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Page 1: Heart & Vascular Institute - Cleveland Clinic

11

Outcomes | 2007

Heart & Vascular Institute

Page 2: Heart & Vascular Institute - Cleveland Clinic

Chairman’s Letter

Outcomes 20072

Patients First

Page 3: Heart & Vascular Institute - Cleveland Clinic

Heart & Vascular Institute

Quality counts when referring patients to hospitals and physicians, so Cleveland Clinic has created a series of Outcomes

books similar to this one for many of its institutes. Designed for a healthcare provider audience, the Outcomes books

contain a summary of our surgical and medical trends and approaches, data on patient volume and outcomes, and a

review of new technologies and innovations.

Although we are unable to report all outcomes for all treatments provided at Cleveland Clinic — omission of outcomes

for a particular treatment does not mean we necessarily do not offer that treatment — our goal is to increase outcomes

reporting each year. When outcomes for a specific treatment are unavailable, we often report process measures that have

documented relationships with improved outcomes. When process measures are unavailable, we report volume measures;

a volume/outcome relationship has been demonstrated for many treatments, particularly those involving

surgical technique.

Cleveland Clinic also supports transparent public reporting of healthcare quality data and participates in the following

public reporting initiatives:

• Joint Commission Performance Measurement Initiative (www.qualitycheck.org)

• Centers for Medicare and Medicaid (CMS) Hospital Compare (www.hospitalcompare.hhs.gov)

• Leapfrog Group (www.leapfroggroup.org)

• Ohio Department of Health Service Reporting (www.odh.state.oh.us)

Our commitment to providing accurate, timely information about patient care is designed to help patients and referring

physicians make informed healthcare decisions. We hope you find these data valuable. To view all our Outcomes books,

visit Cleveland Clinic’s Quality and Patient Safety website at www.clevelandclinic.org/quality/outcomes.

Outcomes 2007

Page 4: Heart & Vascular Institute - Cleveland Clinic

Outcomes 20072

Dear Colleague:

I am proud to present the 2007 Cleveland Clinic Outcomes books. These books provide information on results, volumes and innovations related to Cleveland Clinic care. The books are designed to help you and your patients make informed decisions about treatments and referrals.

Over the past year, our ability to measure outcomes was enhanced by the reorganization of our clinical services into patient-centered institutes. Each institute combines all the specialties and support services associated with a specific disease or organ system under a single leadership at a single site. Institutes promote collaboration, encourage innovation and improve patient experience. They make it easier to benchmark and collect outcomes, as well as implement data-driven changes.

Measuring and reporting outcomes reinforce our commitment to enhancing care and achieving excellence for our patients and referring physicians. With the institutes model in place, we anticipate greater transparency and more comprehensive outcomes reporting.

Thank you for your interest in Cleveland Clinic’s Outcomes books. I hope you will continue to find them useful.

Sincerely,

Delos M. Cosgrove, MD CEO and President

Model of new Heart & Vascular Institute, opening October 2008

Page 5: Heart & Vascular Institute - Cleveland Clinic

what’s insideChairman’s Letter 04

Introducing the Future of Healthcare: New Heart & Vascular Institute 05

Institute Overview 06

Quality and Outcomes Measures

Surgical Overview 08

Ischemic Heart Disease 10

Cardiac Rhythm Disorders 14

Valve Disease 18

Aortic Disease 25

Adult Congenital Heart Disease 34

Hypertrophic Obstructive Cardiomyopathy 36

Heart Failure and Transplant 38

Lung Transplant 40

Peripheral Vascular Disease 42

Venous Disease 43

Cerebrovascular Disease 44

Thoracic Surgery 45

Preventive Cardiology 48

Anesthesiology 50

Surgical Quality Improvement 52

Innovations 54

New Knowledge 64

Heart & Vascular Institute Staff Directory 70

Patient Experience 76

Cleveland Clinic Overview 79

Online Services 79

eCleveland Clinic

Dr Connect

My Consult

Referral Contact Information and Locations 80

Page 6: Heart & Vascular Institute - Cleveland Clinic

Chairman’s Letter

4

Chairman’s Letter

Thank you for your interest in the Cleveland Clinic Heart & Vascular Institute 2007 Outcomes. This represents the 10th year we have shared our clinical outcomes with physicians around the country.

As an institution, Cleveland Clinic has moved toward organizing its clinical areas around organ and disease systems, rather than individual specialties. By fully integrating multiple specialties along disease lines, institutes, such as the Heart & Vascular Institute, have created a synergy among medical professionals with similar clinical, research and educational interests, centering on patient care.

In the Heart & Vascular Institute, the classic departmental structure has been preserved and encompasses the departments of Cardiovascular Medicine, Thoracic and Cardiovascular Surgery and Vascular Surgery. In addition to the medical departments, the Heart & Vascular Institute includes its counterparts in the diagnostic laboratories, inpatient nursing units, operating rooms and research sections. Combined, this includes more than 130 physicians, 2,000 employees (of whom 1,000 are nurses), 369 inpatient beds (including 91 ICU beds) and 16 operating rooms. The Institute structure will help further the innovation and research that is revolutionizing the prevention, diagnosis and treatment of heart disease.

The number of effective therapies for cardiovascular and thoracic diseases continues to increase. Patients will benefit greatly. However, the increased number of therapeutic strategies makes the choices among them more complex. We believe that the Heart & Vascular Institute structure will help us to make the best choices and to carry out these therapies effectively.

Bruce W. Lytle, MDChairman, Heart & Vascular Institute

Page 7: Heart & Vascular Institute - Cleveland Clinic

5Heart & Vascular Institute 5

Introducing the Future of Healthcare

Innovative new buildings improve patient access, experience

In October 2008, Cleveland Clinic is introducing the future of healthcare with the opening of the Sydell and Arnold Miller Family Pavilion and the Glickman Tower.

These buildings, which represent the largest construction and philanthropy project in Cleveland Clinic history, embody the pioneering spirit and commitment to quality that define Cleveland Clinic. These structures are a tangible expression of institutes, our new model of care that organizes patient services by organ and disease.

At 1 million square feet, the Miller Family Pavilion is the country’s largest single-use facility for heart and vascular care. The 12-story Glickman Tower, new home to the Glickman Urological & Kidney Institute, is the tallest building on Cleveland Clinic’s main campus. Both will help us improve patient experience by increasing our capacity and by consolidating services, so patients can stay in one location for their care.

1 Million Square-feet area dedicated to the new Miller Family Pavilion, the country’s largest single-use facility for heart and vascular care, opening in October 2008

278 Private patient rooms

16 State-of-the-art operating rooms

20 Cardiac catheterization suites including electrophysiology labs and hybrid operating rooms

– Cardiac radiology and nuclear medicine facilities

– Recovery unit for same-day procedures

– Robotic surgery suite

• 278 private patient rooms

• 21-bed dialysis suite (nearly double the size as before)

• Conference room equipped with teleconferencing, satellite video and digital imaging capabilities to broadcast lectures and live surgeries around the world

• Rooftop helipad to receive critically ill/injured patients

With a combined total of nearly 200 exam rooms and more than 90 procedure rooms, patients will have faster access to Cleveland Clinic cardiac and urological services.

In 2007, Cleveland Clinic was ranked No. 1 in the nation for heart care and heart surgery (13 years in a row) by U.S. News & World Report. Cleveland Clinic also is ranked second in the nation for urology (eight years in a row), and fifth for kidney disease.

For details, including a virtual tour, please visit eet he uildings.com.m t b

• State-of-the-art technology center with:

– 16 operating rooms

– 20 catheterization suites including electrophysiology labs and hybrid operating rooms

– 4 specialized ICUs: coronary ICU, heart failure ICU and two surgical ICUs, with a combined total of more than 90 ICU beds

Highlights:

Page 8: Heart & Vascular Institute - Cleveland Clinic

Outcomes 20076

Institute Overview

6

The Heart & Vascular Institute at Cleveland Clinic

is composed of more than 130 physicians within

cardiovascular medicine, cardiothoracic surgery

and vascular surgery. In October 2008, the Heart

& Vascular Institute will reside in the newly

constructed Sydell and Arnold Miller Family Pavilion

at Cleveland Clinic. This remarkable facility will

be the home of more than 2,000 employees in

nearly one million square feet dedicated to treating

cardiovascular disease.

Cleveland Clinic is recognized as the national leader

in the clinical care of patients with cardiovascular

disease. Cleveland Clinic heart and vascular

specialists continue to provide leading-edge

innovations in patient care therapies and clinical

research.

This institute overview provides a snapshot of the

variety and volume of clinical therapies currently

provided.

Heart & Vascular Institute Overview 2007 Total Patient Visits 294,022

Total New Patients 8,322

Admissions (Acute and Post-acute Patients) 16,351

Total Beds 369

Coronary Intensive Care Beds 16

Heart Failure Intensive Care Beds 8

Thoracic and Cardiovascular Surgery Intensive Care Beds 67

Cardiology/Vascular Step-Down Beds 278

Severity Indices Cardiology 2.15

Cardiac Surgery 6.86

Thoracic Surgery 4.49

Vascular Surgery 2.96

Non-Surgical Procedures Cardiac Procedures Interventional Cardiac Procedures 2,262

Myocardial Biopsies 1,268

Percutaneous Aortic Valvuloplasty Procedures 64

Percutaneous Mitral Valvuloplasty Procedures 20

Percutaneous Atrial Septal Defect (ASD) Closures 38

Percutaneous Patent Foramen Ovale (PFO) Closures 47

Vascular Procedures Interventional Carotid Procedures 144

Interventional Vascular Procedures 4,060

Electrophysiology Procedures Total Electrophysiology Ablations 1,489

Pulmonary Vein Isolation Catheter Ablation Procedures for Atrial Fibrillation 1,015

Total Device Implants 1,138

Permanent Pacemaker Implants (Including 22 biventricular pacemaker implants and 4 loop recorder implants) 470

Implantable Cardiac Defibrillator (ICD) Insertions (Including 232 biventricular ICD implants) 672

Lead Extractions 249

Cardioversions 962

Page 9: Heart & Vascular Institute - Cleveland Clinic

Heart & Vascular Institute 7

50 statesIn 2007, patients traveled from every

state to Cleveland Clinic for their

cardiovascular care.

77 countriesPatients from 77 different countries

came to Cleveland Clinic for their

cardiovascular care in 2007.

Diagnostic and Imaging Procedures Diagnostic Catheterization Procedures 9,078

Diagnostic Vascular Procedures 3,992

Electrophysiology Diagnostic Studies 1,555

Stress Tests 12,135

Echocardiograms (Echos) 52,572

Electrocardiograms (ECGs) 118,344

Noninvasive Vascular Lab Procedures 40,111

Surgical Procedures Open Heart Surgeries 3,438

Robotically-Assisted Cardiac Surgeries 160

Thoracic and Cardiac Surgeries Coronary Artery Bypass Graft (CABG) Surgeries 1,418

Valve Surgeries (Primary and Reoperations) 2,194

General Thoracic Surgeries 1,493

Adult Lung Transplants 72

Adult Heart Transplants (Including 3 heart/lung transplants and 1 heart/kidney transplant) 64

Pediatric Heart Transplants 5

Congenital Heart Surgeries (including 68 adult congenital heart procedures) 186

Surgical Procedures for Atrial Fibrillation 395

Septal Myectomy Surgeries for Hypertrophic Cardiomyopathy 157

Vascular Surgeries General Vascular Surgeries (including bypasses, blood vessel repair, endarterectomy, wound care, amputations) 1,843

Venous Surgeries (including endovenous ablation, surgical ligation, vein resection, stripping) 756

Arteriovenous Access Surgeries 435

Aorta Surgeries Open Ascending and Arch Repair Surgeries 541

Open Descending and Thoracoabdominal Surgeries 56

Infrarenal Endovascular Abdominal Aortic Aneurysm Repairs 158

Endovascular Repairs of Juxtarenal and Thoracoabdominal Aneurysm 88

Endovascular Repairs of Descending Thoracic Aneurysms or Dissections 87

Page 10: Heart & Vascular Institute - Cleveland Clinic

Outcomes 20078

Surgical Overview

1997 1999 2001 2003 2005 2007

6,0006,000

4,0004,000

VolumeVolume

2,0002,000

00

1997 1999 2001 2003 2005 2007

12,00012,000

10,00010,000

VolumeVolume

8,0008,000

6,0006,000

4,0004,000

2,0002,000

00

Thoracic and Cardiac Surgery VolumeThe Department of Thoracic and Cardiovascular Surgery performs a high volume and variety of procedures. In 2007, the department and its affiliates performed 10,853 cardiovascular and thoracic surgical procedures. Improved clinical outcomes are demonstrably linked to centers with high surgical volumes.

Vascular Surgery VolumeThe Department of Vascular Surgery has consistently performed over 5,000 surgical interventions since 2004 and has more than doubled its volume of procedures in the past 10 years.

Primary Operations and Reoperations

Distribution of Cardiac SurgeriesCleveland Clinic has one of the nation’s largest experiences performing a variety of cardiac operations. Isolated valve and combined valve operations accounted for 64 percent of the total cardiac surgical volume in 2007.

Isolated Valve Surgeries

Isolated CABG Surgeries

Isolated Great Vessel Surgeries 2%

Combined Valve Surgeries

4% Combined CABG Surgeries (valve excluded)2% Transplants

Other Cardiac Surgeries

24%

18%40%

10%

Of the 3,438 cardiac

surgeries performed at

Cleveland Clinic’s main

campus for acquired heart

disease, 27 percent

(N = 920) were reoperations,

which are generally more

complex and entail greater

risk than primary operations

(N = 2,518). Extensive

experience with reoperations

benefits patients and can

ensure better outcomes.

Page 11: Heart & Vascular Institute - Cleveland Clinic

Heart & Vascular Institute 9

Cardiac Surgery Hospital MortalityHospital mortality for all cardiac surgeries in 2007 was 3.1 percent, despite the high patient acuity.

0

6

4

2

8

1997 1999 2001 2003 2005 2007

3.1% Mortality

6.9 Patient Acuity

0

60

40

20

100

80

1997 1999 2001 2003 2005 2007

Endovascular cases

Percent

Open cases

Mortality (%)

Age

Vascular Surgery Volume - Open and Endovascular RepairOur treatment approach over the past six years has transitioned from traditional, open surgical repair to endovascular intervention, revolutionizing the management of patients with vascular disease.

Vascular Surgery Hospital MortalityThe cumulative hospital mortality average for patients discharged by the Vascular Surgery Department from 2002 to 2007 was 3.28 percent, in comparison to the 5.4 percent adjusted national teaching hospital mortality average.

Page 12: Heart & Vascular Institute - Cleveland Clinic

Outcomes 200710

Ischemic Heart Disease

External BenchmarkingCleveland Clinic’s inter-

ventional group believes it

is important, both for their

own quality review and

for the sake of potential

patients, to compare their

results with those of other

hospitals with comparable

volumes of interventional

procedures. The American

College of Cardiology-

National Cardiovascular

Data Registry (ACC-NCDR)

is a comprehensive national

cardiac data repository that

publishes such outcomes.

Cleveland Clinic Adjunctive CareReceiving timely and appropriate adjunctive care before and after PCI procedures is important to optimize outcomes, and has been recognized by the American College of Cardiology (ACC) as an important performance measure. Compared to the average high-volume interventional center, Cleveland Clinic physicians administer these medications more frequently.

Percutaneous ProceduresAs a regional and national referral center, Cleveland Clinic treats both simple and complex ischemic disease. Cleveland Clinic patients undergoing percutaneous coronary interventional (PCI) procedures more often have prior heart attack and prior bypass surgery, as well as depressed left ventricular function, than patients at other comparable hospitals.

Cleveland Clinic Angioplasty Baseline Patient Characteristics Cleveland Clinic (%) Other* (%)

Age (>75 years) 24.6 19.7

Prior heart attack 37.0 30.1

Heart failure 15.4 10.9

Diabetes 37.0 33.5

Renal insufficiency 5.4 3.5

Prior bypass surgery 34.1 20.5

Severe left ventricular dysfunction 9.2 5.1

Multi-vessel disease 53.2 45.4

More than one stenosis treated 76.0 56.6

Data based on one-year rolling average *Comparable ACC/NCDR Hospitals (>500 PCI Procedures/Year)

Adjunctive Care Cleveland Clinic (%) Other* (%)

Aspirin before procedure 98.1 93.6

Beta blockers before procedure 80.3 70.5

Statins before procedure 84.7 61.2

Door to balloon time** 85 minutes 148 minutes

Aspirin at discharge 99.6 96.6

ACE inhibitors at discharge 73.2 76.0

Beta blockers at discharge 85.3 78.9

Statins at discharge 96.0 82.5

Data based on one-year rolling average *Comparable ACC/NCDR Hospitals (>500 PCI Procedures/Year) ** Time from arrival in the Emergency Department to balloon inflation for PCI procedure for patients with ST-elevation acute myocardial infarction.

Page 13: Heart & Vascular Institute - Cleveland Clinic

Heart & Vascular Institute 11

PCI ComplicationsAfter adjustment for complexity and severity of illness, the mortality of PCI procedures and the incidence of unplanned bypass surgery at Cleveland Clinic are lower than the national averages, reported by the American College of Cardiology National-Cardiovascular Data Registry (ACC-NCDR). The number of patients who required emergent CABG surgery following an unsuccessful PCI remained low at 0.7 percent in 2007.

*Comparable ACC/NCDR Hospitals (>500 PCI Procedures/Year)

4.00

3.00

0.00Mortality Emergent CABG Blood Transfusions Major Vascular

Complications

2.00

1.00

Percent

Other*

Cleveland Clinic

Complications of PCI Procedures Performed to Treat Other Cardiac Conditions (Non-Acute MI)

2004 (%) 2005 (%) 2006 (%) 2007 (%)

Cardiac death 0.3 0.6 0.5 0.7

Non-cardiac death 0.1 0.2 0.0 0.1

Q-wave MI 0.1 0.1 0.3 0.2

Non-Q-wave MI 3.3 3.5 3.7 3.4

Emergent CABG 0.2 0.2 0.0 0.2

Blood transfusions 2.6 2.2 2.2 2.0

Complications of PCI Procedures Performed to Treat Acute MI

2004 (%) 2005 (%) 2006 (%) 2007 (%)

Cardiac death 3.6 2.3 2.8 6.2

Non-cardiac death 0.0 1.5 1.0 0.3

Reinfarction 0.8 0.4 0.7 0.6

Emergent CABG 0.4 0.8 0.7 0.7

Blood transfusions 10.8 9.5 10.8 10.1

Page 14: Heart & Vascular Institute - Cleveland Clinic

Outcomes 200712

Ischemic Heart Disease (continued)

1997 1999 2001 2003 2005 2007

44

33

22

11

00

3.04 Severity Score

1.9% Mortality

Mortality (%)Mortality (%) Severity Score

Diagnostic Cardiac Catheterization Complications

The composite rate of procedural complications for diagnostic cardiac catheterizations, including acute myocardial infarction (MI), emergent coronary artery bypass graft (CABG) surgery, stroke and death was 0.03 percent in 2007.

Surgical Treatment for Ischemic Heart Disease

Primary Isolated CABG SurgeriesPrimary isolated CABG surgery refers to a patient’s first CABG when performed without any other procedure. In 2007, Cleveland Clinic surgeons performed 506 primary isolated CABG procedures, and mortality was 1.9 percent.

Severity score is assigned before surgery based on the presence of patient conditions known to lead to complications and high mortality risk after surgery. Cleveland Clinic performs a large volume of primary isolated CABG operations on high-risk patients with greater mean severity scores, yet mortality remains low.

