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Completed________
WASHINGTON UNIVERSITY SCHOOL OF MEDICINE
MOUSE CARDIOVASCULAR PHENOTYPING CORE
REQUEST FOR SURGICAL SERVICES
For more information contact Candy Jones at cjones@dom.wustl.edu (34-362-8909)
or Carla Weinheimer at cweinhei@wustl.edu
Return completed form to Candy Jones, Box 8086, CSRB Room 9900
Fax: 314-362-0186
A.
General Information (please print clearly):
Principal Investigator:
Date Request Submitted:
Company Name: ________________________________________________________
Department/Division:
Address:
Phone:
Fax:
E-mail:
Contact Person, Phone, and Pager:
1.
Specific cardiac physiologic question to be addressed:
This must be completed before request will be considered.
2.
3.
4.
5.
Mouse Strain/Mutation/Transgenic to be studied:
Total Number of Mice_____Number of Sham operations of this total
Billing source (PO):
Veterinary contact or preferred animal vendor:
B.
Services
1.
Check Services Requested
TRANSVERSE AORTIC CONSTRICTION (TAC)

Operative placement of constriction on transverse aorta. Includes recording mouse weight,
echocardiography at study end, and if desired, euthanasia at study end with organ harvest and
determination of left ventricular weight.
*If additional echocardiographic studies are desired, please refer to the “Request for Echocardiography”
form.
*All animals will be echoed at 1 wk post-TAC unless requested otherwise.
2.
NEONATAL ASCENDING AORTIC BANDING (NAB)

Operative placement of “loose” constriction on ascending aorta of 19-22 day old mice only. Includes
recording mouse weight, echocardiography at study end (8-12 weeks), and if desired, euthanasia at
end of study with organ harvest and determination of left ventricular weight.
*If additional echocardiographic studies are desired, please refer to the “Request for
Echocardiography” form.
*All animals will be echoed at 2 months post-NAB unless requested otherwise.
Copyright 2009-2012. Washington University School of Medicine Mouse Cardiovascular Phenotyping Core. Reproduction
of this form, making imitative works or spreading information contained within is unauthorized without expressed written permission
from the copyright holder. Copyright holder has “exclusive rights”.
Revised: November 26, 2014
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3.
ADULT ASCENDING AORTIC BANDING (AAB)

Operative placement of constriction on ascending aorta of adult mice (preferably 18-28 gram weight).
Includes recording mouse weight, echo study at experiment end time, and if desired, euthanasia at
study end with organ harvest and determination of left ventricular weight.
4.
HF MODEL – TRANSVERSE AORTIC CONSTRICTION with

SMALL APICAL INFARCTION
Operative placement of a moderate constriction on the transverse aorta combined with a small
infarction caused by permanent ligation of the apical section of the left anterior descending artery.
Procedure typically causes a gradual heart failure and ventricular remodeling within a 3 week period.
Includes recording mouse weight, echocardiography at study end, and if desired, euthanasia at study
end with organ harvest and left ventricular weight measurements.
*If additional echocardiographic studies are desired, please refer to (and fill out) a “Request for
Echocardiography” form.
5.
MYOCARDIAL INFARCTION (MI)

Operative placement of a permanent occlusion around the left anterior descending artery of the mouse
heart. Includes recording mouse weight, echocardiography at study end, and if desired, euthanasia at
study end with organ harvest and left ventricular weight measurements.
*If additional echocardiographic studies are desired, please refer to the “Request for Echocardiography”
form.
6.
OPEN CHEST MYOCARDIAL ISCHEMIA/REPERFUSION

Operative placement of an occluder around the left anterior descending artery that is removed after 30
minutes of occlusion causing reperfusion.
7.
CLOSED CHEST MYOCARDIAL ISCHEMIA/REPERFUSION

Includes pre-instrumentation one week prior to ischemic event, close chest ischemia of the left anterior
descending artery for 90 minutes followed by closed chest reperfusion.
8.
PARABIOSIS
Operative surgical joining of two mice for parabiotic examination.

9.
PARABIOSIS AND SURGICAL INSULT (TAC OR MI)
Operative surgical joining of two mice AND a subsequent surgical cardiac insult to one
mouse of the pair.

10.
PARABIOTIC CARDIAC INSULT
Surgical cardiac injury (TAC or MI) of one mouse of an established parabiotic pair.

11.
TISSUE FIXATION (In vivo heart perfusions) FOR HISTOLOGY
Entails carotid catheter placement and fixative injection into the heart

12.
CUSTOMIZED SURGERIES
Specialized surgery not listed above but agreed upon by surgeon and investigator

13.
INJECTIONS OF PHARMACOLOGICAL AGENTS (defined by P.I.)
During any of above studies

Copyright 2009-2012. Washington University School of Medicine Mouse Cardiovascular Phenotyping Core. Reproduction
of this form, making imitative works or spreading information contained within is unauthorized without expressed written permission
from the copyright holder. Copyright holder has “exclusive rights”.
Revised: November 26, 2014
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C.
1.
2.
3.
4.
5.
Cost per TAC study ($151 without echo)
Cost per NAB study ($218 without echo)
Cost per AAB study ($218 without echo)
Cost per HF Model ($296 without echo)
Cost per Myocardial Infarction study
($229 without echo)
6. Cost per Open Chest Ischemia/Reperfusion
7. Cost per Closed Chest Ischemia/Reperfusion
8. Cost per Parabiosis
9. Cost per Parabiosis & Surgical Insult
10. Cost per Parabiotic Cardiac Insult
11. Cost per Tissue Fixation Perfusion
12. Customized Surgery
13. Extra pharmacological injections
14. Organ harvest
D.
1.
2.
3.
4.
Charges
$577 x ______ (# of mice) = _____
$644 x ______ (# of mice) =
$644 x ______ (# of mice) =
$829 x ______ (# of mice) =
$762 x ______ (# of mice) =
__
__
__
__
__
$304 x ______ (# of mice) =
__
$754 x ______ (# of mice) =
__
$169 x ______ (# of pairs) = _______________
$465 x ______ (# of pairs) = _______________
$299 x ______ (# of pairs) = _______________
$211 x ______ (# of mice) =_________
__
$273 x ______ (# of hrs.) + F/C=_ _
__
Varies (contact Carla Weinheimer)
__
$ 68 x ______ (# of mice) =_
__
Total estimated cost for surgical services: ______________________________
Terms
Investigator is responsible for transferring animals to the Washington University animal housing
facility.
Housing costs/per diems are the full responsibility of the investigator.
Charges will be billed after the animals have had successful surgery. If the animal(s) die pre-initial
recovery or data cannot be acquired, specific charges will be discounted accordingly.
Charges may be subject to change as the cost of supplies increase.
I agree to follow the terms and conditions described in this application.
I understand the terms and fees for the services and I agree to pay the invoices from the Mouse
Cardiac Physiology Core Facility for the services I have requested.
____
P.I. Signature
Date
Billing Contact Person
Phone Number____________
*
Please use “Mouse Cardiovascular Phenotyping Core” to acknowledge this work in
publications*
FINAL BILLING STATEMENT
Date surgery performed
Number of animals which completed full requested protocol
Amount(s) reduced from request/Reason(s) for reduction
Final Charge
Core Staff Member Initial
Copyright 2009-2012. Washington University School of Medicine Mouse Cardiovascular Phenotyping Core. Reproduction
of this form, making imitative works or spreading information contained within is unauthorized without expressed written permission
from the copyright holder. Copyright holder has “exclusive rights”.
Revised: November 26, 2014