

1.6.1 – If Diabetes Yes, Insulin requiring ?

Yes

Not Available

1.6.2 – If Diabetes Yes – HbA1C

1.7 – LDL (mg/dL)

1.8 – TG (mg/dL)

1.8a – HDL (mg/dL)

1.9 – CKD

Yes

1.9.1 – If CKD Yes, eGFR at time of procedure

Yes

Not Available

1.10 – Previous CAD

Yes

1.10.1 – If Previous CAD Yes, mode of presentation

ACS

CCS

Not Available

1.11 – Previous PCI

Yes

1.11.1 – If Previous PCI Yes, vessel which received stent

LAD -D1

LCX-OM

RCA – PDA – PLV

Not Available

1.12 – Any previous PCI with DCB

Yes

1.13 – Previous CABG

Yes

1.14 – PVOD

Yes

1.15 – Previous CVA

Yes

1.15.1 – If Previous CVA Yes, Ischemic stroke

Yes

Not Available

1.16 – Clinical presentation

STEMI

NSTEMI

CCS

Not Available

1.17 – EF

1.18 – If ACS, Infarct related artery

LAD – D1

LCX – OM

RCA

Ramus

Not Available

Procedural Details

Angiographic data

2.1 – Target Vessel for DCB

LAD

Diagonal

LCX

RCA

PDA

PLV

Others

2.2 – Whether target vessel is culprit lesion for ACS ?

Yes

2.3 – No. of lesions treated with DCB

2.4 – Lesion calcification

Yes

2.4.1 – If Lesion calcification Yes,

Mild

Moderate

Severe

2.5 – Angiographic thrombus

Yes

2.5.1 – If Angiographic thrombus Yes, TIMI thrombus grade

2.6 – Diameter of stenosis (%)

2.7 – Minimum Lesion diameter (MLD) – (mm)

2.8 – Distal reference vessel diameter : (mm)

2.9 – Proximal reference vessel diameter: (mm)

2.10 – Lesion length : (mm)

2.11 – Bifurcation ( any SB > 2mm)

Yes

2.11.1 – Type of bifurcation

1,1,1

1,1,0

1,0,1

0,1,1

0,0,1

0,1,0

1,0,0

2.12 – If DCB used, DCB target vessel

Both

2.13 – Is a stent planned in bifurcation lesion ?

Yes

2.13.1 – If yes, DES landing zone : pMB-SB

Yes

2.13.2 – If yes, DES landing zone : pMB-dMB

Yes

2.14 – Is the target lesion CTO ?

Yes

2.14.1 – If yes, J-CTO score

2.15 – Is target vessel dLM ?

Yes

2.15.1 – If Yes, DCB target vessel

LAD

LCX

PCI Data

3.1 – Vessel treated

LAD

Diagonal

LCX

RCA

PDA

PLV

3.2 – Guide

3.3 – Fr Size

3.4 – Predilatation balloon type

Both

3.5 – Maximum balloon diameter : (mm)

3.6 – Maximum pressure : (atm)

3.7 – Duration of balloon inflation : (sec)

3.8 – Scoring balloon use

Yes

3.8.1 – If yes, Scoring balloon diameter : (mm)

3.8.2 – If yes, pr : (atm)

3.8.3 – If yes, duration : (sec)

3.9 – Cutting balloon use

Yes

3.9.1 – If yes, Cutting balloon diameter : (mm)

3.9.2 – If yes, pr : (atm)

3.9.3 – If yes, duration : (sec)

3.10 – No. of predilatation balloons used :

3.11 – Rotational atherectomy

Yes

3.11.1 – If yes, maximum burr size

1.25

1.5

1.75

2.0

2.25

3.12 – Orbital atherectomy

Yes

3.13 – IVL use

Yes

3.13.1 – If yes, Balloon diameter : (mm)

3.13.2 – No. Of pulses

3.14 – Pre DCB diameter of stenosis : %

3.15 – Dissection

Yes

3.15.1 – if Yes, Type of dissection

3.16 – No. of DCBs planned

3.17 – DCB Diameter : (mm)

3.18 – DCB length : (mm)

3.19 – Duration of inflation : (sec)

3.20 – Type of DCB

SCB

PCB

3.21 – Vendor name

3.22 – Planned DES ?

Yes

3.22.1 – If Yes, DES diameter : (mm)

3.22.2 – If Yes, DES length : (mm)

3.23 – Bail out DES ?