2003 2004 2005 2006

0%

2007

0.050.05

0.040.04

PercentPercent

0.030.03

0.020.02

0.010.01

00

Page 15: Heart & Vascular Institute - Cleveland Clinic

Heart & Vascular Institute 13

Isolated CABG Surgery Volume and MortalityIsolated CABG surgeries include primary operations and reoperations. Nearly 20 percent of Cleveland Clinic isolated CABG surgeries were reoperations in 2007. Reoperations are associated with higher morbidity and mortality. Cleveland Clinic’s expertise in cardiac surgeries leads to a higher percentage of referrals for CABG reoperations.

Primary Isolated CABG MortalityIncreased age is a known risk factor for cardiovascular disease and contributes to the complexity of CABG surgical cases. In 2007, Cleveland Clinic achieved very low mortality rates in patients under age 70.

83%

17%

Primary Operations(N = 506)

Reoperations(N = 103)

Isolated CABG ÍSurgeries

2007 Volume Hospital Mortality

609 2.6%

85% Single ITA

4% Single ITA + Radial

2% Bilateral ITA + Radial

9% Bilateral ITA

Arterial GraftsArterial grafts are known for their excellent long-term patency and are the conduits of choice for coronary revascularization.

2007 Primary Isolated CABG Mortality (N = 50 )6

Age Mortality (%)

< 50 years 0.0

50-59 years 0.0

60-69 years 1.1

70-79 years 4.0

≥ 80 years 7.7

Page 16: Heart & Vascular Institute - Cleveland Clinic

Outcomes 200714

Pulmonary Vein Antrum Isolation Procedures (PVAI)PVAI is an effective treatment option for patients with symptomatic atrial fibrillation that has not been effectively treated with antiarrhythmic medications.

2007 PVAI Procedure Volume (N = 1,015) and Outcomes

Success Rate* 80%

Complications

Stroke 0.6%

Severe Pulmonary Vein Stenosis 1.0%

Other Complications 2.0%

*PVAI success rate is defined as a restored sinus rhythm without dependency on medications to control the heart rhythm for at least six months post-procedure. Success rates for repeat ablations range from 90 percent to 95 percent.

During PVAI, high-frequency energy is applied through catheters to the region of the pulmonary veins. This energy produces a circular scar that blocks abnormal impulses firing from the pulmonary veins, thereby “disconnecting” the pathway of the abnormal rhythm and preventing atrial fibrillation.

Higher Ablation Success with New CatheterA Cleveland Clinic study

demonstrated that using an

open-irrigation-tip ablation

catheter resulted in greater

success for treating atrial

flutter, shorter procedure

times, as well as reduced

X-ray exposure and radio-

frequency delivery. The

study compared treatment

with the open-irrigation-tip

catheter to that of the 8-mm

tip catheter.

Source: Bai R, Fahmy TS, Patel D, et al. Radiofrequency ablation of atypical atrial flutter after cardiac surgery or atrial fibrillation ablation: a randomized comparison of open-irrigation-tip and 8-mm-tip catheters. Heart Rhythm. 2007;4:1489-1496.

Cardiac Rhythm Disorders

Pulmonary VeinsPulmonVeins

Comprehensive Atrial Fibrillation TreatmentCleveland Clinic is expert at catheter-based treatments to effectively cure atrial fibrillation. The Center for Atrial Fibrillation, comprising electrophysiologists, cardiologists, cardiac surgeons, imaging specialists and specially trained nurses and researchers, offers comprehensive, state-of-the-art technologies to tailor treatment for each patient.

Page 17: Heart & Vascular Institute - Cleveland Clinic

Heart & Vascular Institute 15

Atrial Fibrillation Surgical Procedure Volume (N = 395)Surgical techniques for atrial fibrillation (AF) include a minimally invasive “keyhole” approach and the classic Maze procedure in patients who require stand-alone ablation. The choice of operation depends upon the patient’s condition; the left atrial appendage is routinely removed. In 2007, Cleveland Clinic cardiovascular surgeons performed 395 procedures to treat atrial fibrillation. The majority of surgical ablation procedures were performed during other cardiac procedures, as shown in the chart below.

Left Atrial Appendage LigationCleveland Clinic physicians and researchers

have developed a ligation device for clipping

and isolating the left atrial appendage, a

potential source of blood clots that may

cause stroke in atrial fibrillation patients.

Clinical trials of this device are currently

under way in Europe, with more than 25

patients successfully treated.

AF + Valve Surgery + CABG

AF + Other Cardiac Surgery

AF + CABG Surgery

Isolated AF Procedures 2%AF + Valve Surgery

In patients having ablation with other heart surgery, lines of conduction block are created on the heart using radiofrequency, cryothermy or microwave energy sources, instead of incisions, to restore normal sinus rhythm.

Distribution of Atrial Fibrillation Surgical Techniques

Three-dimensional CT view of the ligation device.

60%

27%

6%

6%

35%

15%

49%Radiofrequency

Cut-and-Sew Incision MethodMicrowave Ablation <0.5%

Cryoablation

Page 18: Heart & Vascular Institute - Cleveland Clinic

Outcomes 200716

Cardiac Rhythm Disorders (continued)Device ImplantsThe Electrophysiology Lab utilizes the latest device technology, including pacemakers, implantable cardiac defibrillators (ICDs), biventricular pacemakers and biventricular ICDs.

Device Lead ExtractionsSometimes, patients develop uncommon conditions that require the removal of device leads, such as an untreatable infection, a blockage of the blood vessel through which the lead passes, or an electrical malfunction of the lead wire or insulation.

To minimize trauma and cardiac tissue damage, Cleveland Clinic electrophysiologists have participated in the development and use all of the available tools for lead extraction, including electrosurgical energy, mechanical sheaths and excimer laser energy. With these tools and techniques, almost all leads can be safely removed without the need for surgery.

The data below show that with the appropriate experience, training and tools, the lead extraction procedure can be performed with an excellent success rate.

2007 Volume and Outcomes Year # Extraction # Leads % Clinical % Major Procedures Extracted Success* Complications

2007 249 445 99.8 0.4

2006 357 636 99.2 0.0

2005 326 610 99.7 0.3

2004 273 473 100.0 0.0

2003 291 496 99.0 0.7

Average 299 532 99.5 0.28

*Our success rate is defined as removal of all of the required leads without causing bleeding from the veins or heart.

Cleveland Clinic electro-

physiologists perform the

largest volume of lead

extraction procedures in

the world.

Cleveland Clinic patients

undergoing the highly

specialized lead extraction

procedure come from all over

the United States.

Largest Lead Extraction Volume

Infection Rate

Primary Device Implants Infection Rate (%)

408* 0.25

*Excluding device replacements

2007 Volume

Biventricular Pacemakers and ICDs 254

Pacemakers 444

ICDs 440

Total Device Implants 1,138

Page 19: Heart & Vascular Institute - Cleveland Clinic

Heart & Vascular Institute 17

5,252 Total of remote ICD follow-up transmissions performed at Cleveland Clinic in 2007. The ability to remotely evaluate device patient populations broadens access to care.

10,000

8,000

6,000

4,000

2,000

020072003 2004 2005 2006

Total Evaluations

ICD

Pacemaker

8,170 Holter scans performed in

2007

34,696 Arrhythmia transmissions

received in 2007

7,330 Transtelephonic device

transmissions received in 2007

Device Clinic EvaluationsAll device evaluations are linked to each patient’s electronic medical record. Data are accessible to referring physicians via secure access when necessary.

2007 Volume

Pacemaker Evaluations 8,277

ICD Evaluations 6,275

Total Device Evaluations 14,552

Page 20: Heart & Vascular Institute - Cleveland Clinic

Outcomes 200718

Valve Disease

2,5002,500

2,0002,000

1,5001,500

1,0001,000

500500

00

1010

88

66

44

22

001997 1999 2001 2003 2005 2007

VolumeVolume Primary Operative Mortality (%)

Primary Valve Operations and ReoperationsNearly one-third (N = 610) of valve surgeries performed at Cleveland Clinic in 2007 were reoperations. Cleveland Clinic has expertise in performing complicated valve reoperations.

Valve Surgery Volume and MortalityCleveland Clinic continues to perform the largest number of valve operations in the United States. In 2007, Cleveland Clinic surgeons performed 2,194 total valve operations, including 1,584 primary operations and 610 reoperations.

Distribution of Valve SurgeriesIn 2007, 56 percent of patients undergoing primary valve operations also had other concomitant procedures.

Combined Mitral Valve

All Other

Combined Aortic ValveIsolated Mitral Valve

Isolated Aortic Valve

33%

13%

15%

16%23%

27%Isolated Primary Valve Surgeries 10%Isolated Valve Reoperations

45%

Combined Primary Valve Surgeries

18%

Combined Valve Reoperations

64%Valve surgeries

represented 64

percent of our total

cardiac surgical

volume in 2007.

Page 21: Heart & Vascular Institute - Cleveland Clinic

Heart & Vascular Institute 19

Isolated Aortic Valve Replacement MortalityMortality for primary isolated aortic valve replacement at Cleveland Clinic in 2007 was 1.2 percent, significantly lower than The Society of Thoracic Surgeons’ (STS) benchmark of 2.5 percent.

*Based on data from January to June 2007

** Based on four hospital deaths in 325 cases from January to December 2007

0

1

3

4

2

2006

1.2% Cleveland Clinic**

2.5% STS benchmark*

2002 2003 20052004

Mortality (%)

2007

Aortic Valve ReplacementsBioprostheses (biological tissue valves) are the prostheses of choice for both aortic and mitral valve replacement procedures. These valves are durable and allow most patients to avoid lifetime use of anticoagulants after surgery.

0

1,200

1,000

800

600

400

200

1,400

1997

Volume

1999 2001 2003 2005 2007

Mechanical

Bioprostheses

Allografts

1,5001,500

1,0001,000

AV SparingAV RepairsAV Replacements

AV SparingAV RepairsAV Replacements

500500

001997

Volume

1998 1999 2000 2001 2002 20042003 2006 20072005

Aortic Valve Surgery VolumeCleveland Clinic performs the largest volume of aortic valve-sparing procedures in the nation. In 2007, 88 percent (N = 1,169) of aortic valve surgeries performed at Cleveland Clinic were aortic valve replacements, and 12 percent (N = 165) were aortic valve repairs, including 79 aortic valve-sparing operations.

Systole

Diastole

3D Live three-dimensional

echocardiography of the

aortic valve is available

for diagnostic and

intraoperative imaging,

allowing us to perform

intricate aortic valve

surgical procedures.

Page 22: Heart & Vascular Institute - Cleveland Clinic

Outcomes 200720

Valve Disease (continued)Mitral Valve Surgery Volume

In 2007, 1,057 mitral valve surgeries were performed at Cleveland Clinic; 70 percent were valve repairs, and 30 percent were valve replacements. Additionally, 67 percent of isolated mitral valve procedures were performed with a minimally invasive technique.

Isolated Mitral Valve Repair Mortality In 2007, Cleveland Clinic performed 261 primary isolated mitral valve repairs with 0 percent mortality, significantly lower than The Society of Thoracic Surgeons’ (STS) benchmark of 1.5 percent.

1997 1999 2001 2003 2005 2007

33

Mortality (%)Mortality (%)

22

11

00

1.5% STS benchmark*

0% Cleveland Clinic**

*Based on data from January to June 2007 **Based on data from January to December 2007

ACC/AHA Guidelines for Surgery and Mitral Valve Regurgitation Guidelines published by the the American College of Cardiology (ACC) and the American Heart Association (AHA) recommend surgery for certain asymptomatic patients with mitral valve regurgitation, and encourage patients to find large centers specializing in valve repair procedures.

Mitral valve (MV) repair is recommended over MV replacement in the majority of patients with severe chronic mitral regurgitation who require surgery, and patients should be referred to surgical centers experienced in MV repair.

MV repair is reasonable in experienced surgical centers for asymptomatic patients with chronic severe mitral valve regurgitation (MR) with preserved left ventricular function (ejection fraction greater than 0.60 and end-systolic dimension less than 40 mm) in whom the likelihood of successful repair without residual MR is greater than

90 percent.

Source: Bonow RO, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease). J Am Coll Cardiol, August 1, 2006. 48(3):e1-148.

1,0001,000

800800

600600

001997

Volume

1998 1999 2000 2001 2002 20042003 2006 20072005

400400

200200

Mitral Valve Regurgitation

Page 23: Heart & Vascular Institute - Cleveland Clinic

Heart & Vascular Institute 21

Triangular Resection Mitral Valve Repair

Ruptured chords at free edge of posterior leaflet. Region to be resected is indicated.

Abnormal segment has been removed. Leaflet edges are sewn together.

Annuloplasty completes the repair.

Minimally Invasive Valve Treatments

Cleveland Clinic Heart & Vascular Institute is a worldwide leader in the development and clinical treatment of minimally invasive valve surgery. These techniques encompass a variety of methods including the use of very small incisions, robotic heart surgery and percutaneous procedures. Minimally invasive techniques are known to have a patient benefit in reduction of trauma and shorten recovery times.

Isolated Valve Surgery Volume and Mortality

More than 50 percent of isolated valve surgeries were performed using a minimally invasive approach in 2007.

00

500500

300300

400400

200200

100100

0.00.0

1.01.0

0.60.6

0.80.8

0.40.4

VolumeVolume Mortality (%)

2003 2004 2005 2006 2007

0.2

Procedure 2007 Volume Hospital Mortality (%)

Minimally invasive aortic valve procedures 157 0.6

Minimally invasive mitral valve procedures 220 0.0

Infective endocarditis is a life-threatening condition requiring prompt treatment. Surgery for endocarditis requires extensive experience and familiarity with different reconstructive methods, including the use of homografts (human cadaver valves). Cleveland Clinic heart surgeons have vast experience treating infective endocarditis, with excellent outcomes.

Infective Endocarditis Surgical Treatment Volume and Mortality

120120

100100

8080

6060

4040

001997 1999 2001 2003 2005 2007

2020

Volume

2424

2020

1616

1212

88

44

00

ReoperationMortality (%)

Primary

Page 24: Heart & Vascular Institute - Cleveland Clinic

Outcomes 200722

Valve Disease (continued)

Access ports

30% Shorter

Length of Stay

Surgical instruments attached to robotic arms are inserted through a small incision on the right side of the chest, without the need for the division of the breast bone. Sensors attached to the robotic “wrist” provide the surgeon with precise motion control.

00

300300

2006

Volume

VolumeMortality (%)

Percent

2007 2008Projected

100100

200200

00

7575

2525

5050

Isolated Mitral Valve Repair Robotic Procedures

Robotically-Assisted Valve Surgeries

Robotically-assisted mitral valve repair represents a novel, minimally invasive approach for treating mitral valve regurgitation (leaky mitral valve). Cleveland Clinic began performing robotically-assisted mitral valve repairs in 2006. The volume of these procedures greatly increased in 2007, with 0 percent hospital mortality.

Percutaneous Valve Treatments

Cleveland Clinic is the national leader in the development and application of percutaneous valve approaches and has been the leading center in percutaneous valve approaches over the last decade.

Percutaneous Aortic ValvuloplastiesCritically ill patients and other patients who are not candidates for traditional valve replacement surgery due to comorbid conditions may be candidates for percutaneous aortic valvuloplasty. Many patients with severe,

Robotic surgery for isolated

mitral valve repair was

associated with a

30 percent shorter length

of stay than traditional non-

robotic techniques in 2007.

The average length of stay

for robotic isolated mitral

valve repair in 2007 was

5.0 days, compared to 8.5

days for non-robotic isolated

mitral valve repair. This less

invasive technique provides

excellent patient satisfaction

and quick return to normal

activities.

Hospital mortality for both

groups was 0 percent in

2007.

*Three patients in 2007

2007 Volume Hospital Mortality (%)

64 4.6*

00

8080

2006

Volume

2007

6060

4040

2020

The volume of percutaneous aortic valvuloplasty procedures increased by 49 percent in 2007.

symptomatic aortic valve stenosis who underwent this procedure were successfully bridged to surgical aortic valve replacement.

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Heart & Vascular Institute 23

Additional percutaneous approaches for the treatment of mitral, tricuspid and aortic valve disease are being developed and investigated at Cleveland Clinic. Please see the “Innovations” section on page 54 for more information.

Percutaneous Mitral Valvuloplasties Percutaneous Mitral Valve Repair Procedures

3030

2020

1010

00

3030

2020

1010

002002 2003 2004 2005 2006 2007

Volume Mortality (%)

Percutaneous mitral valvuloplasty (valvotomy), performed in the cardiac catheterization laboratory, is a less invasive treatment approach for mitral valve stenosis and is often the first choice of treatment in most patients. Cleveland Clinic mortality for this procedure has been 0 percent since 2002, with a 10-year cumulative stroke incidence of 0.5 percent and a 0.5 percent rate of emergency surgery.

Percutaneous mitral valve repair is being investigated as an alternative treatment option for select patients with mitral valve regurgitation. During this procedure, a small metal clip is delivered and positioned via the catheter. Please see page 63 for more information.

In 2007, Cleveland Clinic performed 29 percutaneous aortic valve replacements in clinical trials using the transfemoral approach.

Percutaneous aortic valve replacement is being investigated as an alternative treatment option for select patients with severe aortic valve stenosis who are high-risk surgical candidates.

A compressed tissue heart valve is placed on a balloon-mounted catheter that is positioned directly in the diseased aortic valve. When the balloon is inflated, the position of the implant is secured.

The balloon is positioned across the narrowed mitral valve. The valve opening is dilated by inflating the balloon, increasing diameters under close monitoring.

Ultrasound and fluoroscopy are used to guide the placement of the clip, which holds the mitral valve leaflets together. Placement of the clip is adjusted until optimal improvement in hemodynamics is observed; then the clip is released and the catheter withdrawn.

Percutaneous Aortic Valve Replacements

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Outcomes 200724

Valve DiseaseNavy Hopeful Gets “Textbook” Robotic Repair

Robert Laconis was stunned. The Navy turned

him down. He’d applied for a commission in

the Reserves, but the doctors told him he had

a heart murmur. A cardiologist later diagnosed

it as a severely leaking mitral valve caused by

mitral valve prolapse. Robert hoped for a future

in the Navy. Now he was looking at the near-

certainty of heart failure. He needed surgery to

replace or repair that valve. But where could he

go? Who would do the best job? Internet savvy,

Robert and his wife Lexie scoured the web for

information on doctors and hospitals. After

weighing the alternatives, they determined that

Cleveland Clinic Heart & Vascular Institute had

the most experience and the best outcomes. Best

of all, it offered robotically assisted minimally

invasive valve repair for certain cases, and Robert

qualified.

Traveling from Florida to Cleveland, Robert and

Lexie met the surgeon who would be performing

the robotic procedure, A. Marc Gillinov, MD.

They liked his friendly manner and record of

expertise. “What can you say about the surgeon

who performs the most mitral valve repairs in

the world?” Lexie said later. “Robert couldn’t be

in better hands.” On Friday, April 4, Robert had

what Dr. Gillinov later called a “textbook” robotic

repair procedure. It was done through small

incisions on the side of his chest. On Sunday,

April 6, Robert was walking the halls of the

step-down unit. By Tuesday, April 8th, he was

out of the hospital, back in his hotel, and making

plans to visit the Rock and Roll Hall of Fame and

Museum before heading back to Florida. “We

have only great things to say about Dr. Gillinov

and Cleveland Clinic,” says Lexie. “Everyone

was so helpful every step of the way. We were

confident we were getting the best care possible.”

