OMB No. 0915-0157; Expiration Date: XX/XX/20XX
The Adult Heart Status 3 Justification form displays for completion when assigning the candidate to status 3.
All required data must be submitted in order to list a candidate at status 3, or extend their listing at status 3, in accordance with criteria that are specified in OPTN Policy.
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.
Note: All fields denoted with an R are required and must be completed. Submitted forms cannot be edited.
To qualify for status 3, the candidate must meet one of the following criteria.
Dischargeable
left ventricular assist device (LVAD) for discretionary 30
days
Candidate
is supported by a dischargeable LVAD. The 30 days do not have to
be consecutive. If the candidate undergoes a procedure to
receive another replacement dischargeable LVAD, then the candidate
qualifies for a new term of 30 days. When a candidate receives a
replacement device, the 30 day period begins again, and the candidate
cannot use any time remaining from the previous period.
Multiple
inotropes or a single high dose inotrope and hemodynamic
monitoring
Candidate
is admitted to the transplant hospital that registered the candidate
on the waiting list. Within 7 days prior to inotrope administration
or while on inotropes, all of the following are true.
Select one of the following:
Candidate has an invasive pulmonary artery catheter
Candidate has daily hemodynamic monitoring to measure cardiac output and left ventricular filling pressures
Candidate is supported by either:
A continuous infusion of at least one high dose intravenous inotrope:
Dobutamine greater than or equal to 7.5 mcg/kg/min
Milrinone greater than or equal to 0.50 mcg/kg/min
Epinephrine greater than or equal to 0.02 mcg/kg/min
A continuous infusion of at least two intravenous inotropes:
Dobutamine greater than or equal to 3mcg/kg/min
Milrinone greater than or equal to 0.25 mcg/kg/min
Epinephrine greater than or equal to 0.01 mcg/kg/min
Dopamine greater than or equal to 3 mcg/kg/min
The candidate is in cardiogenic shock as evidenced by all the following values obtained within one 24 hour period
Cardiac index was:
Less than 1.8 L/min/m2 if the candidate was not on inotropic or mechanical support within 7 days prior to inotrope administration or
Less than 2.2 L/min/m2 if the candidate was on inotropic or mechanical support
Pulmonary capillary wedge pressure greater than 15 mmHg
Systolic blood pressure less than 90 mmHg
Was the candidate
on inotropic or mechanical support at the time cardiac index was
obtained?: If
the candidate was on inotropic or mechanical support at the time of
cardiac arrest, select Yes.
If not, select No.
This is a required field.
Cardiac
index: Enter
the candidate’s cardiac index in L/min/m2.
The entry must fall between 0 and 1.79 L/min/m2 if
the candidate was not on inotropic or mechanical support and must be
less than 2.2 L/min/m2 if
the candidate was on inotropic or mechanical support. Enter the Test
Date of
when the cardiac index value was obtained. The date must be in
the following format: MM/DD/YYYY. A
calendar link is available. Enter the Test
Time. The
time must be in the following 24-hour format: HH:MM.
Time must be in military format. This
is a required field.
Pulmonary
capillary wedge pressure: Enter
the candidate’s pulmonary capillary wedge pressure in mmHg. The
entry must fall between 16 and 100 mmHg. 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. Enter the Test
Time. The
time must be in the following 24-hour format: HH:MM.
Time must be in military format. This
is a required field.
Systolic
blood pressure: Enter
the candidate’s systolic blood pressure in mmHg. The entry must
fall between 50 and 89 mmHg. Enter the Test
Date of
when the systolic blood pressure was obtained. The date must be
in the following format: MM/DD/YYYY. A
calendar link is available. Enter the Test
Time. The
time must be in the following 24-hour format: HH:MM.
Time must be in military format. This
is a required field.
Mechanical
circulatory support device (MCSD) with hemolysis
Candidate
is supported by an MCSD that is not experiencing device malfunction,
but is experiencing hemolysis, as evidenced by both of the following:
Two separate samples collected within 48 hours of each other confirming markers of active hemolysis as evidenced by at least two of the following:
Blood lactate dehydrogenase (LDH) at least 2.5 times the upper limit of normal at the laboratory reference range
Plasma free hemoglobin greater than 20 mg/dL
Hemoglobinuria
Documentation is available of at least one attempt to treat the condition using an intravenous anticoagulant, intravenous anti-platelet agent, or thrombolytic, with persistent or recurrent hemolysis.
