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EP Procedure Form

Section 1 — Complete for all cases (circle / check as indicated)

Patient & visit

Last name: First name: MRN: DOB:
Date of service: Physician:

Section 1 — All cases

I. Patient information

Sex: | Ht: cm Wt: kg
Key comorbidities (check all): CKD; stage: Other:
Oral anticoagulation (OAC) uninterrupted?
Which OAC:
If on DOAC, which one? Other:
Antiplatelet agents?
Other medications?
On any antiarrhythmic agents? Other:

II. Procedure and disposition

Site:
Lab/room no. designation: Other:
Case start time: : | Case end time: :
Turnover time (prior case): min
Anesthesia:
Procedure time: min Fluoro time: min
Closure device used? Other:
PACU time (arrived to discharged): min
Patient transferred to hospital?
Discharge rhythm:
OAC at discharge:

Section 2.a — AF ablation (circle / check as indicated)

I. Procedural details and outcomes

AF type:
Prior AF ablation?
Baseline rhythm: Other:
Were all PVs isolated?
Lesion set performed (check all): Other:
Other arrhythmias targeted (check all): Other:
Acute success achieved?
Was cardioversion performed/required?
Any complication(s) (check all that apply): Other:

II. Pre-/intra-procedure imaging details

Imaging:
LA enlarged?

III. Technical details

Vascular access:
Mapping:
ICE used? | TS:
TS sheath: Other:
TS needle: Other:
Mapping catheter: Other:
Energy source:
RFA catheter: Other:
PFA catheter: Other:
Reprocessed catheters (check all):
Heparin strategy: Target ACT s Max ACT s
Other:
Other comments:

Section 2.b — Other ablations (circle / check as indicated)

I. Background details and outcomes

Prior ablation for the same arrhythmia?
Prior ablation for another arrhythmia?
Baseline rhythm today:
Abl. being performed:
SVT type:
AT: Other:
AFL type: CTI AFL: | Atyp. AFL: Other:
PVC/VT type:
PVC/VT origin: Other:
Acute success achieved?
Was cardioversion performed/required?
Any complication(s) (check all that apply): Other:

II. Technical details

Vascular access:
No. of diagnostic catheters used:
Types of diagnostic catheters used: Other:
Mapping:
Long sheath: Other:
TS performed?
TS needle: Other:
Mapping catheter: Other:
Energy type:
RFA: Other:
Reprocessed catheters (check all):
Heparin strategy: Target ACT s Max ACT s
Other:
New med at discharge: Other:
Other comments (sections 2.b / 2.c):

Section 2.c — CIED implants (circle / check as indicated)

I. Background details

CIED performed: or | or
ILR/ICM indication: Other:
PPM indication: Other:
ICD indication: Other:
Indication:
Substrate: Other:
CRT indication: QRS: ms

II. Procedural and technical details

Type of implant? If replacement/upgrade, year of original implant:
Manufacturer of existing generator: Other:
Manufacturer of existing leads: Other:
Venous access:
No. of accesses: | Side:
Was the CIED successfully implanted?
DFT? | Cardioversion?
Any complication(s) (check all that apply): Other:

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