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Heart & Vascular Institute 25

1,2001,200

1,0001,000

800800

00

Volume

2001 20021999 2000 20042003 2006 20072005

600600

400400

200200

Ascending/Arch repairAscending/Arch repair

Descending/ThoracoabdominalrepairDescending/ThoracoabdominalrepairThoracoabdominalendovascular repairThoracoabdominalendovascular repairAbdominal open repairAbdominal open repair

Abdominal endovascular repairAbdominal endovascular repair

Diseases affecting the entire aorta, from the aortic valve to the blood supply of the pelvic vasculature, are managed at Cleveland Clinic with a comprehensive, multidisciplinary approach. In addition to conventional surgical therapies, we offer minimally invasive and endovascular approaches for almost every type of aortic disease.

of men aged 65 years and

older will develop an aortic

aneurysm.

5 percent

Aortic Disease

Ascending Aorta

Thoracic Aortic Aneurysm

Iliac ArteryAbdominal Aortic Aneurysm

Stratified ResultsIn this section, we have stratified our results according to treatment indications, extent of aortic involvement and treatment modalities.

Aortic Surgery Volume and Distribution

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Outcomes 200726

Aortic Disease (continued)Ascending Aorta and Arch Disease Surgery VolumeConventional therapy for aneurysms and dissections of the ascending aorta include graft replacement of the diseased vessels (Figure 1). Minimally invasive approaches pioneered at Cleveland Clinic include the use of stent-grafts (Figure 2) and occlusion devices. Therapeutic options are tailored to both the anatomy and physiology of each patient.

Ascending Aorta and Arch Repairs

Over the past five years the volume of ascending aorta and aortic arch repair surgeries performed at Cleveland Clinic increased by 49 percent.

600600

400400

200200

001997 1999 2001 2003 2005 2007

Volume

Elective Ascending Arch Surgery Stroke and Mortality

In 2007, mortality and stroke remained low for elective ascending aorta and arch repairs.

Emergent Ascending Arch Surgery Mortality

The mortality for urgent and emergent ascending aorta and arch repair surgeries decreased by 4.2 percent in 2007 and remains low.

00

250250

150150

200200

100100

5050

00

2525

1515

2020

1010

PatientsPatients Mortality (%)

1997 1999 2001 2003 2005 2007

5

00

500500

300300

400400

200200

100100

00

1010

66

88

44

PatientsPatientsStroke (%)Mortality (%)

1997 1999 2001 2003 2005 2007

2

Aortic dissection results in complex blood flow patterns caused by a split or tear in the aortic wall. The wall of the aorta typically splits. Arteries that supply the kidneys, intestines or lower extremities may derive blood flow from the proper lumen (true lumen) or the split lumen (false lumen).

In the images above, note the false lumen has less contrast and appears more red, while the yellowish true lumen narrows as a result of compression, potentially restricting blood flow to the critical abdominal organs.

Figure 1

Figure 2

Page 29: Heart & Vascular Institute - Cleveland Clinic

Heart & Vascular Institute 27

Descending Thoracic Aortic DiseaseAortic dissections or ruptured aneurysms commonly occur in the descending thoracic aorta and require rapid evaluation and treatment. Physicians carefully assess each patient to determine the optimal therapy based on anatomy and disease presentation.

The development of endovascular grafts has revolutionized the management of patients with descending thoracic aortic disease (DTA). Cleveland Clinic’s team of aortic physicians has pioneered techniques for both surgical and endovascular repair.

DTA Open Repair Distribution

In 2006 and 2007, Cleveland Clinic thoracic surgeons performed 80 open repair procedures for descending thoracic aneurysms, including 61 elective procedures and 19 emergent procedures.

76%

24%

Elective (N = 61)

Emergent (N = 19)

DTA Hospital Mortality

Mortality for both emergent and elective open thoracic aortic repairs in 2006 and 2007 was 5 percent.

1010

88

66

44

00Emergent Elective

22

Percent

Aneurysmal disease of the descending thoracic aorta and aortic arch are frequently coexistent. Figure 1 depicts a three-dimensional reconstruction of a CT scan following arch repair with an elephant trunk graft left in place. The descending thoracic portion of the repair can then be done with a stent-graft, thus creating a hybrid repair. The stent-graft is placed into the elephant trunk graft, which extends from the arch repair, and relines the diseased aorta within the chest and abdomen if necessary (Figure 2).

Figure 1 Figure 2

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Outcomes 200728

Aortic Disease (continued)

67%

33%

Elective (N = 98)

Emergent (N = 48)

Endovascular Repair Volume and MortalityCleveland Clinic has pioneered less invasive therapies for almost every type of aortic disease. Complex aneurysms and aortic dissections that involve the ascending aorta, arch branches, the entire thoracoabdominal aorta and the iliac arteries can be treated with a minimally invasive surgical or percutaneous approach.

2020

1616

1212

88

00Emergent Elective

44

Mortality (%)

The mortality for emergent endovascular thoracic procedures in 2006 and 2007 was 15 percent.

The mortality for elective endovascular thoracic procedures was low at 5 percent.

The most common indication for emergent repair was thoracic aneurysm rupture or dissection (40 percent), followed by 23 percent of patients who presented with ischemia resulting from acute complicated aortic dissection. Other urgent treatment indications included rapid aortic growth in patients with connective tissue diseases (such as Marfan syndrome and Ehlers-Danlos syndrome), traumatic aortic injuries and aorto-bronchial fistulas.

the 13th leading cause of death

Aortic Aneurysms

These two CT scan reconstructions show results following endovascular aortic dissection (Figure 1) and arch rupture (Figure 2) treatments. Following an aortic dissection, the blood to the lower body may be insufficient to sustain life. The placement of an endograft to close off the false lumen of blood flow can re-establish adequate blood flow to the abdomen and legs. Ruptured aneurysms typically are fatal, however, if evaluated in a timely manner, endovascular grafts can be placed to seal the leak. This can be done even when the leaking aorta involves critical branches, such as those to the brain (Figure 2).

Figure 1 Figure 2

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Heart & Vascular Institute 29

Distribution of TAA Surgeries 2007

Thoracoabdominal Aortic Surgeries Diseases of the thoracoabdominal aorta (TAA) are the most difficult to treat due to their complexity, as well as the risk of major complications and mortality. Data published in a 2006 Medicare audit for the state of California support these claims; almost 20 percent of the patients treated for elective thoracoabdominal aneurysms died within 30 days of the procedure, and 31 percent died within 12 months after the procedure.

Reference: Rigberg DA, et al. Thirty-day mortality statistics underestimate the risk of repair of thoracoabdominal aortic aneurysms: A statewide experience. J Vasc Surg. 2006 Feb;43(2):217-222.

Thoracoabdominal aneurysm stent-graft

8080

6060

4040

2020

00Type I Type II

EndovascularOpen

Type III Type IV

Percent

Type I aneurysms involve most or all of the

descending thoracic aorta to the level of the

renal arteries. Type II aneurysms involve most

or all of the descending thoracic aorta, with

abdominal extension to below the renal arteries.

Type III aneurysms involve the lower portion of

the descending thoracic aorta, extending to the

abdominal aorta below the level of the renal

arteries. Type IV aneurysms involve the upper

half or all of the abdominal aorta.

Crawford Classification for Aortic Aneurysms

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Outcomes 200730

Aortic Disease (continued)Thoracoabdominal Aortic Aneurysm (TAAA) Surgery Volume and DistributionFor the first time in history, the treatment of thoracoabdominal aneurysms at Cleveland Clinic was more commonly performed with an endovascular approach rather than an open surgical approach in 2007. A total of 260 procedures were performed to treat thoracoabdominal aneurysms in 2006 and 2007, including 122 open surgeries and 138 endovascular branch vessel grafts.

TAAA Surgery Mortality

4040

3030

2020

1010

00

Elective TAAA Urgent

OpenEndovascular

Percent

Open

47%

53%

Open

Branch Vessel Endovascular Grafts

For 122 open thoracoabdominal procedures performed in 2006 and 2007, mortality was 15.6 percent.

Vascular surgeons performed 138 branch vessel procedures for thoracoabdominal disease in 2006 and 2007, with a 7 percent mortality.

TAAA before endovascular repair TAAA after endovascular repair

The paraplegia rate for patients with

thoracoabdominal aneurysms who were treated

with an endovascular procedure was

2.7 percent, well below the national average.

Cleveland Clinic has the world’s largest volume of

patients with thoracoabdominal aneurysms who

are treated with a stent-graft.

Detailed view of a device that provides a new means of incorporating the vessel that supplies the intestines with blood into a thoracoabdominal aneurysm stent-graft repair.

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Heart & Vascular Institute 31

Open AAA Repair Mortality

4040

3030

2020

1010

00Elective Urgent

Percent

64%

36% Open (N = 171)

Endovascular (N = 299)

88%

12% Urgent (N = 20)

Elective (N = 151)

Abdominal Aortic Aneurysms (AAA)Abdominal aortic aneurysm surgeries are commonly performed at Cleveland Clinic. Aside from the ascending aorta, the abdominal aorta is the most frequent site for aneurysm formation. Both endovascular and open surgery techniques are employed to treat patients with AAA. As evidenced by our results, the mortality for elective abdominal aortic aneurysm repair with open surgery or endovascular surgery is approaching 0 percent.

AAA Procedure Volume and Distribution

In 2006 and 2007, 470 AAA repair surgeries were performed, including 171 open repairs and 299 endovascular (endo and fenestrated grafts) repairs.

Open AAA Repair Distribution

Of 171 open AAA procedures, 151 were performed electively, while 20 were performed urgently.

In 2006 and 2007, mortality for elective AAA open repair was 2 percent.

Mortality for the 20 urgent and ruptured AAAs was 35 percent.

Open Abdominal Aortic Aneurysm Repair

Page 34: Heart & Vascular Institute - Cleveland Clinic

Outcomes 200732

Aortic Disease (continued)

0%The mortality for patients

with juxtrarenal aneurysms

treated with fenestrated

graft procedures (N = 41)

was 0 percent in 2006

and 2007.

Endovascular Repair Volume and Distribution

In 2006 and 2007, 299 elective endovascular AAA procedures were performed, including 41 patients with juxtrarenal aneurysms who were treated with a fenestrated gra andft 13 patients who required emergent surgery.

96%

4%

Elective

Urgent

Endovascular AAA Mortality

2020

1616

1212

88

00Elective Emergent

44

Percent

In 2006 and 2007, mortality for elective repair of an AAA was 2 percent (six patients out of 245). Mortality for patients with juxtrarenal aneurysms treated with fenestrated grafts was 0 percent.

Even in the setting of acute aortic emergencies, mortality was low (15 percent).

Endovascular repair of AAA with stent-grafts

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Heart & Vascular Institute 33

Ruptured Aortic AneurysmWhen 74-year-old Jack Shannon learned that he was being transferred from his local hospital to Cleveland Clinic via helicopter for a ruptured aortic aneurysm, he knew his condition was life-threatening. But, he was also relieved.

“Well, if they’re sending me to Cleveland Clinic, I’ll make it because I’m going to the best hospital around,” Mr. Shannon recounted.

Mr. Shannon previously underwent coronary bypass surgery in 2002, but this time the surgeons in Cincinnati were concerned that he would not survive a conventional approach to this high-risk situation.

Cardiothoracic surgeon Eric Roselli, MD, agreed with their assessment and planned a hybrid repair for Mr. Shannon’s aneurysm while the transfer was coordinated. Hybrid repairs combine open surgical and transcatheter techniques to provide a less invasive, safer treatment alternative for high-risk patients.

In anticipation of Mr. Shannon’s arrival, all members of the multi-disciplinary team of cardiovascular specialists at Cleveland Clinic made preparations. He was taken directly to the hybrid operating room already equipped by the OR nurses and radiology technologists, and the CT anesthesia team proceeded with the extra care needed for an impending rupture. Transesophageal echocardiography was performed while the operation promptly began.

Dr. Roselli and his team performed a successful repair of the leaking 4-inch aortic arch aneurysm by first sewing a prosthetic graft on to his upstream aorta and bypassing the arteries supplying the right and left sides of his brain (Figure 1). A stentgraft was then delivered over a guidewire through a separate limb of this bypass graft using X-ray guidance to completely exclude the leaking aneurysmal portion of his aortic arch and descending thoracic aorta (Figure 2). Finally, because the leaking aneurysm had compromised one of his previous coronary artery bypass grafts, Dr. Roselli performed an off-pump coronary bypass graft to a diseased artery on his heart.

Mr. Shannon was transferred out of the intensive care unit on the third postoperative day and continued to recover on the step-down floor under the watchful care of cardiologist Harry Lever, MD, along with Dr. Roselli’s team. He was discharged to home on postoperative day nine.

Today, Mr. Shannon has returned to enjoying time with his family and is grateful for not only the technical expertise at Cleveland Clinic, but also their dedication, empathy and kindness.

“I’m alive – not only alive, but the kind of care that I had at Cleveland Clinic is just remarkable. It’s the kind of thing that doesn’t just happen.”

Figure 1

Aortic arch aneurysm

Figure 2

Page 36: Heart & Vascular Institute - Cleveland Clinic

Outcomes 200734

Oval-shaped secundum

atrial septal defect (ASD)

is clearly demonstrated by

transesophageal 3-D echo.

2007 Volume

Total Adult Congenital Heart Disease Patient Visits 824

New Referral Visits for Adult Congenital Heart Disease 244

Adult Congenital Heart Disease ClinicAdults with complex congenital heart defects require expert, lifelong care. Cleveland Clinic’s technical expertise, collaboration between pediatric and adult cardiologists and cardiovascular surgeons, as well as state-of-the-art technologies provide the optimal treatment options for these patients, including:

• Adults with relatively benign defects who have not been diagnosed and treated in childhood. These are primarily patients with atrial septal defects, but also include patients with other defects such as atrioventricular (AV) canal defects, ventricular septal defects (VSD), tetralogy of Fallot, coarctation of the aorta, coronary anomalies and others.

• Adults who return with problems after having had surgical repairs in childhood. This patient population is growing steadily due to the development of more successful management strategies for even the most complex defects in childhood. Many of these patients are destined to return as adults with related and new problems that pose very difficult and special diagnostic and treatment challenges. The perioperative and postoperative management of these patients also presents special challenges.

Diagnoses of New Referrals to the Adult Congenital Heart Disease Clinic

AV Canal Defect 4.7%Ventricular Septal Defect 4.7%

Coarctation of Aorta

Transposition of the Great Vessels

Tetralogy of Fallot

Ebstein Anomaly 3.0%

Pulmonic Stenosis 4.7%

Shone Complex 2.4%

1.8% Coronary Anomalies

Other

Other Congenital Conditions TreatedSeveral other congenital anomalies and syndromes generally have not been classified as congenital heart disease. These include patients born with bicuspid aortic valves who present with leaky or stenotic valves as younger adults and patients with Marfan syndrome presenting with an aortic or mitral valve problem. Cleveland Clinic performed reconstructive and valve-preserving surgeries in many of these patients in 2007. Subaortic membranes and stenosis and coronary arteriovenous fistulas are other examples of such conditions posing surgical and percutaneous challenges.

Anomalous right coronary

artery arising from the left

coronary cusp and passing

between the great vessels.

Atrial Septal Defect

Adult Congenital Heart Disease

32.5%

23.1%10.1%

6.5%

6.5%

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Heart & Vascular Institute 35

Interventional Procedures for Congenital Heart Disease2007 Volume and Outcomes

Congenital/Pulmonary Hypertension Cases 236

Vasodilator Challenges 47

Complex Congenital Cases 135

Complex Congenital Interventions 76

Success Rate* 99%

30-Day Mortality 1%

The Amplatzer® Septal

Occluder (top) and the

CardioSEAL® Septal

Occluder (bottom) are two

transcatheter closure devices

used at Cleveland Clinic

for nonsurgical treatment

of atrial septal defects

and patent foramen ovale,

respectively.

Percutaneous Closure Devices

Percutaneous Closure Procedures2007 Volume and Outcomes

Percutaneous ASD Closures 38

Percutaneous PFO Closures 47

Success Rate* 100%

30-day Mortality 1%

Patients Requiring Repeat Procedure 0

Adult Congenital Heart Surgery Distribution

Atrial Septal Defect Repair, Patch

Right Ventricular to Pulmonary Artery Conduit/Pulmonary Valve Replacement

Sinus Venosus/Atrial Septal Defect Repair

Coarctation Repair

Partial Anomalous Pulmonary Venous Connection Repair

Other Adult Congenital Heart Procedures*

*Other adult congenital heart procedures performed at Cleveland Clinic in 2007 included vascular ring, unroofed coronary sinus, Epstein anomaly valve replace-ment, anomalous right coronary artery from opposite sinus/modified unroofing, mitral valve repair for residual mitral valve cleft after previous AV canal repair and one heart transplant for failed Fontan circulation.

*After previous AV canal repair, one patient developed acute respiratory distress syndrome, mitral regurgitation and left ventricular outflow obstruction.

Top photo used with permission from AGA Medical Corporation. Bottom photo used with permission from NMT Medical, Inc.

*Based on one complication, including need for surgery, stroke and myocardial infarction.

*Based on zero complications, including need for surgery, stroke and myocardial infarction.

2007 Volume and Mortality

Adult Congenital Surgeries 68

Mortality* 1.5%

22%

22%

19%

12%

9%

16%

Page 38: Heart & Vascular Institute - Cleveland Clinic

Outcomes 200736

Hypertrophic Obstructive Cardiomyopathy

Sudden Cardiac DeathHypertrophic cardiomyopathy is the most

common cause of sudden cardiac death in

people younger than 30 years of age.

Hypertrophic obstructive cardiomyopathy (HOCM) is thickening of the lower chambers of the heart, especially of the septal muscle, which separates the right and left chambers of the heart. This condition may impede blood flow from the heart to the aorta.

2007 Patient Volume

Total HOCM Outpatient Visits 609

New HOCM Patients 219

Septal Myectomy VolumeCleveland Clinic has one of the largest surgical practices for treating HOCM. In 2007, Cleveland Clinic surgeons performed 157 septal myectomy surgeries.

1997 1999 2001 2003 2005 2007

200200

150150

VolumeVolume

100100

5050

00

During a septal myectomy, the surgeon removes septal muscle to widen the path for blood to leave the heart.

2007 Surgical Volume and Outcomes

Isolated Myectomy and Concomitant Myectomy Procedures 157

Hospital Mortality 0%

1 in 500Hypertrophic cardiomyopathy affects

approximately 1 in 500 people in the U.S.

1,523Since 1967, 1,523 septal myectomies have

been performed at Cleveland Clinic.

O t 2007

2005 2007

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Heart & Vascular Institute 37

Outflow Tract Obstruction Without Septal Hypertrophy

Outflow tract obstruction without septal hypertrophy has been recently recognized as an important cause of outflow tract obstruction, especially in young patients. Advanced imaging with MRI and stress echocardiography can identify this anomaly and most cases can be treated with valve repair.

Hypertrophy

REGISTRY: Hypertrophic CardiomyopathyThe Hypertrophic Cardiomyopathy (HCM) Registry is a case identification registry used to identify patients with HCM or patients who have a

strong history of HCM. The registry comprises a large number of Cleveland Clinic patients and contains data related to the diagnosis, evaluation

and management of HCM patients, including variables related to demographics, patient/family history, clinical information, cardiac procedures,

cardiac surgeries and follow-up information. Through this information, research projects are initiated, statistics are generated, education is

facilitated and manuscripts are written.