Yes

3.23.1 – If Yes, DES diameter : (mm)

3.23.2 – If Yes, DES length : (mm)

3.24 – Was lesion treated with hybrid technique ?

Yes

3.25 – Post DCB segment residual diameter of stenosis :

3.26 – Post DCB minimum lumen diameter (MLD) : mm

3.27 – Acute lumen gain in DCB treated segment :

3.28 – Acute lumen gain in DES treated segment ( in case of hybrid treatment )

3.29 – PCI to other vessels

Yes

3.29.1 – If Yes, specify vessel and device details ( eg: stent/DCB balloon diameter & length)

Imaging Data

4.1 – Mode of imaging used

IVUS

OCT

4.2 – Was imaging performed before any lesion preparation ?

Yes

IVUS

4.3 – dRVD : EEL – EEL

Yes

4.3.1 – if Yes, : mm

4.4 – Lumen – lumen

Yes

4.4.1 – if Yes, : mm

4.5 – MLA : (Sq.mm)

4.6 – Plaque morphology

Fibrous

Fibrocalcific

Calcified

Attenuated

Echolucent

Mixed

4.7 – pRVD : EEL – EEL

Yes

4.7.1 – if Yes : (mm)

4.8 – Lumen – lumen

Yes

4.8.1 – if Yes : (mm)

4.9 – MLA: (Sq.mm)

4.10 – Lesion site MLA – (sq.mm)

4.11 – Lesion site PB : (%)

4.12 – Lesion length : (mm)

4.13 – Plaque morphology

Fibrous

Fibrocalcific

Calcified

Attenuated

Echolucent

Mixed

4.14 – Lesion morphology

Fibrous

Fibrocalcific

Calcified

Attenuated

Echolucent

Mixed

4.15 -Thrombus

Yes

4.16 – Plaque Rupture

Yes

4.17 – If calcified lesion , Calcium score

Post DCB assessment

4.18 – Final MLA :(mm)

4.19 – Final PB at lesion site : (%)

4.20 – Dissection

Yes

4.20.1 – If yes, Extending to media

Yes

4.21 – Length of dissection

Yes

4.22 – IMH

Yes

OCT

Distal reference segment

4.23 – is EEL visible >180°?

Yes

4.23.1 – If yes, EEL – EEL RVD : (mm)

4.24 – Lumen – lumen RVD : (mm)

4.25 – Plaque morphology

Fibrous

Lipidic

Calcified

Proximal reference segment

4.26 – is EEL visible >180°?

Yes

4.26.1 – If yes, EEL – EEL RVD : (mm)

4.27 – Lumen – lumen RVD : (mm)

4.28 – Plaque morphology

Fibrous

Lipidic

Calcified

Lesion site

4.29 – MLA (mm)

4.30 – Lipid

Yes

4.30.1 – if yes, arc:

<90

91-180

181-270

271-360°

4.31 – Calcium

Yes

4.31.1 – if yes, arc:

<90

91-180

181-270

271-360°

4.32 – Thickness : (mm)

4.33 – Calcium Score

4.34 – Macrophages

Yes

4.35 – Plaque Rupture

Yes

4.36 – Thrombus

Yes

4.37 – Lesion length: (mm)

Post DCB assessment

4.38 – Final MLA: (mm)

4.39 – Dissection

Yes

4.39.1 – If yes, Extending to media

Yes

4.40 – Length of dissection

Yes

4.41 – IMH

Yes

Follow up Clinical Events

F1 – Inhospital Events

F1.1 – Inhospital Events?

Yes

F1.2 – Date of Event

DD slash MM slash YYYY

F1.3 – Recurrent MI

Yes

F1.4 – Lesion thrombosis

Yes

F1.5 – TLR

Yes

F1.6 – Acute pulmonary edema

Yes

F1.7 – Hypotension

Yes

F1.8 – Death

Yes

F1.8.1 – Date of Death

DD slash MM slash YYYY

F2 – 30 Day Events

F2.1 – 30 Day Event

Yes

F2.2 – Date of Event

DD slash MM slash YYYY

F2.3 – Recurrent MI

Yes

F2.4 – Lesion thrombosis

Yes

F2.5 – TLR

Yes

F2.6 – Hospitalisation for Heart Failure

Yes

F2.7 – TVR not meeting criteria for TLR

Yes

F2.8 – Unplanned revascularisation to lesions/vessels which were not initial target

