REGISTRY PERFORMA

for

Coronary, Non-Coronary & Peripheral Interventions

Period

from JAN 2010 to Dec 2010.

From:
On behalf of National Interventional Council

JVS Technologies Pvt. Ltd.

B-101, Nirman Complex, Opp. Havmor,
Navrangpura, Ahmedabad, GUJ 380009 INDIA.
Tel. : 91-79-30023120 Fax : 91-79-22161962
Email : contact@jvsgroup.com, Web: www.jvsgroup.com
 Chairman - National Interventional Council
Dr. H. M. Mardikar
Director, Spandan Heart Institute & Research Center
Dhantoli, Nagpur - 12
Tel : 0712 – 2443333, 6453333, Mobile: 09823082609
Email: drmardikar@rediffmail.com

Convenors

Coronary Intervention
Dr. P. P. Mohanan
Director, West Fort Hitech Hospital
Thrissur

Peripheral Intervention Non Coronary Intervention

Dr. N. N. Khanna Dr. Prasanna Nyayadhish
Indraprastha Apollo Hospital KEM Hospital
New Delhi Mumbai

Congenital Heart Disease Rheumatic Heart Disease

Dr. Bharat V. Dalvi Dr. Satyanarayan Routray
Nanavati Hospital, SCB Medical College,
Mumbai Cuttack
NIC Registry Section A

PROFORMA FOR THE YEAR 2010 (JAN – DEC) Coronary Interventions Registry
Name of Hospital

Address

Contact No(S)
Name of Interventional Cardiologists (Primary operators)
1. 3.

2. 4.

Total Number of PCIs during the year No(s)

Gender Male No(s)
Female No(s)
Age Group <40 years No(s)
40 to 70 years No(s)
>70 years No(s)
Procedure approach Femoral No(s)
Radial No(s)
Ulnar No(s)
Vessels treated Single Vessel No(s)
Multi Vessel No(s)
LMCA No(s)
Graft No(s)
Vessels Distribution LAD No(s)
RCA No(s)
LCX No(s)
LMCA No(s)

Stent Details Total No. of Stents used No(s)

Total No. of Drug Eluting Stents (DES) No(s)
Name of DES No(s) Name of DES No(s)
1. No(s) 3. No(s)

2. No(s) 4. No(s)

Other Devices Rotablator No(s)

IVUS No(s)
Cutting Balloon No(s)
Aspiration device No(s)
Distal Protection No(s)
II B/IIIA Blocker
ABCIXIMAB (REOPRO) No(s)
EPTIFIBATIDE No(s)
TIROFIBAN No(s)
In Hospital Death No(s)
Subacute Thrombosis No(s)
Approach to SAT 1. IIB/IIIA BLOCKER No(s)
2. THROMBOLYTIC THERAPY No(s)
3. EMERGENCY PTCA No(s)

PRIMARY PTCA
NO. OF AMI PATIENTS ADMITTED No(s)

NO. OF PRIMARY ANGIOPLASTIES No(s)

Gender Male No(s)

Female No(s)
Age Group <40 years No(s)
30 to 70 years No(s)
>70 years No(s)
Procedure Approach Femoral No(s)
Radial No(s)
Ulnar No(s)

Killip Class at Presentation (In patients undergoing primary angioplasty)

CLASS : I No(s)
CLASS : II No(s)
CLASS : III No(s)
CLASS IV No(s)
Vessel Distribution No(s) Peri-Procedure Adjuncts No(s)
LAD IABP
RCA
LCX GP 2B/3A BLOCKERS
LMCA ABCIXIMAB (REOPRO)
PCI of Non-Culprit Vessel EPTIFIBATIDE
Procedural Success TIROFIBAN
Mortality (In Hospital) THROMBUS ASPIRATION
What Percentage Received IIB/IIIA Blockers during Primary PTCA Percentage

Stents Used DES No(s)

BMS No(s)
Average No. of stents per patient No(s)

FORM COMPLETED BY : NAME OF DOCTOR :

DATE: SIGNATURE
NIC Registry Section B

PROFORMA FOR THE YEAR 2010 (JAN – DEC) Non-Coronary Interventions

Mitral Valvuloplasty
Total Numbers
Mean age
Balloon used – Accura/ Inoue/ Double balloon/
Jomiva/others(specify)
Average balloon size
Complications
MR requiring MVR (Percentage)
Aortic Valvuloplasty
Number
Mean age
Balloon used
Average balloon size
Complications
AR (More than moderate)
Pulmonary Valvuloplasty
Number
Mean age
Balloon used
Average balloon size
Complications
Tricuspid Valvuloplasty
Number
Mean age
Balloon used
Average balloon size
Complications
Aortic Procedures
IVAR Mean Age
Number
Location
Combined(+surgical / standalone)
Devices used
Coarctation Balloon
Mean Age
Number
Average balloon size
Stent
Mean Age
Number
Average stent size
Complications
 NIC Registry Section C

PROFORMA FOR THE YEAR 2010 (JAN – DEC) Peripheral Interventions

Iliac
Mean Age Number
Average stent size Complications
Femoropopliteal
Mean Age Number
Average stent size Complications
Carotid
Mean Age Number
Average stent size Distal protection use (%)
Complications
Renal
Mean Age Number
Average stent size Complications
ASD device closure
Mean Age Number
Percentage success (attempted- succeeded)
Type of device used TEE use
Amplatzer Average device size
Non-Amplatzer(Specify) Complications
VSD device closure (Include Post MI VSD also separately)
Mean Age Number
Percentage success (attempted/ succeeded)
Type of device used TEE use
Average device size Complications
PDA – Device/Coil
Mean Age Number
Type of device used Average device size
Coil Closure
Single coil Multiple coils
Bioptome use (%) Percentage success
Complications
Other shunts(AP window/ CAVF/RSOV)
Total Number Device used
Ductal Stenting Nos.
Pulmonary Valve Perforation Nos.
Balloon Atrial Septostomy Nos.
PAVF Closure Nos.
MAPCA Embolisation Nos.
Others (Please use additional sheets if required) Nos.
Instructions

 Please fill all form with complete and accurate data of procedures
performed during 1st January, 2010 to 31st December, 2010.

 For any assistance in filling up the forms, call on +91 9825528002.

or email to saket@jvsgroup.com.

 Please send your completed forms to below address by post or email:

Post:
JVS Technologies Pvt. Ltd.
B-101, Nirman Complex,
Opp. Havmor, Navrangpura,
Ahmedabad – 380009 (Gujarat)
Phone: 079-30023120

E-mail: saket@jvsgroup.com

 If you have any questions, please contact Dr. P. P. Mohanan on

+91 9846076006.

 Please note your completed forms must reach us by

25th March, 2011 in order to include them in the registry.