Septal Myectomy and Concomitant Procedure DistributionHOCM is an uncommon but serious problem, especially when associated with mitral valve dysfunction. In 2007, 41 percent of septal myectomies were performed in conjunction with a valve procedure, including 13 percent performed to treat mitral valve disease. Of these, 60 percent were mitral valve repair procedures.

Isolated Septal Myectomy

Septal Myectomy + Valve + CABG

Septal Myectomy + Other

Septal Myectomy + CABG

Septal Myectomy + Valve34%

11%17%

8%

30%

Papillary muscles directed toward septum

Sutures in papillary muscles Papillary muscles “reoriented” toward mitral valves

Page 40: Heart & Vascular Institute - Cleveland Clinic

Outcomes 200738

Waiting List Mortality In 2007, Cleveland Clinic’s

waiting list mortality was

consistently lower than the

national median wait list

mortality.

Source: SRTR. Center and OPO-Specific Reports, January 2008. Ohio, Heart Centers, Cleveland Clinic. Table 4. www.ustransplant.org/csr/current/csrDefault.aspx

1,349 Number of adult heart

transplants performed at

Cleveland Clinic since

inception of the Cardiac

Transplant Program in 1984.

Heart Failure and Transplant

100

Survival (%)

90

80

70

50

1 Year** 3 Years

Expected*Observed

60

Heart Transplant Patient Survival The January 2008 report of the Scientific Registry of Transplant Recipients (SRTR) demonstrates Cleveland Clinic achieved better-than-expected patient survival at 12 and 36 months post transplant.

Heart Transplant VolumeCleveland Clinic’s Cardiac Transplant Program remains the leading center in both Ohio and the Midwest, and is the fourth largest transplant program in the U.S. In 2007, 64 adult heart transplants were performed at Cleveland Clinic, including three heart-lung transplants and one heart-kidney transplant. Five pediatric heart transplants were performed.

Source: SRTR. Center and OPO-Specific Reports, January 2008. Ohio, Heart Centers, Cleveland Clinic. Table 11. www.ustransplant.org/csr/current/csrDefault.aspx *Expected based on risk adjustment **One year survival is statistically higher

10

Median Months

8

6

4

0

Cleveland Clinic Region

2

United States

Median (50th percentile) months to transplant for patients registered on wait list. Our waiting times are consistently lower than the national average.

Source: SRTR. Center and OPO-Specific Reports, January 2008. Ohio, Heart Centers, Cleveland Clinic. Table 6. www.ustransplant.org/csr/current/csrDefault.aspx

Reduced Waiting Time for Heart Transplant

Page 41: Heart & Vascular Institute - Cleveland Clinic

Heart & Vascular Institute 39

Mechanical Circulatory Device SupportCleveland Clinic has significant depth and breadth of experience with mechanical circulatory device support, including the utilization of pumps for acute support as a bridge to transplant and as permanent support for patients who are not candidates for organ replacement.

In 2007, mechanical circulatory support devices were implanted into 23 patients. Access to and expertise with four mechanical support devices allows us to utilize the optimal device in each patient.

Heartmate II LVASCleveland Clinic uses

the Heartmate II LVAS in

clinical trials for destination

therapy and recently began

using the device as a

bridge to transplant. This

next-generation pump is

small, light-weight, quiet

and easier to implant, with

shorter surgical times than

previous models. The device

has been shown to restore

hemodynamic function and

improve patient outcomes

and quality of life.

Image used with permission from Thoratec Corp.

Left Ventricular RemodelingThe treatment data below represent patients who have undergone mitral valve repair with CorCap and the control group represents patients who have undergone mitral valve repair surgery alone. There is a consistent and sustained reduction in heart size in the patients who underwent mitral valve repair, with additional benefits seen in patients who were also treated with the cardiac support device.

This study demonstrates the potential of existing and evolving therapies to promote “reverse remodeling” and improved heart function.

Note: The CorCap device is available in Europe and in clinical trials in the United States.

-100

-20

-40

-60

-80

0

0

LV End Diastolic Volume

6 12 18 24 30 36

Treatment

Est. Treatment Dif. = -16.0P = 0.032

Follow-up Month

Control

Treatment: 72 64 64 45 49 26 Control: 72 63 60 36 44 21

Get with the Guidelines - Heart Failure ProgramIn 2007, Cleveland Clinic was recognized with the Silver Performance Achievement Award by the American Heart Association for achieving the aggressive goal of treating heart failure patients for 12 consecutive months in compliance with core heart failure treatment measures outlined by the AHA. The “Get with the Guidelines - Heart Failure Program” is the AHA’s quality improvement initiative that aims to decrease re-hospitalizations and reduce mortality in heart failure patients.

Source: Starling RC, et al. Sustained benefits of the CorCap Cardiac Support Device on left ventricular remodeling: three year follow-up results from the Acorn clinical trial. Ann Thorac Surg. 2007 Oct;84(4):1236-1242. Figure adapted with permission.

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Outcomes 200740

Lung Transplant

In 2007, Cleveland Clinic performed three heart-lung transplants, one liver-lung transplant, 53 double-lung transplants and 15 single-lung transplants.

Distribution of Lung Transplant Procedures

100100

8080

Liver-LungHeart-LungDouble LungSingle Lung

Liver-LungHeart-LungDouble LungSingle Lung

6060

00

Volume

2002 20042003 2006 20072005

4040

2020

Primary Disease of Lung Transplant Recipients*

*Patients who received a lung transplant from 7/1/06 to 6/30/07, N = 67.

Source: Scientific Registry of Transplant Recipients. Center and OPO-Specific Reports, January 2008. Ohio, Lung Centers, Cleveland Clinic. Table 7. www.ustransplant.org/csr/current/csrDefault.aspx

72Adult lung transplants

performed in 2007.

Cleveland Clinic’s Lung Transplant Program is the leading program in Ohio and among the top programs nationally. The program has gained a reputation for accepting and transplanting challenging and complex cases. Patients have been referred nationally and internationally for lung and heart-lung transplantation evaluations.

Cystic FibrosisIdiopathic Pulmonary Fibrosis

38.8%

40.3%

16.4%

Emphysema/COPD

Other 2% Unknown 1.5%

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Heart & Vascular Institute 41

Waiting List Mortality*

Lung Transplant Survival

Reduced Waiting Time for Lung TransplantMedian (50th percentile) months to transplant for patients registered on wait list between 07/01/2001 and 12/31/2006.

Cleveland Clinic’s waiting list mortality has been consistently lower than the national median wait list mortality.

Percent

50

90

100

70

60

80

360 12

Months

Observed Survival

Expected Survival*

24

2020

1515

1010

55

00Cleveland Clinic Region United States

Median Months

1010

88

66

44

22

006 12 18

Cleveland Clinic (N=61)United States (N=1,562)

Percent

Median Months

Source: SRTR. Center and OPO-Specific Reports, January 2008. Ohio, Lung Centers, Cleveland Clinic. Table 4. www.ustransplant.org/csr/current/csrDefault.aspx

Cleveland Clinic lung transplant survival compares favorably to the expected national experience.

*Expected based on risk adjustment Source: SRTR. Center and OPO-Specific Reports, January 2008. Ohio, Lung Centers, Cleveland Clinic. Table 11. www.ustransplant.org/csr/current/csrDefault.aspx

Source: SRTR. Center and OPO-Specific Reports, January 2008. Ohio, Lung Centers, Cleveland Clinic. Table 6. www.ustransplant.org/csr/current/csrDefault.aspx

*Patients placed on wait list between 1/1/2005 and 12/31/2005

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Outcomes 200742

Peripheral Vascular Disease

29,857Total volume of ultrasound

procedures performed in the

Non-Invasive Vascular Lab

in 2007

Lower Extremity Interventional ProceduresOur vascular surgeons and cardiologists are skilled in performing procedures on the peripheral arteries, including angioplasty, atherectomy, stenting, thrombectomy and thrombolysis.

2007 Interventional Procedure Volume

Angioplasty 945

Atherectomy 87

Lower Extremity Stenting 570

Thrombolysis 218Lower extremity procedures: Superficial femoral artery disease is the most common site of blockage in peripheral artery disease. Multiple modalities exist to treat blockages causing intermittent claudication.

Renal mesenteric procedures: Patients with atherosclerotic arterial disease to the kidney and mesentery receive targeted treatment from our multidisciplinary team, which includes vascular surgeons, interventional and vascular medicine specialists, as well as nephrologists and gastroenterologists.

Lower Extremity (LE) Surgery Volume and MortalityOur vascular surgeons specialize in performing peripheral artery bypass surgery and strive to use autologous vein grafts.

Non-Invasive Vascular Lab Ultrasound Study Distribution

3% Arterial Mapping (Mammary Artery)

5% Evaluation of Mass7% Renal/Messenteric Duplex

2% Arterial Duplex

Carotid Duplex

<1% Carotid Intimal-Medial Thickness

Venous Duplex

<1% Valvular IncompetencyPhysiologic Testing

4% Vein Mapping

18%

13%

47%

2007 Mortality (%)

LE Bypass 1.0

2007 Volume

Lower Extremity Bypass 194

Thrombectomy 8

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Heart & Vascular Institute 43

Venous Disease

Disposable catheter inserted into vein

Vein treated Catheter withdrawn, closing vein

Four weeks post-endovenous ablation

Before endovenous ablation

Endovenous Ablation ProcedureEndovenous ablation is the treatment choice at Cleveland Clinic for valvular incompetency of the great saphenous vein. This minimally invasive procedure improves outcomes with less scarring, bruising or swelling compared to vein stripping. During the procedure, radiofrequency or laser energy is applied to ablate, or scar, the diseased vein.

Number of endovenous ablation procedures performed at Cleveland Clinic in 2007182

Venous Diseases Treated at Cleveland ClinicCleveland Clinic vascular medicine physicians and vascular surgeons offer a full range of therapies for venous diseases.

Varicose vein treatments include conservative treatments such as properly-fitting support stockings, skin care and a regular walking program. When further treatment is needed, medical and surgical options include sclerotherapy, endovenous ablation with radiofrequency or laser energy sources, stab excision and ligation of saphenous veins and varicose vein branches.

Venous stasis ulcer treatments include endoluminal therapy for proximal venous occlusion and endoscopic therapy for perforator incompetence.

Venous occlusive diseases, such as deep vein thrombosis and venous scarring due to venous catheters or device leads, are treated with venous procedures such as mechanical thrombectomy, thrombolysis, venous angioplasty and stenting.

Saphenous Varicose Veins

PhlebotestThe Cleveland Clinic Non-

Invasive Vascular Laboratory

is only the second institution

in the United States to use the

Phlebotest system. Phlebotest

is a comprehensive venous

physiologic examination using

air plethysmography and an

automated positioning chair.

Multiple aspects of vein

function are assessed, and

the system can be used to

diagnose lower extremity

venous obstruction, valvular

incompetency and calf muscle

pump dysfunction. The simple

diagnostic exam usually lasts

only 10 minutes.

Page 46: Heart & Vascular Institute - Cleveland Clinic

Outcomes 200744

Cerebrovascular Disease

CTA of the internal carotid artery showing a stenosis of the vessel.

Carotid Stenting and Endarterectomy TrialsCleveland Clinic Heart &

Vascular Institute is one of a

few institutions participating

in prospective randomized

trials to evaluate both carotid

stenting and carotid endar-

terectomy in symptomatic

and asymptomatic patients.

300300

200200

100100

00CarotidStenting

CarotidEndarterectomy

Cerebral VascularReconstruction

200520062007

Volume

Cerebrovascular disease is a potentially devastating process that may result in temporary or permanent stroke. People with carotid artery stenosis have an increased risk for heart attack and peripheral arterial disease (PAD). Treatment options include medical therapy, surgical treatment with carotid endarterectomy or minimally invasive carotid stenting.

These volumes represent all procedures performed at Cleveland Clinic’s main campus and its affiliates.

Innovative Devices to Treat Cerebrovascular Disease

Flow Reversal System

A novel system of carotid protection during stenting is currently being investigated for its ability to reverse blood flow during stent placement. This device may reduce the risk of debris reaching the brain, thereby preventing stroke.

Carotid Filter and Stenting Devices

Cleveland Clinic is investigating carotid stenting procedures that utilize different types of embolic protection devices. These devices, or filters, are placed to catch any particles that may dislodge during stent placement to treat patients at risk of stroke.

Embolic protection deviceStent

Image used with permission of W.L. Gore and Associates.

2007 Procedural Complications* (N) MI (%) Stroke (%) Mortality (%)

Carotid Stenting 109 0 4.6 0

Diagnostic Angiograms 220 0 0.9 0

Carotid Endarterectomy 163 2.5 2.4 0.6*All procedures performed at Cleveland Clinic’s main campus

Images courtesy of Abbott Vascular. ©2008 Abbott Laboratories. All rights reserved.

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Heart & Vascular Institute 45

Thoracic Surgery

General Thoracic SurgeryIn 2007, Cleveland Clinic thoracic surgeons performed 1,520 procedures and continued to maintain a low mortality of 0.4 percent. A high volume of operative procedures translates into depth of clinical expertise.

Distribution of Thoracic Surgeries

1997 1999 2001 2003 2005 2007

1,6001,600

1,2001,200

800800

400400

00

3.003.00

2.252.25

1.501.50

0.750.75

00

Surgical VolumeSurgical Volume Mortality (%)

Cleveland Clinic thoracic surgeons specialize in the diagnosis and surgical treatment of diseases of the lung and esophagus, including lung and esophageal cancer, lung failure, swallowing disorders and airway disease. Our staff offers a broad range of services, from cutting-edge screening techniques to the latest advances in minimally invasive surgical procedures.

Esophagogastric

18%

11%

5%

24%16%

22%

5%

Mediastinum–Neck

Lung Transplant

AirwayPleura and Pericardium

Other

Pulmonary

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Outcomes 200746

Median Postoperative Length of Stay (Days)

00 332211 44 55 66

Wedge Resection

Segmentectomy

Lobectomy

Pneumonectomy

Thoracic Surgery (continued)

Distribution of Pulmonary Resection (N = 311)

Pulmonary Resection MortalityCleveland Clinic continues to perform a large number of pulmonary resections, having done 311 in 2007.

44

33

22

11

001997 1999 2001 2003 2005 2007

Median age

8080

6060

4040

2020

00

Mortality (%)

Pulmonary Resection Length of Stay (LOS)Cleveland Clinic’s multidisciplinary care model results in shorter length of stay for patients.

51%

40%

6%

Lobectomy

Pneumonectomy

3% Segmentectomy

Wedge

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Heart & Vascular Institute 47

Distribution of Esophageal Surgery by Indication (N = 274)

Esophageal Surgery Length of Stay (LOS)

00

44

33

1997

Percent

22

11

1999 2001 2003 20072005

Median Postoperative Length of Stay (Days)

00 4422 66 88 1010

Fundoplication

Esophagectomy

Esophagectomy remains one of the most challenging of general thoracic operations. Cleveland Clinic’s experience with this procedure leads to shorter LOS for patients.

SuperficialEsophageal Cancer

ESOPHAGECTOMY FOR SUPERFICIAL CANCER

Patients with superficial esophageal cancer generally underwent resection without a chest incision (transhiatal esophagectomy).

Esophageal Surgery Operative Mortality

Major esophageal surgery includes resections for cancer and reoperative surgery for motility and reflux disorders. In 2007, 274 esophageal operations were performed with a low mortality of 0.37 percent.

43%

29%

22%

5%

Cancer

1% Esophageal PerforationOtherReflux

Achalasia

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Outcomes 200748

Preventive Cardiology

9,0009,000

7,0007,000

5,0005,000

3,0003,000

1,0001,000Prevention Phase I Rehab Phase II Rehab Phase III Rehab

Volume

20052004

20072006

250

0HDL

200

LDL Triglycerides Total Cholesterol

150

50

100

Value (mg/dL)

49.71 50.95

141.6

100.3

225.2

152

236.9

182.2After 2nd Follow-up Visit

Baseline Visit

2007 Volume

Prevention Outpatient Visits 6,293

Phase I Rehab 8,248

Phase II Rehab 4,601

Phase III Rehab 3,539

Outcome MeasuresPreventive Cardiology

and Rehabilitation tracks

outcomes on numerous

cardiovascular risk factors,

including lipid levels, blood

pressure, body mass index,

Framingham risk score,

diabetes, smoking, high

sensitivity c-reactive protein

and emerging nontraditional

cardiac risk factors.

The Cardiac Rehabilitation

Program reports outcomes

related to quality of life,

functional capacity, blood

pressure and compliance.

Preventive Cardiology Adult PatientsTypically, the patients first seen in the Preventive Cardiology program are already taking lipid-lowering drugs and have mixed dyslipidemia or a history of statin intolerance. Despite this, our patients achieved significant improvements in fasting lipid profiles. This graph represents all adult patients who initially entered the Preventive Cardiology program and had two follow-up visits in 2007.

In 2007, the volume of patients in the Preventive Cardiology and Rehabilitation Department grew by 26 percent.

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Heart & Vascular Institute 49

Cardiac Rehabilitation PatientsParticipants in our Cardiac Rehabilitation Program demonstrated marked improvements in fasting lipid profiles, indices of diabetes control, functional capacity, blood pressure and both physical and psychosocial measures.

This table represents the average entry and exit parameters of 2007 program participants (N = 4,601) for whom one or more risk factors were identified as elevated and targeted goals for optimal cardiovascular risk reduction were defined.

Entry Exit Absolute Changes

Systolic Blood Pressure (mm/Hg) 143 128 - 15

Diastolic Blood Pressure (mm/Hg) 78 73 - 5

LDL (mg/dL) 89 83 - 6

Total Cholesterol (mg/dL) 175 156 - 19

Triglycerides (mg/dL) 143 132 - 11

HDL (mg/dL) 50 46 - 4

Glucose (mg/dL) 131 118 - 13

SF-36 PCS 37.6 44.3 + 6.74

SF-36 MCS 47.8 52.2 + 4.38

Preventive Cardiology Pediatric Lipid Clinic PatientsThis graph represents all patients aged <18 years who had two follow-up visits in 2007. The Pediatric Lipid Clinic offers expert medication and lifestyle management for genetic dyslipidemic patients and their families.

350

0HDL

300

LDL Triglycerides Total Cholesterol

250

50

200

Value (mg/dL)

150

100

51.00 44.00

254.4

156.3 138.4

73.20

334.8

215.2

After 2nd Follow-up Visit

Baseline Visit

Exercise PrescriptionsThe need for physician-supervised exercise

programs is steadily increasing. Preventive

Cardiology offered 260 exercise prescriptions

in 2007 to start individuals on a safe

and effective exercise regimen. Exercise

prescriptions are office visits combined with

exercise stress testing to individually tailor

a person’s exercise program. A complete

medical history, exercise history with exercise

test results, limited physical exam,

quality-of-life questionnaire, and readiness for

change are all part of the assessment.

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Outcomes 200750

Anesthesiology Cardiothoracic Anesthesiology

Relative Frequency (%)Relative Frequency (%)

Glucose Range (mg/dL)Glucose Range (mg/dL)

Cumulative Relative Frequency (%)

Postoperative Glucose ControlControlling postoperative blood glucose, a national quality measure, has been shown to reduce mortality, the incidence of infection and renal failure, the need for red blood cell transfusion and ventilator support, as well as the median ICU length of stay. Blood glucose is measured at 6 am the day after surgery.