Yes

F2.9 – CVA

Yes

F2.10 – Unplanned CABG

Yes

F2.11 – Echo performed

Yes

F2.11.1 – If yes, EF

F3 – 3 Month Events

F3.1 – 3 Month Events

Yes

F3.2 – Date of Event

DD slash MM slash YYYY

F3.3 – Recurrent MI

Yes

F3.4 – Lesion thrombosis

Yes

F3.5 – TLR

Yes

F3.6 – Hospitalisation for Heart Failure

Yes

F3.7 – TVR not meeting criteria for TLR

Yes

F3.8 – Unplanned revascularisation to lesions/vessels which were not initial target

Yes

F3.9 – CVA

Yes

F3.10 – Unplanned CABG

Yes

F3.11 – Echo performed

Yes

F3.11.1 – If yes, EF

F4 – 6 Month Events

F4.1 – 6 month events

Yes

F4.2 – Date of Event

DD slash MM slash YYYY

F4.3 – Recurrent MI

Yes

F4.4 – Lesion thrombosis

Yes

F4.5 – TLR

Yes

F4.6 – Hospitalisation for Heart Failure

Yes

F4.7 – TVR not meeting criteria for TLR

Yes

F4.8 – Unplanned revascularisation to lesions/vessels which were not initial target

Yes

F4.9 – CVA

Yes

F4.10 – Unplanned CABG

Yes

F4.11 – Echo performed

Yes

F4.11.1 – If yes, EF

F5 – 12 Month Events

F5.1 – 12 month events

Yes

F5.2 – Date of Event

DD slash MM slash YYYY

F5.3 – Recurrent MI

Yes

F5.4 – Lesion thrombosis

Yes

F5.5 – TLR

Yes

F5.6 – Hospitalisation for Heart Failure

Yes

F5.7 – TVR not meeting criteria for TLR

Yes

F5.8 – Unplanned revascularisation to lesions/vessels which were not initial target

Yes

F5.9 – CVA

Yes

F5.10 – Unplanned CABG

Yes

F5.11 – Echo performed

Yes

F5.11.1 – If yes, EF

F6 – Follow up Angiogram

F6.1 – Follow Up Angiogram

Done

Not Done

F6.2 – Vessel assessed

LAD

Diagonal

LCX

RCA

PDA

PLV

Others

F6.3 – Length of previously treated DCB segment :

F6.4 – In lesion diameter of stenosis : (%)

F6.5 – In segment diameter of stenosis : (%)

F6.6 – Minimum lumen diameter in DCB treated segment : (mm)

F6.7 – In lesion late loss : (mm)

F6.8 – In segment late loss : (mm)

F6.9 – Any new lesion outside insegment portion

Yes

F6.10 – Any new lesion in non target vessel ?

Yes

PROFORMA

24.10 – Clinical Proforma

Procedural Details

Angiographic data

PCI Data

Imaging Data

IVUS

Post DCB assessment

OCT

Distal reference segment

Proximal reference segment

Lesion site

Post DCB assessment

Follow up Clinical Events

F1 – Inhospital Events

F2 – 30 Day Events

F3 – 3 Month Events

F4 – 6 Month Events

F5 – 12 Month Events

F6 – Follow up Angiogram

INMENZO

Lets Build Together your Business.

Inmenzo Technologies LLP

Kerala, India

info@inmenzo.com
mail@inmenzo.com

Opening hours: Mon - Fri: 10 AM - 6 PM

We are on

© 2024 INMENZO | All Rights Reserved

Privacy Policy | Terms and Condition

Tell us you about your
Business and Requirements.

PROFORMA

24.10 – Clinical Proforma

Procedural Details

Angiographic data

PCI Data

Imaging Data

IVUS

Post DCB assessment

OCT

Distal reference segment

Proximal reference segment

Lesion site

Post DCB assessment

Follow up Clinical Events

F1 – Inhospital Events

F2 – 30 Day Events

F3 – 3 Month Events

F4 – 6 Month Events

F5 – 12 Month Events

F6 – Follow up Angiogram

INMENZO

Lets Build Together your Business.

Inmenzo Technologies LLP

Kerala, India

info@inmenzo.com mail@inmenzo.com

Opening hours: Mon - Fri: 10 AM - 6 PM

We are on

© 2024 INMENZO | All Rights Reserved

Privacy Policy | Terms and Condition

Tell us you about your Business and Requirements.

info@inmenzo.com
mail@inmenzo.com

Tell us you about your
Business and Requirements.