EVENT ADVERSE REPORT

Physician name: *
Hospital: *
City: *
Country: *
Patient ID:
Patient's Birth Date / MM / DD YYYY
Implant Date: * / MM / DD YYYY
Event Date: * / MM / DD YYYY
DEVICE
TLPB Aortic TLPB Mitral TLPB-A Supra G Dokimos Plus Aortic T07
S/N:
Death
Yes No
< 30 postoperative days > 30 postoperative days
Adverse Event:

Functional

Stenosis Insufficiency
Structural Valve Deterioration
Wear (tear) Calcification Leaflet tear Leaflet disruption Leaflet retraction Stent Fracture Stent creep Suture line disruption
Nonstructural Dysfunction:
Entrapment by Pannus Entrapment by Tissue Entrapment by Suture Paravalvular leak Inappropriate sizing or positioning Residual leak Hemolytic anemia Thrombosis Embolism Stroke Transient ischemic attack Cluster (repeated event during a short period) Bleeding event
Opinion and comments:
Date / MM / DD YYYY
Type the letters you see in the image below.