Of 2,970 Cleveland Clinic patients undergoing heart surgery in 2007, 97 percent (2,881) achieved the benchmark level of ≤200 mg/dL, with 79 percent falling below 150 mg/dL. This degree of control was achieved with only 0.10 percent of patients developing hypoglycemia (<50 mg/dL) at the 6 am measurement. Blood glucose control was similar in patients with insulin-dependent diabetes mellitus (IDDM) and noninsulin-dependent diabetes mellitus (NIDDM) after heart surgery.

Postoperative Pain ControlCleveland Clinic cardiothoracic anesthesiologists extensively use thoracic epidural catheters for postoperative pain control in patients undergoing thoracotomy or high abdominal laparotomy procedures. Patients undergoing procedures not suited to thoracic epidural catheter placement are treated with multiple modalities.

In 2007, more than 60 percent of Cleveland Clinic thoracic and cardiovascular surgery patients reported a pain score of three or less at postoperative days one and two.

0 1 2 3 4 5 6 7 8 9 10

8080

6060

4040

2020

00

100100

7575

5050

2525

00

Relative Frequency (%)Relative Frequency (%)

Pain ScorePain Score

Cumulative Relative Frequency (%)

24-Hour Pain Score - Cardiac and Thoracic Surgery (Nonepidural) N = 2,431

6 am Glucose for All Cardiac Patients N = 2,970

24-Hour Pain Score - Cardiac and Thoracic Surgery (Epidural)N = 419

0 1 2 3 4 5 6 7 8 9 10

8080

6060

4040

2020

00

100100

7575

5050

2525

00

Relative Frequency (%)Relative Frequency (%) Cumulative Relative Frequency (%)

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Heart & Vascular Institute 51

Vascular Surgery Anesthesiology

6060

4040

2020

001st Qtr. 2nd Qtr. 3rd Qtr. 4th Qtr.

N=369 N=340 N=354 N=394Percent

The Section of Anesthesia for Vascular Surgery continues its emphasis on the management of perioperative normothermia (≥36.0˚C). Although the trend in 2007 was upward, the addition of this measure in early 2008 to the Anesthesiologist Dashboard clinical practice reporting tool for staff anesthesiologists will provide data for continuous improvement.

The Department of General Anesthesiology visits vascular surgery inpatients on their second postoperative day in the hospital to evaluate the early postoperative period and to obtain patients’ responses to a standardized anesthesia experience survey. Favorable responses to the statement “I threw up or felt like throwing up” are “Disagree very much” or “Disagree moderately.”

A question in the postoperative patient satisfaction survey obtained during postoperative rounds asks for the response to the statement “I was satisfied with my anesthesia care.” Favorable responses include “Agree very much” or “Agree moderately.” Results for 2006 and 2007 for vascular surgery patients are shown here.

Perioperative Normothermia

Management of Postoperative Nausea Vomitingand

Satisfaction with Anesthesia Services

00

100100

2006N=116

Percent

2007N=287

6060

8080

4040

2020

00

100100

2006N=115

Percent

2007N=283

6060

8080

4040

2020

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Outcomes 200752

Surgical Quality Improvement

Surgical Care Improvement Program (SCIP)SCIP is a national campaign aimed at reducing surgical complications by 25 percent by the year 2010. SCIP is sponsored by the Centers for Medicare and Medicaid Services (CMS) in collaboration with a number of other national partners serving on the steering committee, including the American Hospital Association (AHA), Centers for Disease Control and Prevention (CDC), Institute for Healthcare Improvement (IHI), The Joint Commission and others. Cleveland Clinic is committed to improving the care of surgical patients and participates in SCIP. A multidisciplinary team including the Surgery Institute, Anesthesiology Institute, Infectious Disease Department, Nursing Institute, and Quality and Patient Safety Institute works together to ensure that our surgical patients receive appropriate care.

Percent

0

20

100

40

60

80

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Cleveland ClinicNational Average*Top Hospitals*

Appropriate Preoperative Prophylactic Antibiotic Timing 2007

Cleveland ClinicNational Average*Top Hospitals*

Percent

0

20

100

40

60

80

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Appropriate Prophylactic Antibiotic Selection 2007

Cleveland ClinicNational Average*Top Hospitals*

Percent

0

20

100

40

60

80

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Prophylactic Antibiotics Discontinued within 24 Hours After Surgery 2007

Cleveland ClinicNational Average**Top Hospitals**

Percent

0

20

100

40

60

80

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Recommended Venous Thromboembolism Prophylaxis Received by Patient 2007

* Source:

United States Department of Health and Human Services, Hospital Compare.

Most current reported discharges July 2006 to June 2007.

“Top Hospitals” represent the top 10 percent of reporting hospitals nationwide.

National average of all reporting hospitals in the United States.

** Source:

United States Department of Health and Human Services, Hospital Compare.

Most current reported discharges January to June 2007.

“Top Hospitals” represent the top 10 percent of reporting hospitals nationwide.

National average of all reporting hospitals in the United States.

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Heart & Vascular Institute 53

Recommended Venous Thromboembolism Prophylaxis Ordered 2007

Jan Feb Mar Apr May Jun Jul

Cleveland Clinic**

Aug Sep Oct Nov Dec

Percent

0

20

100

40

60

80

Surgery Patients Who Received their Beta Blocker Perioperatively 2007

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Cleveland ClinicNational Average*Top Hospitals*

Percent

0

20

100

40

60

80

* Source:

United States Department of Health and Human Services, Hospital Compare.

Most current reported discharges January to June 2007.

“Top Hospitals” represent the top 10 percent of reporting hospitals nationwide.

National average of all reporting hospitals in the United States.

** No national benchmark data available at this time

National Surgical Quality Improvement Program (NSQIP)

The American College of Surgeons’ National Surgical Quality Improvement Program is a national program that objectively measures surgical outcomes. It reports risk-adjusted 30-day mortality and morbidity outcomes. Currently, the program includes Cleveland Clinic’s surgical cases from colorectal surgery, general surgery and vascular surgery. As this program continues to grow at a national level, Cleveland Clinic is committed to expanding it to all surgical areas. We view NSQIP as a valid, independent way to document our surgical outcomes and provide a basis for ongoing performance improvement.

0

10

20

30

PercentPercent

MorbidityMortality

ExpectedObserved

NSQIP July 1, 2006 to June 30, 2007 Vascular Surgery (N = 284)

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Outcomes 200754

Innovations

Cleveland Clinic Innovation CenterCleveland Clinic Innovation Center (CCI) is Cleveland Clinic’s technology commercialization arm, which has a mission to “benefit the sick through the broad and rapid deployment of Cleveland Clinic technology.” CCI facilitates innovation, creates spin-off companies, licenses technology, secures resources and establishes strategic collaborations with corporate partners.

Cardiovascular technologies supported by CCI include:

self-supported mitral and tricuspid valve annuloplasty ring•

elephant trunk vascular ring-graft•

artificial chordae for mitral valve repair •

percutaneous aortic valve graft •

dry storage for percutaneous tissue valves•

percutaneous mitral and tricuspid valve replacement •

sealable cardiac port •

Robotically Assisted Valve Surgery

Robotically assisted mitral valve repair represents a novel, minimally

invasive approach for treating mitral valve regurgitation. It allows

performance of complex mitral valve repairs with the least amount of

trauma to the patient. The operation is performed through small incisions

and ports on the right side of the chest, without the need for dividing the

breast bone. The clinical application of robotic surgery includes treatment

of coronary artery disease.

Cleveland Clinic performs the highest volume of robotic heart surgeries

among U.S. academic medical centers, and has a team of surgeons trained

in this high-tech approach.

da Vinci Surgical System. Image used with permission from Intuitive Surgical, Inc.

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Heart & Vascular Institute 55

Sensei Robotic Catheter System. Images used with permission from Hansen Medical, Inc.

Robotic Catheter System to Treat Atrial FibrillationA new Food and Drug Administration-approved robotic catheter ablation system, used in the Electrophysiology Laboratory, enables placement of ablation catheters through small incisions, with improved precision and stability. The system, used to treat atrial and ventricular arrhythmias, is composed of a control catheter and an ergonomically designed, remotely placed workstation where the physician is seated during the procedure.

Cleveland Clinic began using this system in June 2007 and was the first center to use it for clinical applications. It has helped improve the accuracy and efficiency of complex catheter ablation procedures, without adding procedure time or exposing the operator to radiation.

Global Cardiovascular Innovation Center

Founded in 2007, the Global Cardiovascular Innovation Center (GCIC)

is a technology commercialization consortium made possible by a $60

million grant from the State of Ohio’s Third Frontier Program. GCIC is

led by Cleveland Clinic and includes Case Western Reserve University,

the Ohio State University, the University of Cincinnati, the University of

Toledo and University Hospitals and is linked to industry and economic

development partners.

GCIC assists institutions and companies by providing resources and

funding for cardiovascular technology commercialization. GCIC seeks

to expand the thriving medical device and biotech industry located

in Ohio by leveraging partner resources and capabilities to develop

and attract new companies. Upon its completion in 2009, the GCIC

Incubator Building will be home to 20 new early stage cardiovascular

companies. By fostering technology and company development, GCIC

will create hundreds of new jobs in Ohio.

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Outcomes 200756

InnovationsLargest Government Grant for Atrial Fibrillation Research

The Atrial Fibrillation Innovation Center (AFIC), an Ohio Wright Center of Innovation, is supported by the largest single government grant in the world for atrial fibrillation research. Cleveland Clinic, together with its institutional partners, Case Western Reserve University and the University of Cincinnati, and its commercial

partners, received this $23-million grant from the State of Ohio’s Third Frontier human genetics and biomedical engineering initiative.

The Center’s preclinical research facilities feature two large laboratories designed to enable both chronic and acute procedures. The lab also features a preparation room and a conference room equipped with video conferencing capabilities and the ability to view surgeries remotely. Proximal to the laboratories is a testing room, fully fitted with treadmill and telemetry equipment, permitting the monitoring of animals in an adjacent boarding area.

The AFIC labs serve as a world center for training physicians in the use of the robotic catheter ablation system for minimally invasive atrial fibrillation treatment, and a specialized multi-lumen balloon catheter system for use in pulmonary vein ablation procedures.

Sealable Cardiac Port A sealable cardiac port device is being developed at Cleveland Clinic to provide safe, transapical access to the heart chambers for percutaneous aortic and mitral valve replacement.

Sensei Robotic Catheter System. Images used with permission from Hansen Medical, Inc.

Investigation with the latest robotic systems for heart rhythm therapy

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Heart & Vascular Institute 57

Artificial Chordae for Mitral Valve Repair A novel system for repairing or replacing mitral valve chordae is currently being investigated. The PreChord System consists of premeasured artificial chordae and a measuring/attachment device that mechanically attaches the new chordae with one simple maneuver — thereby reducing surgeon and patient time in the operating room.

Percutaneous Valve Repair TechnologyMyoRing is a complete, self-supported and semi-flexible annuloplasty stent-ring introduced percutaneously into the mitral or tricuspid valve annulus and deployed using balloon technology. It is made from a nickel-titanium shape-memory alloy, and the hooks allow placement without stitching. This prosthetic ring is being developed at Cleveland Clinic for use in treating valve regurgitation to restore valve function, while reestablishing the normal shape and contour of the native valve annulus. This technology will serve as a platform for developing the next generation of percutaneous valve repair devices.

Multi-lumen branches

Mid sewing ring

Distal ring radiograph markersOval sewing ring

Proximal ring(may include a prosthetic valve)

Elephant Trunk Vascular Ring-Graft This vascular ring-graft is being evaluated for surgical repair of acute and chronic aortic dissection, aortic aneurysms and peripheral blood vessel abnormalities. It features a mid-ring that reduces mismatch between the graft and descending aorta, while reducing tension on distal anastomoses to minimize bleeding and graft/tissue tearing. It also features proximal and distal rings, multi-lumen branches and a compressed graft configuration with a removable delivery sheath for ease of placement. The radiopaque markers on the rings improve visualization for endovascular and surgical elephant trunk procedures. This ring-graft potentially may be used for minimally invasive aorta repair procedures. Additionally, the graft may be Y-shaped for the repair of the iliac and femoral arteries.

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Outcomes 200758

Innovations

Percutaneous Aortic Valve GraftTo replace the aortic root, a combined aortic valve stent-graft and ascending aortic prosthetic stent-graft with two side branches for the coronary arteries is being investigated for percutaneous insertion. These side branches provide optimal alignment with the coronary ostium. The design of the graft eliminates the potential for perivalvular leakage in high-risk patients with a heavily calcified or aneurysmal aorta.

Dry Storage for Percutaneous Tissue Valves A new method of preserving, crimping, storing and sterilizing tissue valves is under investigation to enable stented cardiac tissue valves to be preloaded into a cannula for percutaneous delivery.

Percutaneous Mitral and Tricuspid Valve Replacement

The unique stent framework of this valve provides secure attachment to the annulus of the mitral or tricuspid valve in percutaneous and minimally invasive valve procedures. The replacement valve may be deployed transapically via a catheter delivery system.

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Heart & Vascular Institute 59

Septal Puncture Device This device is being investigated to enable clinicians to puncture the septum in a precise location under fluoroscopic guidance. It may be used in a variety of procedures requiring access to the left atrium, including percutaneous valve replacement and repair, atrial fibrillation ablation and left atrial appendage closure. This device also is compatible with echocardiography.

Lung Transplant Innovation: Bronchial Artery RevascularizationOne of the most common problems with lung transplantation is the breakdown of airway anastomoses. Bronchial healing problems and complications occur in 15 percent of our lung transplant patients, and sometimes these complications are very serious and occasionally even fatal.

Cleveland Clinic surgeons have developed a technique to revascularize the bronchial arteries that improves healing at the anastomosis. As part of a pilot study, the first bronchial artery revascularization in lung transplantation was successfully performed at Cleveland Clinic in December 2007, with primary healing of the airway.

The airway perfectly healed six weeks following en bloc double lung transplantation with a tracheal anastomosis.

Selective bronchial arteriogram that shows an internal thoracic artery providing blood flow into donor bronchial arteries.

Percutaneous Aortic Valve Conduit This conduit is being investigated to supplement blood flow through a patient’s aortic valve without disturbing any existing stenoses or other potentially obstructing material in the heart – addressing the needs of patients who are experiencing reduced cardiac output due to aortic valve disease. The conduit creates an artificial path from the left ventricle outflow tract directly to the ascending aorta. A ventricular assist device also may be included in the conduit to provide additional blood flow into the ascending aorta.

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Outcomes 200760

InnovationsDysfunctional High-Density Lipoprotein CholesterolCleveland Clinic researchers identified a mechanism for how high-density liproprotein (HDL) cholesterol becomes dysfunctional in the artery wall when it is modified by myeloperoxidase (MPO), an enzyme present in white blood cells and found in atherosclerotic plaque. MPO modifies a specific region within HDL, inhibiting the ability of HDL to mature and effectively carry cholesterol from cells of the artery wall. As part of the study, an improved structure of HDL was determined. Measuring this marker could be used in clinical applications to identify those at greatest risk for developing heart attack, stroke and death. Supported by the National Institutes of Health.

Protein Carbamylation and Increased Atherosclerosis Risk

Cleveland Clinic researchers identified a molecular link between cardiovascular disease risk and smoking. Chemicals released by burning tobacco found in the blood were discovered, when combined with inflammation, to promote a reaction called carbamylation that corrupts low- and high-density lipoprotein cholesterol function, promoting cholesterol accumulation and plaque formation on arterial walls. The present studies identify carbamylation as a process that occurs much more widely than had previously been believed because it contributes to atherosclerosis in subjects with normal kidney function, and even in nonsmokers within the general population. The findings could lead to new diagnostic tests that gauge the risk of atherosclerosis, acute myocardial infarction and stroke in smokers and nonsmokers alike. Supported by the National Institutes of Health.

Source: Wang Z, Nicholls SJ, Rodriguez ER, Kummu O, Hörkkö S, Barnard J, Reynolds WF, Topol EJ, DiDonato JA, Hazen SL. Protein carbamylation links inflammation, smoking, uremia and atherogenesis. Nat Med. 2007 Oct;13(10)1176-1184.

Normal HDL is described as having “solar flare” structures, with two protruding solvent exposed loops that are important for HDL to dock with an enzyme necessary to mature the particle into an optimally effective form for carrying cholesterol cargo from the arteries to the liver for removal.

Source: Wu Z, Wagner MA, Zheng L, Parks JS, Shy JM 3rd, Smith JD, Gogonea V, Hazen SL. The refined structure of nascent HDL reveals a key functional domain for particle maturation and dysfunction. Nat Struct Mol Biol. 2007 Sep;14(9):861-868.

Solar Flares Model of Discoidal HDL

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New Endovascular Approaches in the Treatment of Complex Aortic DiseaseWe have pioneered minimally invasive therapies for almost every type of aortic disease. Complex aneurysms and aortic dissections that involve the ascending aorta, arch branches, entire thoracoabdominal aorta and iliac arteries are frequently treated percutaneously or with a small incision in the groin under regional or local anesthesia.

This 3D reconstruction of the aortic arch demonstrates the ability to preserve the brachiocephalic vessels using branches or fenestrations. In this case, there is a thoracic endograft that has a fenestration for the left common carotid artery.

Endovascular grafting techniques have been developed to treat select abnormalities in the ascending thoracic aorta. This patient had a psuedoaneurysm from a cannulation site that was successfully treated with an ascending aortic stent-graft.

The 3D reconstruction of the aortoiliac segment clearly identifies an aortic aneurysm with a thrombus and a left common iliac aneurysm free of any thrombus. The patient had undergone a prior thoracic repair without reimplantation of the intercostal vessels. The importance of pelvic blood flow for collateral spinal cord and hip muscle perfusion has been reported. The patient was treated with an endograft incorporating an internal iliac artery branch.

Before Repair After Repair

Percutaneous Aortic Valve ReplacementsPercutaneous aortic valve replacement is being investigated as an alternative treatment option for select patients with severe aortic valve stenosis who are high-risk surgical candidates. During this transapical approach, a compressed tissue heart valve is placed on a balloon-mounted catheter that is positioned directly in the diseased aortic valve; when the balloon is inflated, the position of the implant is secured.

Cleveland Clinic is one of a few select U.S. centers participating in the PARTNER trial (Placement of Aortic Transcatheter Valves), a prospective, randomized pivotal trial evaluating the safety and effectiveness of the Edwards SAPIEN™ transcatheter heart valve in select patients with severe aortic stenosis.

Images used with permission from Edwards Lifesciences, LLC.

p y

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Innovations

HeartMate® II

VentrAssist™

Next-Generation Heart Assist DevicesCleveland Clinic continues to offer the newest technology available for support of patients with advanced heart failure. We have implanted over 500 devices to date, including in 24 patients supported with five different devices in 2007. We are currently participating in clinical trials for new mechanical circulatory support devices. These devices are compact, easier to implant, and may be used in smaller patients who previously might not have been candidates for this type of support. The devices include Thoratec Corporation’s Heartmate® II Left Ventricular Assist System and VentrAssist™ by Ventracor.

Images used with permission from Transmedics™

Beating Heart Organ Procurement A new organ procurement system maintains a beating heart for transplantation during transport to the recipient. The system stores the heart in a warm, functioning state outside the body to optimize organ preservation and allow continuous clinical evaluation.

In the fall of 2007, Cleveland Clinic’s heart failure team enrolled the first patient in a multicenter clinical feasibility study of the Transmedics™ Organ Care System (PROCEED trial – Prospective, Multi-Center, Safety and Effectiveness Evaluation of the Organ Care System Device for Cardiac Use) to evaluate the safety and efficacy of the system. This patient had an excellent outcome, was weaned easily from cardiopulmonary bypass without requiring inotropic support and was discharged from the hospital in 11 days.

