Generator Explant Data

Date of Report (mo/day/yr):

1. ID Number:
2. Institution:
3. Implant Date (mo/da/yr):
4. Explant Date (mo/da/yr):
5. Manufacturer:
6. Model Number:
7. Generator Serial Number:

8. Reason for Explant (Check Choice)

End of life indicators present

Extracardiac pacing

Associated with lead change (generator working properly)

Generator electronic failure

Manufacturer's recall (generator working at explant)

Infection

Elective upgrade (generator working properly)

9. Generator Characteristics at Explant

	        PROGRAMMED          MEASURED

a. Mode --------------------------------------

b. Rate ------------------------------------------

c. AV Interval-------------

d. Upper Rate Limit -------

e. Rate Response Curve---

f. Hysteresis ---------------

                      Programmed
                   Ventricle    Atrium

g. Pulse Amplitude ---------- -------

h.Pulse Width ------------ ------ -----

i. Sensitivity ------------------------ --

10. Telemetered Battery Voltage:

11. Comments

Your Name: Your E-Mail Address:

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