Mechanical
circulatory support device (MCSD) with pump thrombosis
Candidate
is admitted to the transplant hospital that registered the candidate
on the waiting list, is supported by MCSD, and the transplant program
has identified a suspected pump thrombosis in either an implanted
LVAD or a dischargeable paracorporeal device and both of the
following criteria are met:
The candidate has one of the
following conditions:
Transient Ischemic Attack (TIA) lasting less than 24 hours or Reversible Ischemic Neurologic Deficit (RIND) lasting less than 72 hours (as observed by symptoms such as, but not limited to unilateral facial weakness, vision problems, and/or slurred speech), Cerebrovascular Accident (CVA), or peripheral thromboembolic event in the absence of intracardiac thrombus or significant carotid artery disease
A condition that requires inotropic support and presence of leftsided heart failure not explained by structural heart disease such as Aortic Insufficiency (AI) as demonstrated by
Pulmonary Capillary Wedge Pressure (PCWP) greater than 15, and
Mean Arterial Pressure (MAP) less than 90
Abnormal pump parameters, such as significant and persistent increase in pump power and low flow despite good blood pressure control
Visually detected
thrombus in a paracorporeal ventricular device (VAD)
AND The
candidate is supported by one of the following treatments in the
hospital:
Intravenous anticoagulation (e.g., heparin)
Intravenous thrombolytics (e.g., tPA)
Intravenous antiplatelet therapy (e.g., eptifibatide or tirofiban)
Mechanical
circulatory support device (MCSD) with right heart failure
Candidate
is supported by an MCSD and has at least moderate right ventricular
malfunction in the absence of the left ventricular assist device
(LVAD) malfunction and meets the following qualifying requirements:
Has been treated with at least one of the following therapies for at least 14 consecutive days and requires ongoing treatment with at least one of the following therapies:
Dobutamine: Enter the dosage of dobutamine in mcg/kg/min. The entry must fall between 5 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 4 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 0.05 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 0.35 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.
Inhaled nitric oxide: Select checkbox, if applicable. Enter the Date of Initiation. The date must be in the following format: MM/DD/YYYY. A calendar link is available.
Intravenous prostacyclin: Select checkbox, if applicable. Enter the Date of Initiation. The date must be in the following format: MM/DD/YYYY. A calendar link is available.
Within 7 days prior to initiation of any of the therapies above, all of the following are true within one 24 hour period:
Pulmonary capillary wedge pressure less than 20 mmHg
Central venous
pressure greater than 18 mmHg
Pulmonary
capillary wedge pressure: Enter
the candidate’s pulmonary capillary wedge pressure in mmHg. The
entry must fall between 0 and 19 mmHg. 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. Enter the Test
Time. The
time must be in the following 24-hour format: HH:MM.
Time must be in military format.
Central
venous pressure: Enter
the candidate’s central venous pressure in mmHg. The entry must
fall between 19 and 50 mmHg. Enter the Test
Date of
when the CVP value was obtained. The date must be in the
following format: MM/DD/YYYY. A
calendar link is available. Enter the Test
Time. The
time must be in the following 24-hour format: HH:MM.
Time must be in military format.
Mechanical
circulatory support device (MCSD) with device infection
Candidate
is supported by an MCSD, is experiencing a pump-related local or
systemic infection and has one of the following symptoms or continues
to require IV antibiotics:
Erythema and pain along the driveline with either leukocytosis or a 50 percent increase in white blood cell count from the last recorded white blood cell count, and either:
Positive bacterial or fungal cultures from the driveline exit site within the last 14 days
A culture positive fluid collection between the exit site and the device
Debridement of the driveline with positive cultures from sites between the exit site and the device requiring IV antibiotics
Recurrent debridement
Positive culture of material from the pump pocket of an implanted device
Bacteremia treated with antibiotics
Recurrent bacteremia that recurs from the same organism within four weeks following antibiotic treatment to which the bacteria is susceptible
Mechanical
circulatory support device (MCSD) with mucosal bleeding
Candidate
is admitted to the transplant hospital that registered the candidate
on the waiting list, and meets all of the following qualifying
requirements:
Is supported by an MCSD
Has been hospitalized for mucosal bleeding at least two times within the past six months, excluding the candidate's hospitalization for implantation of the MCSD
The candidate has received blood transfusions of at least two units of packed red blood cells per hospitalization during at least two hospitalizations for mucosal bleeding
The candidate's international normalized ratio (INR) was less than 3.0 at the time of at least one of the bleeds
The candidate's hematocrit upon admission is less than or equal to 0.20 or decreased by 20 percent or more relative to the last measured value at any time during the bleeding episode
Number of
hospitalizations for mucosal bleeding within the past six months:
Select 2 or 3
or more.