Heart transplant using cold ischemic storage has traditionally been used to preserve procured organs, but this method limits organ procurement to a specific region due to time constraints. Our hope is that this new technology will allow us to travel the continental U.S. to procure hearts for transplantation without the previous adverse outcomes associated with long ischemic times.

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Real-Time Three-Dimensional EchocardiographyThree-dimensional echocardiography is an innovative imaging technique used at Cleveland Clinic to diagnose complex valve problems and facilitate surgical and percutaneous repair of structural heart conditions. This technique displays accurate heart chamber volumes and functions, and provides detailed, real-time views of heart valves that cannot be obtained by conventional echocardiography.

A surgical view of severe posterior leaflet prolapse (mid, p2, segment)

Myxomatous Mitral Valve Disease

MDCT images of a severely calcified aortic valve. The dimensions of the aortic root, calcification of the valve leaflets, and relationship to the coronary arteries are important for planning percutaneous aortic valve replacement.

MDCT image of the entire aorta including the iliac arteries. These data are useful for precise

planning of vascular access and procedures.

High-Resolution Scanning Assists in Planning Endovascular and Surgical ProceduresCleveland Clinic Cardiovascular Imaging Center is one of a few leading cardiovascular centers refining perioperative cardiac imaging with multi-detector computed tomography (MDCT) and magnetic resonance imaging modalities. An interdisciplinary team of cardiologists and radiologists continues to develop and improve specific imaging protocols to comprehensively assess the cardiovascular system and aid in the planning of endovascular and surgical treatments of cardiac conditions.

Percutaneous Mitral Valve RepairCleveland Clinic is investigating an endovascular mitral valve repair system in the EVEREST II (Endovascular Valve Edge-to-edge REpair STudy) clinical research trial to evaluate the safety and efficacy of this clip device in reducing or eliminating mitral valve regurgitation.

Ultrasound and fluoroscopy are used to guide the placement of the clip device that connects the mitral valve leaflet edges.

Investigational device – limited by U.S. federal law to investigational use.

MitraClip™ Cardiovascular Valve Repair System. Image used with permission from Evalve, Inc.MitraClip™ Cardiovascular VImage used with permission

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The Heart & Vascular Institute staff authored 799

publications in 2007. For a complete list, go to

www.clevelandclinic.org/quality/outcomes.

799 Publications

C5ResearchC5Research, Cleveland Clinic Coordinating Center for Clinical

Research, is an Academic Research Organization (ARO) that

provides clinical research services and academic expertise to

support the biotechnology, medical device and pharmaceutical

industries, the National Institutes of Health, Cleveland Clinic and

other academic and contract research organizations.

C5Research has more than 100 employees who specialize in the

planning, coordination, management and conduct of clinical trials

in cardiovascular and other therapeutic areas. C5Research services

include: project management, data management, biostatistics,

new business, research contracts and finance and seven core

laboratories. The clinical and academic expertise of Cleveland

Clinic physicians and scientists, combined with our experience and

expertise in clinical trial management, promote success through

every phase of a clinical trial.

C5Research has broadened its research scope to include

multidisciplinary studies and other medical specialties such as

bariatric surgery, gastroenterology and emergency medicine.

Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC Jr, Jacobs AK, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation. 2007 Aug 14;116(7):e148-e304.

Anwaruddin S, Askari AT, Topol EJ. Redefining risk in acute coronary syndromes using molecular medicine. J Am Coll Cardiol. 2007 Jan 23;49(3):279-289.

Arruda M, Mlcochova H, Prasad SK, Kilicaslan F, Saliba W, Patel D, Fahmy T, Morales LS, Schweikert R, Martin D, Burkhardt D, Cummings J, Bhargava M, Dresing T, Wazni O, Kanj M, Natale A. Electrical isolation of the superior vena cava: An adjunctive strategy to pulmonary vein antrum isolation improving the outcome of AF ablation. J Cardiovasc Electrophysiol. 2007 Dec;18(12):1261-1266.

Arruda MS, He DS, Friedman P, Nakagawa H, Bruce C, Azegami K, Anders R, Kozel P, Chiavetta A, Marad P, Macadam D, Jackman W, Wilber DJ. A novel mesh electrode catheter for mapping and radiofrequency delivery at the left atrium-pulmonary vein junction: a single-catheter approach to pulmonary vein antrum isolation. J Cardiovasc Electrophysiol. 2007 Feb;18(2):206-211.

Atik FA, Navia JL, Vega PR, Gonzalez-Stawinski GV, Alster JM, Gillinov AM, Svensson LG, Pettersson BG, Lytle BW, Blackstone EH. Surgical treatment of postinfarction left ventricular pseudoaneurysm. Ann Thorac Surg. 2007 Feb;83(2):526-531.

Barrows BR, Azimzadeh AM, McCulle SL, Vives-Rodriguez G, Stark WN Jr, Ambulos N, Yin J, Chen H, Balke CW, Moravec CS, Pierson RN III, Gottlieb SS, Bond M, Johnson FL. Robust gene expression with amplified RNA from biopsy-sized human heart tissue. J Mol Cell Cardiol. 2007 Jan;42(1):260-264.

Bavry AA, Bhatt DL. Drug-eluting stents: dual antiplatelet therapy for every survivor? Circulation. 2007 Aug 14;116(7):696-699.

Select Journal ArticlesThis is a representative sample of nearly 800 publications authored by the Heart & Vascular Institute in 2007. For a complete list, go to www.clevelandclinic.org/quality/outcomes.

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Clinical Investigations

Population-centric clinical registries, quality investigations,

investigator-initiated observational clinical studies,

methodological research and development, and clinical

research education are the five interrelated thrusts of the

multidisciplinary Clinical Investigations group. Our products

include process and outcomes quality reporting, marketing

statistics, publications and presentations of new knowledge

generated from analyses of clinical cohorts, novel advanced

clinical data management tools and statistical methodology,

and presentations and publications of medical students,

residents, and fellows that demonstrate aspects of their

competency in clinical research.

We are housed in a 21,256-square-foot facility physically

laid out according to workflow. The multidisciplinary

team ranges from technicians to nurses, data managers,

computer scientists, artificial intelligence experts, statistical

programmers, and statisticians.

Formation of the Heart & Vascular Institute has afforded us

the opportunity to integrate data from registries across all its

subspecialties, provide a uniform, highly expert approach to

data analysis, and foster collaboration as never before.

Beshai JF, Grimm RA, Nagueh SF, Baker JH II, Beau SL, Greenberg SM, Pires LA, Tchou PJ. Cardiac-resynchronization therapy in heart failure with narrow QRS complexes. N Engl J Med. 2007 Dec 13;357(24):2461-2471.

Bhatt DL, Flather MD, Hacke W, Berger PB, Black HR, Boden WE, Cacoub P, Cohen EA, Creager MA, Easton JD, Hamm CW, Hankey GJ, Johnston SC, Mak KH, Mas JL, Montalescot G, Pearson TA, Steg PG, Steinhubl SR, Weber MA, Fabry-Ribaudo L, Hu T, Topol EJ, Fox KAA. Patients with prior myocardial infarction, stroke, or symptomatic peripheral arterial disease in the CHARISMA trial. J Am Coll Cardiol. 2007 May 15;49(19):1982-1988.

Bhavani SS, Tchou P, Saliba W, Gillinov AM. Surgical options for refractory ventricular tachycardia. J Card Surg. 2007 Nov;22(6):533-534.

Bhudia SK, McCarthy PM, Kumpati GS, Helou J, Hoercher KJ, Rajeswaran J, Blackstone EH. Improved outcomes after aortic valve surgery for chronic aortic regurgitation with severe left ventricular dysfunction. J Am Coll Cardiol. 2007 Apr 3;49(13):1465-1471.

Bian J, Popovic ZB, Benejam C, Kiedrowski M, Rodriguez LL, Penn MS. Effect of cell-based intercellular delivery of transcription factor GATA4 on ischemic cardiomyopathy. Circ Res. 2007 Jun 8;100(11):1626-1633.

Burkhardt JD, Wilkoff BL. Interventional electrophysiology and cardiac resynchronization therapy: delivering electrical therapies for heart failure. Circulation. 2007 Apr 24;115(16):2208-2220.

Canter CE, Shaddy RE, Bernstein D, Hsu DT, Chrisant MRK, Kirklin JK, Kanter KR, Higgins RSD, Blume ED, Rosenthal DN, Boucek MM, Uzark KC, Friedman AH, Young JB. Indications for heart transplantation in pediatric heart disease: a scientific statement from the American Heart Association Council on Cardiovascular Disease in the Young; the Councils on Clinical Cardiology, Cardiovascular Nursing, and Cardiovascular Surgery and Anesthesia; and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007 Feb 6;115(5):658-676.

Chang ASY, Smedira NG, Chang CL, Benavides MM, Myhre U, Feng J, Blackstone EH, Lytle BW. Cardiac surgery after mediastinal radiation: extent of exposure influences outcome. J Thorac Cardiovasc Surg. 2007 Feb;133(2):404-413.

Cooper LT, Baughman KL, Feldman AM, Frustaci A, Jessup M, Kuhl U, Levine GN, Narula J, Starling RC, Towbin J, Virmani R. The role of endomyocardial biopsy in the management of cardiovascular disease: a scientific statement from the American Heart Association, the American College of Cardiology, and the European Society of Cardiology. Circulation. 2007 Nov 6;116(19):2216-2233.

Di Biase L, Fahmy TS, Patel D, Bai R, Civello K, Wazni OM, Kanj M, Elayi CS, Ching CK, Khan M, Popova L, Schweikert RA, Cummings JE, Burkhardt JD, Martin DO, Bhargava M, Dresing T, Saliba W, Arruda M, Natale A. Remote magnetic navigation: human experience in pulmonary vein ablation. J Am Coll Cardiol. 2007 Aug 28;50(9):868-874.

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Dumont E, Gillinov AM, Blackstone EH, Sabik JF III, Svensson LG, Mihaljevic T, Houghtaling PL, Lytle BW. Reoperation after mitral valve repair for degenerative disease. Ann Thorac Surg. 2007 Aug;84(2):444-450.

Dyke CM, Aldea G, Koster A, Smedira N, Avery E, Aronson S, Spiess BD, Lincoff AM. Off-pump coronary artery bypass with bivalirudin for patients with heparin-induced thrombocytopenia or antiplatelet factor four/heparin antibodies. Ann Thorac Surg. 2007 Sep;84(3):836-839.

Eagleton MJ, Schaffer JL. The vascular surgery operating room: Development of an up-to-date operating room that will meet the demands of the vascular surgery patient and team. Endovascular Today. 2007 Aug;6(8):25-30.

Einstein AJ, Moser KW, Thompson RC, Cerqueira MD, Henzlova MJ. Radiation dose to patients from cardiac diagnostic imaging. Circulation. 2007 Sep 11;116(11):1290-1305.

Ellis SG, Colombo A, Grube E, Popma J, Koglin J, Dawkins KD, Stone GW. Incidence, timing, and correlates of stent thrombosis with the polymeric paclitaxel drug-eluting stent: a TAXUS II, IV, V, and VI meta-analysis of 3,445 patients followed for up to 3 years. J Am Coll Cardiol. 2007 Mar 13;49(10):1043-1051.

Fonarow GC, Abraham WT, Albert NM, Stough WG, Gheorghiade M, Greenberg BH, O’Connor CM, Pieper K, Sun JL, Yancy C, Young JB. Association between performance measures and clinical outcomes for patients hospitalized with heart failure. JAMA. 2007 Jan 3;297(1):61-70.

Fonseca C, Lindahl GE, Ponticos M, Sestini P, Renzoni EA, Holmes AM, Spagnolo P, Pantelidis P, Leoni P, McHugh N, Stock CJ, Shi-Wen X, Denton CP, Black CM, Welsh KI, du Bois RM, Abraham DJ. A polymorphism in the CTGF promoter region associated with systemic sclerosis. N Engl J Med. 2007 Sep 20;357(12):1210-1220.

George KM, Pettersson GB. Reoperative quadrivalvular surgery including Ross reversal for complex left ventricular outflow tract obstruction. J Heart Valve Dis. 2007 Nov;16(6):690-691.

Gillinov AM, Svensson LG. Ablation of atrial fibrillation with minimally invasive mitral surgery. Ann Thorac Surg. 2007 Sep;84(3):1041-1042.

Gillinov AM. Choice of surgical lesion set: answers from the data. Ann Thorac Surg. 2007 Nov;84(5):1786-1792.

Gillinov AM. Advances in surgical treatment of atrial fibrillation. Stroke. 2007 Feb;38(2):618-623.

Gillinov AM, Banbury MK. Pre-measured artificial chordae for mitral valve repair. Ann Thorac Surg. 2007 Dec;84(6):2127-2129.

Goel S, Clair DG, Carman TL. An 18-year-old with effort-related arm swelling. Cleve Clin J Med. 2007 Apr;74(4):283-288.

Gonzalez-Stawinski GV, Cook DJ, Chui J, Gupta S, Navia JL, Hoercher K, Taylor DO, Yamani MH, Starling RC, Smedira NG. A comparative analysis between survivors and nonsurvivors with antibody mediated cardiac allograft rejection. J Surg Res. 2007 Oct;142(2):233-238.

Gonzalez-Stawinski GV, Cook DJ, Smedira NG, Navia JL, Taylor DO, Yamani MH, Hoercher K, Starling RC, Banbury MK. Attrition from heart transplant waiting list for patients on ventricular assist devices is not affected by desensitization strategies. Transplant Proc. 2007 Jun;39(5):1571-1572.

Gonzalez-Stawinski G. Early and late outcomes of cardiac surgery in patients with liver cirrhosis. Liver Transpl. 2007 Jul;13(7):956.

Griffin BP. Statins in aortic stenosis: new data from a prospective clinical trial. J Am Coll Cardiol. 2007 Feb 6;49(5):562-564.

Haulon S, Greenberg RK, Pfaff K, Francis C, Koussa M, West K. Branched grafting for aortoiliac aneurysms. Eur J Vasc Endovasc Surg. 2007 May;33(5):567-574.

Higashiura W, Greenberg RK, Katz E, Geiger L, Bathurst S. Predictive factors, morphologic effects, and proposed treatment paradigm for type II endoleaks after repair of infrarenal abdominal aortic aneurysms. J Vasc Interv Radiol. 2007 Aug;18(8):975-981.

Iskandrian AE, Bateman TM, Belardinelli L, Blackburn B, Cerqueira MD, Hendel RC, Lieu H, Mahmarian JJ, Olmsted A, Underwood SR, Vitola J, Wang W. Adenosine versus regadenoson comparative evaluation in myocardial perfusion imaging: results of the ADVANCE phase 3 multicenter international trial. J Nucl Cardiol. 2007 Sep;14(5):645-658.

Jane-Wit D, Altuntas CZ, Johnson JM, Yong S, Wickley PJ, Clark P, Wang Q, Popovic ZB, Penn MS, Damron DS, Perez DM, Tuohy VK. Beta1-adrenergic receptor autoantibodies mediate dilated cardiomyopathy by agonistically inducing cardiomyocyte apoptosis. Circulation. 2007 Jul 24;116(4):399-410.

Kanj MH, Wazni O, Fahmy T, Thal S, Patel D, Elay C, Di Biase L, Arruda M, Saliba W, Schweikert RA, Cummings JE, Burkhardt JD, Martin DO, Pelargonio G, Dello Russo A, Casella M, Santarelli P, Potenza D, Fanelli R, Massaro R, Forleo G, Natale A. Pulmonary vein antral isolation using an open irrigation ablation catheter for the treatment of atrial fibrillation: a randomized pilot study. J Am Coll Cardiol. 2007 Apr 17;49(15):1634-1641.

Kashyap VS, Sepulveda RN, Bena JF, Nally JV, Poggio ED, Greenberg RK, Yadav JS, Ouriel K. The management of renal artery atherosclerosis for renal salvage: Does stenting help? J Vasc Surg. 2007 Jan;45(1):101-108.\

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King SB III, Aversano T, Ballard WL, Beekman RH III, Cowley MJ, Ellis SG, Faxon DP, Hannan EL, Hirshfeld JW Jr, Jacobs AK, Kellett MA Jr, Kimmel SE, Landzberg JS, McKeever LS, Moscucci M, Pomerantz RM, Smith KM, Vetrovec GW, Creager MA, Holmes DR Jr, Newby LK, Weitz HH, Merli G, Pina I, Rodgers GP, Tracy CM. ACCF/AHA/SCAI 2007 update of the clinical competence statement on cardiac interventional procedures: a report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training (writing Committee to Update the 1998 Clinical Competence Statement on Recommendations for the Assessment and Maintenance of Proficiency in Coronary Interventional Procedures). Circulation. 2007 Jul 3;116(1):98-124.

Koch CG, Li L, Lauer M, Sabik J, Starr NJ, Blackstone EH. Effect of functional health-related quality of life on long-term survival after cardiac surgery. Circulation. 2007 Feb 13;115(6):692-699.

Lauer MS, Martino D, Ishwaran H, Blackstone EH. Quantitative measures of electrocardiographic left ventricular mass, conduction, and repolarization, and long-term survival after coronary artery bypass grafting. Circulation. 2007 Aug 21;116(8):888-893.

Lauer MS, Murthy SC, Blackstone EH, Okereke IC, Rice TW. [18F]fluorodeoxyglucose uptake by positron emission tomography for diagnosis of suspected lung cancer: Impact of verification bias. Arch Intern Med. 2007 Jan 22;167(2):161-165.

Lin R, Svensson L, Gupta R, Lytle B, Krieger D. Chronic ischemic cerebral white matter disease is a risk factor for nonfocal neurologic injury after total aortic arch replacement. J Thorac Cardiovasc Surg. 2007 Apr;133(4):1059-1065.

Lincoff AM, Wolski K, Nicholls SJ, Nissen SE. Pioglitazone and risk of cardiovascular events in patients with type 2 diabetes mellitus: a meta-analysis of randomized trials. JAMA. 2007 Sep 12;298(10):1180-1188.

Little SG, Rice TW, Bybel B, Mason DP, Murthy SC, Falk GW, Rybicki LA, Blackstone EH. Is FDG-PET indicated for superficial esophageal cancer? Eur J Cardiothorac Surg. 2007 May;31(5):791-796.

London B, Albert C, Anderson ME, Giles WR, Van Wagoner DR, Balk E, Billman GE, Chung M, Lands W, Leaf A, McAnulty J, Martens JR, Costello RB, Lathrop DA. Omega-3 fatty acids and cardiac arrhythmias: prior studies and recommendations for future research: a report from the National Heart, Lung, and Blood Institute and Office Of Dietary Supplements Omega-3 Fatty Acids and their Role in Cardiac Arrhythmogenesis Workshop. Circulation. 2007 Sep 4;116(10):e320-e335.

Lytle BW. Percutaneous aortic valve replacement. J Thorac Cardiovasc Surg. 2007 Feb;133(2):299.

Mason DP, Solovera-Rozas M, Feng J, Rajeswaran J, Thuita L, Murthy SC, Budev MM, Mehta AC, Haug M III, McNeill AM, Pettersson GB, Blackstone EH. Dialysis after lung transplantation: prevalence, risk factors and outcome. J Heart Lung Transplant. 2007 Nov;26(11):1155-1162.

Mason DP, Brizzio ME, Alster JM, McNeill AM, Murthy SC, Budev MM, Mehta AC, Minai OA, Pettersson GB, Blackstone EH. Lung transplantation for idiopathic pulmonary fibrosis. Ann Thorac Surg. 2007 Oct;84(4):1121-1128.

