Adult Heart and HeartLung Status 3 Criteria 5 Extension Justification Form Medical Urgency Data

OMB No. 0915-0157; Expiration Date: XX/XX/20XX

Adult Heart and HeartLung Status 3 Criteria 5 Extension Justification Form Medical Urgency Data

You will be informed of any downgrades that are pending in the Critical Data section of Secure Enterprise. You may also view the Candidates Pending Downgrade Report section of Waitlist^SM. The “Extend” button will be available 2 days prior to expiration of the status.

All required data must be submitted in order to list a candidate at status 3, or extend their listing at status 3, in accordance with criteria that are specified in OPTN Policy. Use the search feature to locate specific policy information concerning adult heart status requirements.

Status 3 Extension Criteria 5

If status 3, criteria 5: Mechanical circulatory support device (MCSD) with right heart failure, is selected, enter the following information: 

Mechanical circulatory support device (MCSD) with right heart failure

Candidate is supported by an MCSD and has at least moderate right ventricular malfunction in the absence of the left ventricular assist device (LVAD) malfunction and meets the following qualifying requirements:

Has been treated with at least one of the following therapies for at least 14 consecutive days and requires ongoing treatment with at least one of the following therapies:

• Dobutamine: Enter the dosage of dobutamine in mcg/kg/min. The entry must fall between 5 and 999 mcg/kg/min. Enter the Date of Initiation. The date must be in the following format: MM/DD/YYYY. A calendar link is available.

• Dopamine: Enter the dosage of dopamine in mcg/kg/min. The entry must fall between 4 and 999 mcg/kg/min. Enter the Date of Initiation. The date must be in the following format: MM/DD/YYYY. A calendar link is available.

• Epinephrine: Enter the dosage of epinephrine in mcg/kg/min. The entry must fall between 0.05 and 999 mcg/kg/min. Enter the Date of Initiation. The date must be in the following format: MM/DD/YYYY. A calendar link is available.

• Milrinone: Enter the dosage of milrinone in mcg/kg/min. The entry must fall between 0.35 and 999 mcg/kg/min. Enter the Date of Initiation. The date must be in the following format: MM/DD/YYYY. A calendar link is available.

• Inhaled nitric oxide: Select checkbox, if applicable. Enter the Date of Initiation. The date must be in the following format: MM/DD/YYYY. A calendar link is available.

• Intravenous prostacyclin: Select checkbox, if applicable. Enter the Date of Initiation. The date must be in the following format: MM/DD/YYYY. A calendar link is available.

Within 7 days prior to initiation of any of the therapies above, all of the following are true within one 24 hour period:

• Pulmonary capillary wedge pressure less than 20 mmHg

• Central venous pressure greater than 18 mmHg

Pulmonary capillary wedge pressure: Enter the candidate’s pulmonary capillary wedge pressure in mmHg. The entry must fall between 0 and 19 mmHg. Enter the Test Date of when the PCWP value was obtained. The date must be in the following format: MM/DD/YYYY. A calendar link is available. Enter the Test Time. The time must be in the following 24-hour format: HH:MM. Time must be in military format.

Central venous pressure: Enter the candidate’s central venous pressure in mmHg. The entry must fall between 19 and 50 mmHg. Enter the Test Date of when the CVP value was obtained. The date must be in the following format: MM/DD/YYYY. A calendar link is available. Enter the Test Time. The time must be in the following 24-hour format: HH:MM. Time must be in military format.

 

Extending the candidate status under criteria 5

The candidate continues to be treated by one of the following therapies:

• Dobutamine: Enter the dosage of dobutamine in mcg/kg/min. The entry must fall between 5 and 999 mcg/kg/min. Enter the Date of Initiation. The date must be in the following format: MM/DD/YYYY. A calendar link is available.

• Dopamine: Enter the dosage of dopamine in mcg/kg/min. The entry must fall between 4 and 999 mcg/kg/min. Enter the Date of Initiation. The date must be in the following format: MM/DD/YYYY. A calendar link is available.

• Epinephrine: Enter the dosage of epinephrine in mcg/kg/min. The entry must fall between 0.05 and 999 mcg/kg/min. Enter the Date of Initiation. The date must be in the following format: MM/DD/YYYY. A calendar link is available.

• Milrinone: Enter the dosage of milrinone in mcg/kg/min. The entry must fall between 0.35 and 999 mcg/kg/min. Enter the Date of Initiation. The date must be in the following format: MM/DD/YYYY. A calendar link is available.

• Inhaled nitric oxide: Select checkbox, if applicable. Enter the Date of Initiation. The date must be in the following format: MM/DD/YYYY. A calendar link is available.

• Intravenous prostacyclin: Select checkbox, if applicable. Enter the Date of Initiation. The date must be in the following format: MM/DD/YYYY. A calendar link is available.

 Public Burden Statement: The private, non-profit Organ Procurement and Transplantation Network (OPTN) collects this information in order to perform the following OPTN functions: to assess whether applicants meet OPTN Bylaw requirements for membership in the OPTN; and to monitor compliance of member organizations with OPTN Obligations. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0157 and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit per 42 CFR §121.11(b)(2). All data collected will be subject to Privacy Act protection (Privacy Act System of Records #09-15-0055). Data collected by the private non-profit OPTN also are well protected by a number of the Contractor’s security features. The Contractor’s security system meets or exceeds the requirements as prescribed by OMB Circular A-130, Appendix III, Security of Federal Automated Information Systems, and the Departments Automated Information Systems Security Program Handbook. The public reporting burden for this collection of information is estimated to average 0.27 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or paperwork@hrsa.gov.   

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