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mdhv
[p. 176]

Section M4 - HEART VALVE (HV) PAGE

Check item 9
Enter name and person number from Table MDI.

Name ____
Person No. ____

These next questions are about your artificial heart valve.
1a. How many artificial heart valves do you NOW have?

Number ____

There are four different heart valves - the mitral valve, the aortic valve, the tricuspid valve, and the pulmonic valve.
b. Which of these did you have replaced with (an) artificial valve(s)?
Mark all that apply.

1 [] Mitral
2 [] Aortic
3 [] Tricuspid
4 [] Pulmonic
9 [] DK

Check item 10
Enter each heart valve in a separate column, as well as name and person number in check item 9.

Valve ____
2a. Is the artificial (entry in check item 10) heart valve you have now a replacement for a previous artificial valve?

1 [] Yes
2 [] No (3)
9 [] DK (3)

b. How many times has this artificial valve been replaced?

Times ____

c. Why did you have the artificial (entry in check item 10) heart valve replaced (the last time)?
Mark first three mentioned

00 [] Normal growth
01 [] Blood clots
02 [] Infection
03 [] Bleeding
04 [] Defect or malfunction
88 [] Some other reason - Specify ____

Ask for each entry in 2c, except "Normal Growth"
d. How long after that heart valve was implanted was this (entry in 2c) first noticed? Was it less than 30 days, 30 to 90 days, or more than 90 days?

01 [] Blood clots
1 [] Less than 30 days
2 [] 30-90 days
3 [] More than 90 days
02 [] Infection
1 [] Less than 30 days
2 [] 30-90 days
3 [] More than 90 days
03 [] Bleeding
1 [] Less than 30 days
2 [] 30-90 days
3 [] More than 90 days
04 [] Defect or malfunction
1 [] Less than 30 days
2 [] 30-90 days
3 [] More than 90 days
88 [] Some other reason
1 [] Less than 30 days
2 [] 30-90 days
3 [] More than 90 days

e. How long did you have the artificial (entry in check item 10) heart valve before it was replaced with the one you have now?

97 [] Less than 6 months
98 [] 6-11 months
Years ____

f. In what month and year did you get it?

Month ____
Year 19____
0000 [] Before 1968
9898 [] 1968 or later

3a. How long have you had the artificial (entry in check item 10) heart valve you have now?

97 [] Less than 6 months
98 [] 6-11 months
Years ____

b. In what month and year did you get this one?

Month ____
Year ____
0000 [] Before 1968
9898 [] 1968 or later

[p. 177]

Section M4 - HEART VALVE (HV) PAGE - Continued

4. (Some artificial heart valves are made from substances such as metal or plastic. Others are made from animal or human tissue.) What is your artificial (entry in check item 10) heart valve made from?

1 [] Manmade substance
2 [] Animal tissue
3 [] Human tissue
9 [] DK

5a. Did you get a registration card for this artificial heart valve?

1 [] Yes
2 [] No
9 [] DK

b. Do you know the name of the manufacturer?

1 [] Yes
2 [] No
9 [] DK

c. Who is the manufacturer?

Manufacturer ____

Please tell me if you have had any of the following problems or complaints with or as a result of the artificial (entry in check item 10) heart valve you have now?

6a. Have you had blood clots?

1 [] Yes
2 [] No (6c)
9 [] DK (6c)

b. How long had you had the artificial valve when the blood clots were first noticed? Was it less than 30 days, 30 to 90 days, or more than 90 days?

1 [] Less than 30 days
2 [] 30-90 days
3 [] More than 90 days

c. Have you had an infection or endocarditis (as a result of the (entry in check item 10) heart valve you have NOW?

1 [] Yes
2 [] No (6e)
9 [] DK (6e)

d. How long had you had the artificial valve when the infection or endocarditis was first noticed? Was it less than 30 days, 30 to 90 days, or more than 90 days?

1 [] Less than 30 days
2 [] 30-90 days
3 [] More than 90 days

e. Did you have any bleeding problems related to the surgery (for the artificial (entry in check item 10) heart valve you have now)?

1 [] Yes
2 [] No (6g)
9 [] DK (6g)

f. How long had you had the artificial valve when the problem with bleeding was first noticed? Was it less than 30 days, 30 to 90 days, or more than 90 days?

1 [] Less than 30 days
2 [] 30-90 days
3 [] More than 90 days

g. Have you had any defects with the artificial valve or any reason to believe it is not working properly?

1 [] Yes
2 [] No (6j)
9 [] DK (6j)

h. How long had you had the artificial valve when this defect or problem was first noticed? Was it less than 30 days, 30 to 90 days, or more than 90 days?

1 [] Less than 30 days
2 [] 30-90 days
3 [] More than 90 days

i. Have you had any other problems or complications with or as a result of the artificial (entry in check item 10) heart valve you have now?

1 [] Yes
2 [] No (7)
9 [] DK

j. What were they?
Record first three mentioned.

01[] ____
02[] ____
03[] ____

Ask for each entry in 6j:
k. How long had you had the artificial heart valve when the (entry in 6j) was first noticed? Was it less than 30 days, 30 to 90 days, or more than 90 days?

[option for 3 entries in the original document -01 to 03- not presented here]
Comment: 01 -03

01[] ____
1 [] Less than 30 days
2 [] 30-90 days
3 [] More than 90 days

[p. 178]

Section M4 - HEART VALVE (HV) PAGE - Continued

Mark 7a-c or ask:
7a. Anticoagulants are medications that help prevent blood clots. Do you take anticoagulants?

1 [] Yes (7c)
2 [] No
9 [] DK

b. Do you take aspirin or any other medicine to help prevent blood clots?

1 [] Yes
2 [] No (8)
9 [] DK (8)

c. How many days a week do you take them?

7 [] Everyday
0 [] Less than once a week
Days per week ____

8. Why did you need to get the artificial (entry in check item 10) heart valve in the first place?
Mark all mentioned

1 [] Congenital defect
2 [] Rheumatic heart disease
3 [] Heart attack or myocardial infarction
4 [] Calcification
5 [] Endocarditis
8 [] Other - Specify ____

Check item 11
Mark appropriate respondent box and enter relationship to MDI person if proxy.

1 [] Self - personal
2 [] Self - telephone
3 [] Proxy - personal
Relationship ____
4 [] Proxy - telephone
Relationship ____

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