Mason DP, Marsh DH, Alster JM, Murthy SC, McNeill AM, Budev MM, Mehta AC, Pettersson GB, Blackstone EH. Atrial fibrillation after lung transplantation: timing, risk factors, and treatment. Ann Thorac Surg. 2007 Dec;84(6):1878-1884.

Maybaum S, Mancini D, Xydas S, Starling RC, Aaronson K, Pagani FD, Miller LW, Margulies K, McRee S, Frazier OH, Torre-Amione G. Cardiac improvement during mechanical circulatory support: a prospective multicenter study of the LVAD Working Group. Circulation. 2007 May 15;115(19):2497-2505.

Meadows TA, Bhatt DL. Clinical aspects of platelet inhibitors and thrombus formation. Circ Res. 2007 May 11;100(9):1261-1275.

Mihaljevic T, Lam BK, Rajeswaran J, Takagaki M, Lauer MS, Gillinov AM, Blackstone EH, Lytle BW. Impact of mitral valve annuloplasty combined with revascularization in patients with functional ischemic mitral regurgitation. J Am Coll Cardiol. 2007 Jun 5;49(22):2191-2201.

Moon MC, Morales JP, Greenberg RK. The aortic arch and ascending aorta: are they within the endovascular realm? Semin Vasc Surg. 2007 Jun;20(2):97-107.

Mosca L, Banka CL, Benjamin EJ, Berra K, Bushnell C, Dolor RJ, Ganiats TG, Gomes AS, Gornik HL, Gracia C, Gulati M, Haan CK, Judelson DR, Keenan N, Kelepouris E, Michos ED, Newby LK, Oparil S, Ouyang P, Oz MC, Petitti D, Pinn VW, Redberg RF, Scott R, Sherif K, Smith SC Jr, Sopko G, Steinhorn RH, Stone NJ, Taubert KA, Todd BA, Urbina E, Wenger NK. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. J Am Coll Cardiol. 2007 Mar 20;49(11):1230-1250.

Murthy S, Gonzalez-Stawinski GV, Rozas MS, Gildea TR, Dumot JA. Palliation of malignant aerodigestive fistulae with self-expanding metallic stents. Dis Esophagus. 2007;20(5):386-389.

Murthy SC, Arroliga AC, Walts PA, Feng J, Yared JP, Lytle BW, Blackstone EH. Ventilatory dependency after cardiovascular surgery. J Thorac Cardiovasc Surg. 2007 Aug;134(2):484-490.

Murthy SC, Blackstone EH, Gildea TR, Gonzalez-Stawinski GV, Feng J, Budev M, Mason DP, Pettersson GB, Mehta AC. Impact of anastomotic airway complications after lung transplantation. Ann Thorac Surg. 2007 Aug;84(2):401-409,409.e1-e4.

Navia JL, Roselli EE, Atik FA, Gonzalez-Stawinski GV, Smedira NG. Orthotopic heart transplantation through minimally invasive approach. Asian Cardiovasc Thorac Ann. 2007 Oct;15(5):446-448.

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Navia JL, Doi K, Atik FA, Fukamachi K, Kopcak MW Jr, Dessoffy R, Ruda-Vega P, Garcia M, Houghtaling PL, Martin M, Blackstone EH, McCarthy PM, Lytle BW. Acute in vivo evaluation of a new stentless mitral valve. J Thorac Cardiovasc Surg. 2007 Apr;133(4):986-994.

Nicholls SJ, Tuzcu EM, Sipahi I, Grasso AW, Schoenhagen P, Hu T, Wolski K, Crowe T, Desai MY, Hazen SL, Kapadia SR, Nissen SE. Statins, high-density lipoprotein cholesterol, and regression of coronary atherosclerosis. JAMA. 2007 Feb 7;297(5):499-508.

Nissen SE, Tardif JC, Nicholls SJ, Revkin JH, Shear CL, Duggan WT, Ruzyllo W, Bachinsky WB, Lasala GP, Tuzcu EM. Effect of torcetrapib on the progression of coronary atherosclerosis. N Engl J Med. 2007 Mar 29;356(13):1304-1316.

Nissen SE, Nicholls SJ, Wolski K, Howey DC, McErlean E, Wang MD, Gomez EV, Russo JM. Effects of a potent and selective PPAR-alpha agonist in patients with atherogenic dyslipidemia or hypercholesterolemia: two randomized controlled trials. JAMA. 2007 Mar 28;297(12):1362-1373.

Nissen SE, Wolski K. Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. N Engl J Med. 2007 Jun 14;356(24):2457-2471.

Penn MS. Patient and cellular characteristics determine efficacy of cell therapy. Circ Res. 2007 Apr 27;100(8):1101-1103.

Pettersson GB, Crucean AC. Segmental approach to repair of regurgitant bicuspid aortic valves. Operative Techniques in Thoracic and Cardiovascular Surgery. 2007 Spring;12(1):14-24.

Rajeswaran J, Blackstone EH. Interval estimation for individual categories in cumulative logit models. Stat Med. 2007 Sep 30;26(22):4150-4162.

Reznik SI, Rice TW, Murthy SC, Mason DP, Apperson-Hansen C, Blackstone EH. Assessment of a pathophysiology-directed treatment for symptomatic epiphrenic diverticulum. Dis Esophagus. 2007;20(4):320-327.

Rice TW, Mason DP, Murthy SC, Zuccaro G Jr, Adelstein DJ, Rybicki LA, Blackstone EH. T2N0M0 esophageal cancer. J Thorac Cardiovasc Surg. 2007 Feb;133(2):317-324.

Rice TW, Blackstone EH. Does a biologic prosthesis really reduce recurrence after laparoscopic paraesophageal hernia repair? Ann Surg. 2007 Dec;246(6):1116-1117.

Roselli EE, Greenberg RK, Pfaff K, Francis C, Svensson LG, Lytle BW. Endovascular treatment of thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg. 2007 Jun;133(6):1474-1482.

Sabik JF III, Blackstone EH, Firstenberg M, Lytle BW. A benchmark for evaluating innovative treatment of left main coronary disease. Circulation. 2007 Sep 11;116(11 Suppl):I232-I239.

Shea KJ, Sopko NA, Ludrosky K, Hoercher K, Smedira NG, Taylor DO, Starling RC, Gonzalez-Stawinski GV. The effect of a donor’s history of active substance on outcomes following orthotopic heart transplantation. Eur J Cardiothorac Surg. 2007 Mar;31(3):452-456.

Shemin RJ, Cox JL, Gillinov AM, Blackstone EH, Bridges CR. Guidelines for reporting data and outcomes for the surgical treatment of atrial fibrillation. Ann Thorac Surg. 2007 Mar;83(3):1225-1230.

Shishehbor MH, Lauer MS, Singh IM, Chew DP, Karha J, Brener SJ, Moliterno DJ, Ellis SG, Topol EJ, Bhatt DL. In unstable angina or non-ST-segment acute coronary syndrome, should patients with multivessel coronary artery disease undergo multivessel or culprit-only stenting? J Am Coll Cardiol. 2007 Feb 27;49(8):849-854.

Sipahi I, Tuzcu EM, Wolski KE, Nicholls SJ, Schoenhagen P, Hu B, Balog C, Shishehbor M, Magyar WA, Crowe TD, Kapadia S, Nissen SE. Beta-blockers and progression of coronary atherosclerosis: pooled analysis of 4 intravascular ultrasonography trials. Ann Intern Med. 2007 Jul 3;147(1):10-18.

Starling RC, Jessup M, Oh JK, Sabbah HN, Acker MA, Mann DL, Kubo SH. Sustained benefits of the CorCap Cardiac Support Device on left ventricular remodeling: three year follow-up results from the Acorn clinical trial. Ann Thorac Surg. 2007 Oct;84(4):1236-1242.

Steg PG, Bhatt DL, Wilson PWF, D’Agostino R Sr, Ohman EM, Rother J, Liau CS, Hirsch AT, Mas JL, Ikeda Y, Pencina MJ, Goto S. One-year cardiovascular event rates in outpatients with atherothrombosis. JAMA. 2007 Mar 21;297(11):1197-1206.

Stone GW, Bertrand ME, Moses JW, Ohman EM, Lincoff AM, Ware JH, Pocock SJ, McLaurin BT, Cox DA, Jafar MZ, Chandna H, Hartmann F, Leisch F, Strasser RH, Desaga M, Stuckey TD, Zelman RB, Lieber IH, Cohen DJ, Mehran R, White HD. Routine upstream initiation vs deferred selective use of glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: the ACUITY Timing trial. JAMA. 2007 Feb 14;297(6):591-602.

Stone GW, Moses JW, Ellis SG, Schofer J, Dawkins KD, Morice MC, Colombo A, Schampaert E, Grube E, Kirtane AJ, Cutlip DE, Fahy M, Pocock SJ, Mehran R, Leon MB. Safety and efficacy of sirolimus- and paclitaxel-eluting coronary stents. N Engl J Med. 2007 Mar 8;356(10):998-1008.

Stone GW, Ellis SG, Colombo A, Dawkins KD, Grube E, Cutlip DE, Friedman M, Baim DS, Koglin J. Offsetting impact of thrombosis and restenosis on the occurrence of death and myocardial infarction after paclitaxel-eluting and bare metal stent implantation. Circulation. 2007 Jun 5;115(22):2842-2847.

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Svensson LG, Blackstone EH, Feng J, de Oliveira D, Gillinov AM, Thamilarasan M, Grimm RA, Griffin B, Hammer D, Williams T, Gladish DH, Lytle BW. Are Marfan syndrome and marfanoid patients distinguishable on long-term follow-up? Ann Thorac Surg. 2007 Mar;83(3):1067-1074.

Svensson LG, Gillinov AM, Blackstone EH, Houghtaling PL, Kim KH, Pettersson GB, Smedira NG, Banbury MK, Lytle BW. Does right thoracotomy increase the risk of mitral valve reoperation? J Thorac Cardiovasc Surg. 2007 Sep;134(3):677-682.

Svensson LG, Deglurkar I, Ung J, Pettersson G, Gillinov AM, D’Agostino RS, Lytle BW. Aortic valve repair and root preservation by remodeling, reimplantation, and tailoring: technical aspects and early outcome. J Card Surg. 2007 Nov;22(6):473-479.

Tang WHW, Francis GS, Morrow DA, Newby LK, Cannon CP, Jesse RL, Storrow AB, Christenson RH, Apple FS, Ravkilde J, Wu AHB. National Academy of Clinical Biochemistry Laboratory Medicine practice guidelines: Clinical utilization of cardiac biomarker testing in heart failure. Circulation. 2007 Jul 31;116(5):e99-e109.

Tang WHW, Tong W, Troughton RW, Martin MG, Shrestha K, Borowski A, Jasper S, Hazen SL, Klein AL. Prognostic value and echocardiographic determinants of plasma myeloperoxidase levels in chronic heart failure. J Am Coll Cardiol. 2007 Jun 19;49(24):2364-2370.

Tang WHW, Francis GS. The year in heart failure. J Am Coll Cardiol. 2007 Dec 11;50(24):2344-2351.

Temes RT. Thoracentesis. N Engl J Med. 2007 Feb 8;356(6):641-642.

Tulsyan N, Kashyap VS, Greenberg RK, Sarac TP, Clair DG, Pierce G, Ouriel K. The endovascular management of visceral artery aneurysms and pseudoaneurysms. J Vasc Surg. 2007 Feb;45(2):276-283.

Verma A, Minor S, Kilicaslan F, Patel D, Hao S, Beheiry S, Lakkireddy D, Elayi SC, Cummings J, Martin DO, Burkhardt JD, Schweikert RA, Saliba W, Tchou PJ, Natale A. Incidence of atrial arrhythmias detected by permanent pacemakers (PPM) post-pulmonary vein antrum isolation (PVAI) for atrial fibrillation (AF): correlation with symptomatic recurrence. J Cardiovasc Electrophysiol. 2007 Jun;18(6):601-606.

Videtic GMM, Adelstein DJ, Mekhail TM, Rice TW, Stevens GHJ, Lee SY, Suh JH. Validation of the RTOG recursive partitioning analysis (RPA) classification for small-cell lung cancer-only brain metastases. Int J Radiat Oncol Biol Phys. 2007 Jan 1;67(1):240-243.

Wang Z, Nicholls SJ, Rodriguez ER, Kummu O, Horkko S, Barnard J, Reynolds WF, Topol EJ, DiDonato JA, Hazen SL. Protein carbamylation links inflammation, smoking, uremia and atherogenesis. Nat Med. 2007 Oct;13(10):1176-1184.

Wazni OM, Beheiry S, Fahmy T, Barrett C, Hao S, Patel D, Di Biase L, Martin DO, Kanj M, Arruda M, Cummings J, Schweikert R, Saliba W, Natale A. Atrial fibrillation ablation in patients with therapeutic international normalized ratio: comparison of strategies of anticoagulation management in the periprocedural period. Circulation. 2007 Nov 27;116(22):2531-2534.

Yared JP, Bakri MH, Erzurum SC, Moravec CS, Laskowski DM, Van Wagoner DR, Mascha E, Thornton J. Effect of dexamethasone on atrial fibrillation after cardiac surgery: prospective, randomized, double-blind, placebo-controlled trial. J Cardiothorac Vasc Anesth. 2007 Feb;21(1):68-75.

Zhang M, Mal N, Kiedrowski M, Chacko M, Askari AT, Popovic ZB, Koc ON, Penn MS. SDF-1 expression by mesenchymal stem cells results in trophic support of cardiac myocytes after myocardial infarction. FASEB J. 2007 Oct;21(12):3197-3207.

BooksAskari AT, Messerli AW, Lincoff AM. Management Strategies in Antithrombotic Therapy. Chichester, England; Hoboken, NJ: John Wiley and Sons; 2007.

Ellenbogen KA, Kay GN, Lau CP, Wilkoff BL. Clinical Cardiac Pacing, Defibrillation and Resynchronization Therapy. 3rd ed. Philadelphia, PA: Saunders Elsevier; 2007.

Griffin BP, Rimmerman CM, Topol EJ. The Cleveland Clinic Cardiology Board Review. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.

McCarthy PM, Young JB. Heart Failure: A Combined Medical and Surgical Approach. Malden, MA: Blackwell Futura; 2007.

Natale A, Wazni O. Handbook of Cardiac Electrophysiology. London, England: Informa Healthcare; 2007.

Nixon JV, Aurigemma GP, Bolger AF, Chaitman BR, Crawford MH, Fletcher GF, Francis GS, Gersony WM, Harrington RA, Ott P, Wenger NK, Alpert JS. The AHA Clinical Cardiac Consult. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.

Penn MS. Stem Cells and Myocardial Regeneration. Totowa, NJ: Humana Press; 2007.

Shiota T. 3D Echocardiography. London, England: Informa Healthcare; 2007.

Young JB, Narula J. Heart Failure, Part I. Philadelphia, PA: Saunders, 2007. Cardiology Clinics; v.25(4).

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Heart & Vascular Institute Staff Directory

Outcomes 200770

Heart & Vascular Institute LeadershipBruce W. Lytle, MD, Chairman, Heart & Vascular Institute

Daniel Clair, MD, Chairman, Vascular Surgery

Steven E. Nissen, MD, Chairman, Cardiovascular Medicine

Joseph F. Sabik, MD, Chairman, Thoracic and Cardiovascular Surgery

Quality Review Offlcers, Heart & Vascular Institute Frederick A. Heupler, Jr., MD

Nicholas G. Smedira, MD

Sunita Srivastava, MD

Thoracic and Cardiovascular SurgeryJoseph F. Sabik, MD, Chairman

Cardiovascular Surgery

Eugene H. Blackstone, MD

A. Marc Gillinov, MD

Gonzalo Gonzalez-Stawinski, MD

Douglas Johnston, MD

Bruce W. Lytle, MD

Tomislav Mihaljevic, MD

José L. Navia, MD

Gosta B. Pettersson, MD, PhD, Vice-Chairman

Eric E. Roselli, MD

Joseph F. Sabik, MD

Nicholas G. Smedira, MD

Edward Soltesz, MD

Lars G. Svensson, MD, PhD

Thoracic Surgery

Thomas W. Rice, MD, Section Head

David P. Mason, MD

Sudish C. Murthy, MD, PhD

Vascular Surgery Daniel Clair, MD, Chairman

Linda Graham, MD, Vice-Chair

Matthew Eagleton, MD

Roy K. Greenberg, MD

Vikram Kashyap, MD, FACS

Leonard Krajewski, MD

Sean Lyden, MD

Tara Mastracci, MD

Patrick O‘Hara, MD

Timur Sarac, MD

Sunita Srivastava, MD

Cardiovascular MedicineSteven E. Nissen, MD, Chairman

Randall C. Starling, MD, MPH, Vice-Chairman

E. Murat Tuzcu, MD, Vice-Chairman

A. Michael Lincoff, MD, Vice-Chairman

Cardiac Electrophysiology and Pacing

Bruce D. Lindsay, MD, Section Head

Mandeep Bhargava, MD

Lon W. Castle, MD

Mina K. Chung, MD

Jennifer E. Cummings, MD

Thomas Dresing, MD

Thomas B. Edel, MD

Fetnat Fouad-Tarazi, MD

Fredrick J. Jaeger, DO

Mohamed Kanj, MD

David O. Martin, MD, MPH

Robert D. Mosteller, MD

Walid I. Saliba, MD

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Heart & Vascular Institute 71

Adam Grasso, MD, PhD

Heather L. Gornik, MD, RVT

Donald F. Hammer, MD

Joel B. Holland, MD

Julie Huang, MD

Fuad Y. Jubran, MD

Vidyasagar Kalahasti, MD

Richard Krasuski, MD

Girish Mood, MD*

Steven E. Nissen, MD

Marc S. Penn, MD, PhD

Mehdi Razavi, MD

Curtis Rimmerman, MD

Michael B. Rocco, MD

Michael B. Rollins, MD

Mustaphasahim Shaaraoui, MD*

Terrence G. Tulisiak, MD

Donald A. Underwood, MD

Bennett Werner, MD

*Hospitalists

Heart Failure and Cardiac Transplant Medicine

Randall C. Starling, MD, MPH, Section Head

Corinne Bott-Silverman, MD

Mazen A. Hanna, MD

Robert E. Hobbs, MD

Eileen Hsich, MD

Karen B. James, MD

Christine Moravec, PhD

Gustavo Rincon, MD

W.H. Wilson Tang, MD

David O. Taylor, MD

James B. Young, MD

Richard Sterba, MD

Patrick J. Tchou, MD

Oussama Wazni, MD

Bruce L. Wilkoff, MD

Cardiac Electrophysiology and Pacing - Syncope Clinic

Fetnat Fouad-Tarazi, MD

Frederick J. Jaeger, DO

Cardiovascular Imaging

James D. Thomas, MD, Section Head

Manuel Cerqueira, MD*

Ronan Curtin, MD

Milind Desai, MD

Scott Flamm, MD*

Brian P. Griffin, MD

Richard A. Grimm, DO

Wael Jaber, MD

Allan L. Klein, MD

Harry M. Lever, MD

Chiara Liguori, MD

Venugopal Menon, MD

L. Leonardo Rodriguez, MD

Paul Schoenhagen, MD*

Ellen Mayer Sabik, MD

Takahiro Shiota, MD

Srikanth Sola, MD

William James Stewart, MD

Maran Thamilarasan, MD

*Joint appointment with Radiology

Clinical Cardiology

Gary S. Francis, MD, Section Head

Arman T. Askari, MD

Ajay Bhargava, MD

Caroline Casserly, MD, MBA

Michael Faulx, MD

Adriana Fodor, MD

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Heart & Vascular Institute Staff Directory

Outcomes 200772

Invasive Cardiology

Stephen Ellis, MD, Section Head

Christopher Bajzer, MD*

Corinne Bott-Silverman, MD

Sorin Brener, MD

Leslie Cho, MD*

Khosrow Dorosti, MD

Michael Faulx, MD

Irving Franco, MD*

Mazen A. Hanna, MD

Frederick A. Heupler, Jr., MD

Robert E. Hobbs, MD

Vidyasagar Kalahasti, MD

Samir Kapadia, MD*†

Richard Krasuski, MD†

A. Michael Lincoff, MD*

Ravi N. Nair, MD

Marc S. Penn, MD, PhD

Russell E. Raymond, DO*

Gustavo Rincon, MD

Conrad C. Simpfendorfer, MD*

E. Murat Tuzcu, MD*†

Patrick L. Whitlow, MD*

*Coronary Interventionalists †Interventionalists who also perform percutaneous structural heart procedures

Preventive Cardiology and Rehabilitation

Stanley L. Hazen, MD, PhD, Section Head

Leslie Cho, MD, Medical Director

Gordon Blackburn, PhD, Program Director, Cardiac Rehabilitation

John Campbell, MD Department of General Internal Medicine

Byron Hoogwerf, MD Department of Endocrinology

Julie Huang, MD Department of Cardiovascular Medicine

Sangeeta Kashyap, MD Department of Endocrinology

Richard Lorber, MD Department of Pediatric Cardiology

Leo Pozuelo, MD Department of Psychiatry and Psychology

Michael B. Rocco, MD Department of Cardiovascular Medicine

Douglas Rogers, MD Head, Section of Pediatric Endocrinology

Paul Schoenhagen, MD Department of Diagnostic Radiology

Vascular Medicine

John R. Bartholomew, MD, Section Head

Firas Al Solaiman, MD, RVT

Christopher Bajzer, MD*

Deepak Bhatt, MD*

Carmel Celestin, MD

Carmen Fonseca, MD

Marcelo Gomes, MD

Heather L. Gornik, MD, RVT

Douglas Joseph, DO, RVT

Samir Kapadia, MD*

Michael Maier, DPM, CWS

William Ruschhaupt, MD

Patrick L. Whitlow, MD*

*Vascular interventionalists who perform interventional and endovascular procedures

Women’s Cardiovascular Center

Leslie Cho, MD Director

Julie Huang, MD

Ellen Mayer Sabik, MD

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Heart & Vascular Institute 73

Some physicians may practice in multiple locations.