Note: Hospitalizations
must exclude candidate's hospitalization for implantation of the
MCSD.
Mechanical
circulatory support device (MCSD) with aortic insufficiency
(AI)
Candidate
is supported by an MCSD and is not exhibiting evidence of device
malfunction, but is experiencing AI and meets all of the following
requirements:
At least moderate AI by any imaging modality in the setting of the mean arterial pressure (MAP) less than or equal to 80 mmHg
Pulmonary capillary wedge pressure greater than 20 mmHg
New York Heart Association (NYHA) Class III-IV symptoms
Veno-arterial
extracorporeal membrane oxygenation (VA ECMO) after 7 days
Candidate
is admitted to the transplant hospital that registered the candidate
on the waiting list, is supported by VA ECMO, and the transplant
hospital has already assigned the candidate to status 1 under the VA
ECMO criteria for 7 days.
Note: The
system will not allow this selection unless the prerequisites have
been met.
Non-dischargeable,
surgically implanted, non-endovascular left ventricular assist device
(LVAD) after 14 days
Candidate
is admitted to the transplant hospital that registered the candidate
on the waiting list, is supported by a non-dischargeable, surgically
implanted, non-endovascular left ventricular assist device (LVAD),
and the transplant hospital has already assigned the candidate to
status 2 under the non-dischargeable, surgically implanted,
non-endovascular left ventricular assist device (LVAD)criteria for 14
days.
Note: The
system will not allow this selection unless the prerequisites have
been met.
Percutaneous
endovascular circulatory support device after 14 days
Candidate
is admitted to the transplant hospital that registered the candidate
on the waiting list, is supported by a percutaneous endovascular
circulatory support device, and the transplant hospital has already
assigned the candidate to status 2 under the percutaneous
endovascular circulatory support device criteria for 14
days.
Note: The
system will not allow this selection unless the prerequisites have
been met.
Intra-aortic
balloon pump after 14 days
Candidate
is admitted to the transplant hospital that registered the candidate
on the waiting list, is supported by an intra-aortic balloon pump,
and has already assigned the candidate to status 2 under the
intra-aortic balloon pump criteria for 14 days.
Note: The
system will not allow this selection unless the prerequisites have
been met.
Mechanical
Circulatory Support Device (MCSD) with life threatening ventricular
arrhythmia after 7 days
Candidate
is admitted to the transplant hospital that registered the candidate
on the waitlist, has already been assigned to status 1 under
Mechanical Circulatory Support Device (MCSD) with Life Threatening
Ventricular Arrhythmia for 7 days criteria for 7 days, and is
supported by:
Select at least
one of the following:
Placement of a biventricular mechanical circulatory support device for the treatment of sustained ventricular arrhythmias.
Receiving continuous intravenous antiarrhythmic therapy.
Exception for
status 3
Candidate
does not meet any of the criteria above but is admitted to the
transplant hospital that registered the candidate on the waiting list
and has an urgency and potential for benefit comparable to that of
other candidates at this status. A clinical narrative must be
provided to support the candidate's eligibility at this status.
A transplant
program may assign a candidate who does not meet any of the above
status 3 criteria to status 3 by requesting an exception. The
candidate must be admitted to the transplant hospital that registered
the candidate on the waiting list, and the program must explain why
it considers the candidate to have an urgency and potential for
benefit comparable to other status 3 candidates using acceptable
medical criteria. The review board will retrospectively review
exception requests. If the review board denies an exception request,
then within one day of receiving notification of the denial, the
candidate's transplant program must either appeal to the review board
or assign the candidate to the status for which the candidate
qualifies.
Clinical
Narrative: Enter
a clinical narrative which supports the eligibility of the candidate
for an exceptional case. Note: A maximum
of 5000 characters is accepted.
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 [email protected].
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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 |