Adult Heart and HeartLung Status 4 Criteria 2 Extension Justification Form Medical Urgency Data

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

Adult Heart and HeartLung Status 4 Criteria 2 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 7 days prior to expiration of the status.

All required data must be submitted in order to list a candidate at status 4, or extend their listing at status 4, in accordance with criteria that are specified in OPTN Policy. Use the search feature to locate specific policy information concerning adult heart status requirements.

If you do not submit this form to extend the candidate's status beyond the time frame described in policy, the candidate will automatically be downgraded to status 5 (if the candidate is registered for at least one other organ at the same transplant hospital, including VCA registrations) or status 6. Heart-Lung candidates will downgrade to status 5 since they are in need of two organs; a heart and a lung.

Status 4 Extension Criteria 2

If status 4, criteria 2: Inotropes without hemodynamic monitoring, is selected, enter the following information: 

Inotropes without hemodynamic monitoring

Candidate is supported by a continuous infusion of a positive inotropic agent.

1. Requires treatment with at least one of the following intravenous inotropes:

   • Dobutamine: Enter the dosage of dobutamine in mcg/kg/min. The entry must fall between 3 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 0.25 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 0.01 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 3 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.

2. Meets the following qualifying requirements:
   Cardiac index: Enter the candidate’s cardiac index in L/min/m2. The entry must fall between 0 and 2.19 within 7 days prior to inotropic administration or while on inotrope infusion. Enter the Test Date of when the cardiac index value were obtained. The date must be in the following format: MM/DD/YYYY. A calendar link is available.
   Note: The test date for cardiac index must be within 7 days prior to, or anytime after, the date of initiation of one of the inotropes.
   Pulmonary capillary wedge pressure: Enter the candidate’s pulmonary capillary wedge pressure in mmHg. The entry must fall between 16 and 100. 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.

Extending the candidate’s status under criteria 2

The candidate requires treatment with at least one of the following intravenous inotropes:

• Dobutamine: Enter the dosage of dobutamine in mcg/kg/min. The entry must fall between 3 and 999 mcg/kg/min.

• Milrinone: Enter the dosage of milrinone in mcg/kg/min. The entry must fall between 0.25 and 999 mcg/kg/min.

• Epinephrine: Enter the dosage of epinephrine in mcg/kg/min. The entry must fall between 0.01 and 999 mcg/kg/min.

• Dopamine: Enter the dosage of dopamine in mcg/kg/min. The entry must fall between 3 and 999 mcg/kg/min.

 

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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File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	Living Donor Registration LDR Instructions
Author	Tara Taylor
File Modified	0000-00-00
File Created	2025-07-03