Page 6 - Heart Transplant Guidelines
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Heart Function Service: Heart Transplant Guidelines

               Referring Physician Listing Notification Letter ............................................................................................ 43

               Outpatient Follow-up .................................................................................................................................. 44
                  Mental Health Screening ........................................................................................................................ 44

                  Pre-transplant Outpatient Follow-up Guidelines.................................................................................... 44

                    Listed Status 1A: VAD Patient ............................................................................................................. 44
                    Listed Status 1B ................................................................................................................................... 45

                    Listed Status 2 ..................................................................................................................................... 45
                    Cardiac Catheterization ....................................................................................................................... 45

                    Infectious Disease Work Up ................................................................................................................ 45
                  Post-transplant Follow-up: Infant (< 1yr age at transplant) ................................................................... 47

                    Day of Transplant – 2 months (POD 60) ............................................................................................. 47
                    Month 2-4 Post Transplant (POD 120) ................................................................................................ 47

                    Month 4-6 months Post Transplant .................................................................................................... 47
                    Months 7-11 ........................................................................................................................................ 47

                    Month 12 following transplant ........................................................................................................... 47

                    Years 2-5 following transplant: ........................................................................................................... 48
                    >5 years following transplant: ............................................................................................................ 48

                  Post-transplant Follow-up: Child (> 1yr age at transplant) ..................................................................... 49
                    Day of Transplant – 2 months (POD 60) ............................................................................................. 49

                    Month 2-4 Post Transplant (POD 120) ................................................................................................ 49
                    Month 4-6 months Post Transplant .................................................................................................... 49

                    Months 7-11 ........................................................................................................................................ 49

                    Month 12 following transplant ........................................................................................................... 49
                    Years 2-5 following transplant: ........................................................................................................... 50

                    >5 years following transplant: ............................................................................................................ 50
                  Shared Care Arrangements ..................................................................................................................... 51

                  SOTP Policies in Policy Tracker ................................................................................................................ 52
                  Consent for Evaluation Form .................................................................................................................. 53

                  High Risk Donor Disclosure/Consent Form ............................................................................................. 57
                  HLA Requisition Form ............................................................................................................................. 61

                  C1Q Form ................................................................................................................................................ 63
                  Immunization Letter for Providers .......................................................................................................... 64






               Updated December 14, 2018                                                                    6
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