For a detailed list including staff photos, please visit

www.clevelandclinic.org/staff.

Clinical Investigations

Eugene H. Blackstone, MD, Director

Edward Nowicki, MD

Vascular Surgery Research

Roy K. Greenberg, MD, Director of Endovascular Research

C5Research (Cleveland Clinic Coordinating Center for Clinical Research)

A. Michael Lincoff, MD, Director

Associate Directors of C5Research

Deepak Bhatt, MD

Heather L. Gornik, MD, M.H.S., MMSc

Wael A. Jaber, MD

David Martin, MD, MPH

Stephen Nicholls, MD, PhD

W.H. Wilson Tang, MD

Oussama Wazni, MD

Patrick Whitlow, MD

C5Research Core Laboratory Directors

Arman T. Askari, MD

Roy K. Greenberg, MD

Stanley L. Hazen, MD, PhD

Wael A. Jaber, MD

Douglas E. Joseph, DO, RVT

Venu Menon, MD

Stephen J. Nicholls, MD, PhD

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Heart & Vascular Institute Staff Directory

Outcomes 200774

Regional Medical Practice

Cleveland Clinic Avon Lake Family Health Center

Bret Butler, MD, Vascular Surgery

Cleveland Clinic Beachwood Family Health and Surgery Center

Joel B. Holland, MD, Cardiovascular Medicine

Vikram Kashyap, MD, Vascular Surgery

Darryl Miller, MD, Cardiovascular Medicine

Michael B. Rocco, MD, Cardiovascular Medicine

Sunita Srivastava, MD, Vascular Surgery

Emad Zakhary, MD, Vascular Surgery

Cleveland Clinic Elyria Chestnut Commons Family Health Center

Daniel Clair, MD, Vascular Surgery

Cleveland Clinic in Florida -- Cardiovascular Medicine

Craig Asher, MD

Howard S. Bush, MD

Bernardo Fernandez, MD

Kenneth R. Fromkin, MD

Marcelo Eduardo Helguera, MD

Gian M. Novaro, MD

Sergio Pinski, MD

Michael Shen, MD, MS

Cleveland Clinic Independence Family Health Center

Neal Hadro, MD, Vascular Surgery

Michael B. Rollins, MD, Cardiovascular Medicine

Cleveland Clinic Lorain Family Health and Surgery Center

Brett Butler, MD, Vascular Surgery

Sean Lyden, MD, Vascular Surgery

Samuel Puccinelli, Jr., MD, Cardiovascular Medicine

Richard Sterba, MD, Pediatric Cardiology

Cleveland Clinic Solon Family Health Center

Joseph Martin, MD, Cardiovascular Medicine

Cleveland Clinic Strongsville Family Health and Surgery Center

Matthew Eagleton, MD, Vascular Surgery

Tara Mastracci, MD, Vascular Surgery

Terrence G. Tulisiak, MD, Cardiovascular Medicine

Cleveland Clinic Westlake Family Health Center

Brett Butler, MD, Vascular Surgery

Caroline Casserly, MD, MBA, Cardiovascular Medicine

Lon W. Castle, MD, Cardiovascular Medicine

Thomas B. Edel, MD, Cardiovascular Medicine

Robert D. Mosteller, MD, Cardiovascular Medicine

Ashoka Nautiyal, MD, Cardiovascular Medicine

Samuel Puccinelli, Jr., MD, Cardiovascular Medicine

Curtis Rimmerman, MD, Cardiovascular Medicine

Cleveland Clinic Willoughby Hills Family Health Center

J. Michael Koch, MD, Cardiovascular Medicine

Emad Zakhary, MD, Vascular Surgery

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Heart & Vascular Institute 75

Thomas G. Santoscoy, MD, Thoracic and Cardiovascular Surgery

Donna J. Waite, MD, Thoracic and Cardiovascular Surgery

Emad Zakhary, MD, Vascular Surgery

LakeWest HospitalRami Akhrass, MD, Thoracic and Cardiovascular Surgery

Mark Botham, MD, Thoracic and Cardiovascular Surgery

Thomas G. Santoscoy, MD, Thoracic and Cardiovascular Surgery

Donna J. Waite, MD, Thoracic and Cardiovascular Surgery

Marymount HospitalNeal Hadro, MD, Vascular Surgery

Gregory Schnier, MD, Vascular Surgery

R. Thomas Temes, MD, Thoracic and Cardiovascular Surgery

Donna J. Waite, MD, Thoracic and Cardiovascular Surgery

McLeod Heart & Vascular InstituteFred Holland, II, MD, Thoracic and Cardiovascular Surgery

Gregory Jones, MD, Thoracic and Cardiovascular Surgery

Robert Phillips Jr., MD, Thoracic and Cardiovascular Surgery

MetroHealth Medical CenterRami Akhrass, MD, Thoracic and Cardiovascular Surgery

Inderjit S. Gill, MD, Thoracic and Cardiovascular Surgery

Joseph A. Lahorra, MD, Thoracic and Cardiovascular Surgery

R. Thomas Temes, MD, Thoracic and Cardiovascular Surgery

Rochester General HospitalEli Becker, MD, Thoracic and Cardiovascular Surgery

David Cheeran, MD, Thoracic and Cardiovascular Surgery

Ronald Kirshner, MD, Thoracic and Cardiovascular Surgery

Cleveland Clinic Wooster

Kenneth E. Shafer, MD, Cardiovascular Medicine

Bennett Werner, MD, Cardiovascular Medicine

Richard Sterba, MD, Pediatric Cardiology

Affiliate Programs

Cape Fear Valley Health SystemAli Husain, MD, Thoracic and Cardiovascular Surgery

Robert Maughan, MD, Thoracic and Cardiovascular Surgery

Chester County Hospital Verdi DiSesa, MD, Thoracic and Cardiovascular Surgery

Martin LeBoutillier, III, MD, Thoracic and Cardiovascular Surgery

Cleveland Clinic in Florida W. Douglas Boyd, MD, Thoracic and Cardiovascular Surgery

Mercedes Dullum, MD, Thoracic and Cardiovascular Surgery

Keith Mortman, MD, Thoracic and Cardiovascular Surgery

EMH Regional Medical CenterAltagracia M. Chavez, MD, Thoracic and Cardiovascular Surgery

Michael S. Mikhail, MD, Thoracic and Cardiovascular Surgery

Fairview HospitalBrett Butler, MD, Vascular Surgery

Inderjit S. Gill, MD, Thoracic and Cardiovascular Surgery

R. Thomas Temes, MD, Thoracic and Cardiovascular Surgery

Joseph A. Lahorra, MD, Thoracic and Cardiovascular Surgery

Hillcrest HospitalGeorge Anton, MD, Vascular Surgery

Mark J. Botham, MD, Thoracic and Cardiovascular Surgery

Anthony Rizzo, MD, Vascular Surgery

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Outcomes 200776

Patient Experience

0

20

40

60

100

Cleveland Clinic

Total Cleveland Clinic Survey Respondents = 4,725

HCAHPS National Average

Percent “9” or “10”Percent “9” or “10”

80

0

20

40

60

100

Cleveland Clinic HCAHPS National Average

Percent “Yes, definitely”Percent “Yes, definitely”

80

Total Cleveland Clinic Survey Respondents = 4725

Overall Rating of Care (0 worst - 10 best scale) October 2006 - June 2007

Would Recommend Facility October 2006 - June 2007

Inpatient - Cleveland ClinicWith the support of the Center for Medicare and Medicaid Services (CMS) and its partner organizations, the first national standard patient experience survey was implemented in late 2006. Adult medical, surgical, and obstetrics and gynecology patients treated at acute care hospitals across the country are included in the survey. Results collected for initial public reporting, published on www.hospitalcompare.gov in March 2008, are shown here.

We ask our patients about their experiences and satisfaction with the services provided by our staff. Although our patients are already indicating we provide excellent care, we are committed to continuous improvement.

Excellent Very Good Good Fair Poor

PercentPercent

00

100100

6060

8080

4040

2020

Excellent Very Good Good Fair Poor

PercentPercent

00

100100

6060

8080

4040

2020

ExtremelyLikely

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

PercentPercent

00

100100

6060

8080

4040

2020

Overall Rating of Care - 2007(N = 6,573)

Outpatient - Heart & Vascular Institute

Rating of Provider - Ambulatory Setting 2007(N = 6,585)

Recommend Provider - Ambulatory Setting 2007(N = 6,427)

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Heart & Vascular Institute 77

Live Web ChatsIn 2007 Cleveland Clinic began offering live web chat events. Patients and the community can post questions about specific cardiovascular topics and receive online answers from our Heart & Vascular Institute experts. The web chat transcripts are posted after the events so they can be viewed by a wider audience. To view a list of chat transcripts, go to http://www.clevelandclinic.org/heart/webchat.

We have hosted web chats on a wide variety of cardiovascular topics, with answers posted by cardiologists, vascular medicine specialists, cardiovascular surgeons, and other health care professionals. Cleveland Clinic web chats provide information but are not intended to take the place of advice provided by a physician.

PodCastsDownloadable audio programs and video presentations are available online at www.clevelandclinic.org/heart. A wide variety of cardiovascular topics are available including cardiovascular disease risk factors and diagnosis, heart failure, abnormal heart rhythms, coronary artery disease, valve disease, great vessel disease, thoracic surgery and women and heart failure.

Patient and Family Health & Education CenterThe Patient and Family Health & Education

Center, opening in the fall 2008, will provide

education, health information, support and

resources to patients and visitors. The Education

Center will feature a library of educational

handouts as well as current journals and other

publications; computer terminals with Internet

access; audio and video education programs;

and health education classes for patients and

caregivers. The library will be staffed by health

educators and will house our Heart & Vascular

Institute Resource Nurses and support staff.

Healing SolutionsCleveland Clinic Heart & Vascular Institute piloted a Healing Solutions program, offering a host of complimentary wellness services, to patients on one of its inpatient nursing units in late 2007.

This innovative program made pastoral care, social work, holistic nursing, and the touch therapies of massage, Healing Touch and Reiki, part of the team approach that addresses the well-being of our patients and families.

In a survey of pilot participants, 93 percent of participants said they found the services helpful. Ninety percent of those surveyed said they would recommend the services to others.

The pilot program hopes to create a truly caring community, looking at needs beyond the physical – as body, mind and spirit are all important to each patient’s wellbeing. The initiative is part of a larger movement at Cleveland Clinic, led by newly appointed Chief Experience Officer M. Bridget Duffy, MD, to enhance the quality of the hospital experience for patients and their families. These efforts reinforce Cleveland Clinic’s mission: “Patients First.”

The program will be introduced to other floors of the Heart & Vascular Institute and throughout Cleveland Clinic as it is tailored to meet the needs of various patient populations.

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Patient Experience (continued)

Never Giving Up HopeOn November 28, 2007, Marianne Cooke, a 32-year-old single mother of two from Arnett, West Virginia, wasn’t feeling well and decided to take a hot bath. As she was climbing into the tub, she suddenly felt dizzy and fell. The water continued running as Marianne blacked out. She could hear her 2-year-old crying and calling for her, but she couldn’t move.

Twenty hours later, a maintenance man investigating a complaint of leaking water found Marianne unconscious on the floor and her son sitting in the water crying next to his Mom. And so began the heroic efforts to save her.

Still unconscious, she was placed on life support at a nearby hospital. Emergency physicians repeatedly asked her parents to sign a “Do Not Resuscitate” order. “She is brain dead,” they told her mother.

Hours later, Marianne was airlifted to a West Virginia teaching hospital. Tests revealed a tumor inside her heart had broken apart, causing clots throughout her body, triggering a massive stroke. Doctors now knew the extent of the problem, and that they weren’t equipped to fix it.

Marianne’s parents didn’t give up. Ten other hospitals refused her case, saying it was too risky. Finally, three days later, a deteriorating Marianne was airlifted to Cleveland Clinic where cardiac and vascular surgeons removed the heart tumor and the blood clots in an eight-hour operation.

“Pieces of the tumor had broken off and were speeding down her arteries like race cars, lodging in her brain, her legs, her feet…,” Cleveland Clinic cardiac surgeon A. Marc Gillinov, MD, said. This most intricate of operations by Dr. Gillinov and vascular surgeon Sean Lyden, MD, demonstrates the multidisciplinary collaboration that routinely benefits patients, such as Marianne, at the Heart & Vascular Institute.

The clots in Marianne’s brain were too numerous and difficult to remove safely, but fortunately, her brain was able to adapt to compensate for the functions from the damaged areas. Eight days later, Marianne started to move a toe. The recovery had begun.

After Christmas, Marianne was released to a nursing home where therapists predicted she would remain for a year. But less than three months after her collapse, Marianne returned home, walking and talking, and ever so grateful.

In all, Marianne lost vision in one eye and may end up losing a toe from the lack of circulation. But her prognosis is good. She and her family say they don’t know much about miracles. But this, they say, certainly comes close.

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Cleveland Clinic Overview Online Services

Cleveland Clinic, founded in 1921, is a nonprofit multispecialty academic medical center that integrates clinical and hospital care with research and education. Today, 1,800 Cleveland Clinic physicians and scientists practice in 120 medical specialties and subspecialties, annually recording more than 3 million patient visits and more than 70,000 surgeries.

In 2007, Cleveland Clinic restructured its practice, bundling all clinical specialties into integrated practice units called institutes. An institute combines all the specialties surrounding a specific organ or disease system under a single roof. Each institute has a single leadership and focuses the energies of multiple professionals onto the patient. From access and communication to billing and point-of-care service, institutes will improve the patient experience at Cleveland Clinic.

Cleveland Clinic’s main campus, with 37 buildings on 140 acres in Cleveland, Ohio, includes a 1,000-bed hospital, outpatient clinic, specialty institutes and supporting labs and facilities. Cleveland Clinic also operates 14 family health centers; eight community hospitals; two affiliate hospitals; a 150-bed hospital and clinic in Weston, Fla.; and health and wellness centers in Palm Beach, Fla., and Toronto, Canada. Cleveland Clinic Abu Dhabi (United Arab Emirates), a multispecialty care hospital and clinic, is scheduled to open in 2011.

At the Cleveland Clinic Lerner Research Institute, hundreds of principal investigators, project scientists, research associates and postdoctoral fellows are involved in laboratory-based research. Total annual research expenditures exceed $150 million from federal agencies, non-federal societies and associations, and endowment funds. In an effort to bring research from bench to bedside, Cleveland Clinic physicians are involved in more than 2,400 clinical studies at any given time.

In September 2004, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University opened and will graduate its first 32 students as physician-scientists in 2009.

Cleveland Clinic is consistently ranked among the top hospitals in America by U.S.News & World Report, and our heart and heart surgery program has been ranked No. 1 since 1995.

For more information about Cleveland Clinic, visit clevelandclinic.org.

eCleveland CliniceCleveland Clinic uses state-of-the-art digital information systems to offer several services, including remote second opinions to patients around the world; personalized medical record access for patients; patient treatment progress for referring physicians (see below); and imaging interpretations by our subspecialty trained radiologists. For more information, please visit eclevelandclinic.org.

DrConnectOnline Access to Your Patient’s Treatment Progress

Whether you are referring from near or far, DrConnect can streamline communication from Cleveland Clinic physicians to your office. This online tool offers you secure access to your patient’s treatment progress at Cleveland Clinic. With one-click convenience, you can track your patient’s care using the secure DrConnect website. To establish a DrConnect account, visit eclevelandclinic.org or email [email protected].

MyConsultMyConsult Remote Second Medical Opinion is a secure online service providing specialist consultations and remote second opinions for more than 600 life-threatening and life-altering diagnoses. The MyConsult service is particularly valuable for people who wish to avoid the time and expense of travel. For more information, visit eclevelandclinic.org/myconsult, email [email protected] or call 800.223.2273, ext 43223.

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Referral Contact Information

Heart & Vascular Institute

On the Web at clevelandclinic.org/heart

General Patient Referral

24/7 hospital transfers or physician consults 800.553.5056

Thoracic and Cardiovascular Surgery Evaluation

Nurse practice managers will expedite patient record review with a Cleveland Clinic surgeon and address questions

216.444.3500 or toll-free 877.8.HEART1

Cardiovascular Medicine Appointments/Referrals

216.444.4467 or 800.223.2273, ext. 44467

Vascular Surgery Appointments/Referrals

216.444.4508 or 800.223.2273, ext. 44508

Heart & Vascular Institute Resource Center

For questions or concerns about heart disease, or to schedule a second opinion Monday through Friday, 8:30 a.m. to 4 p.m.

216.445.9288 or toll-free 866.289.6911

General Information

216.444.2200 or 216.444.2000

Medical Concierge for Out-of-State Patients

Complimentary assistance for out-of-state patients and families 800.223.2273, ext. 55580, or email [email protected]

International Center

Complimentary assistance for international patients and families 800.884.9551 or 216.444.6404 or visit clevelandclinic.org/ic

Cleveland Clinic in Florida

866.293.7866

For address corrections or changes, please call 800.890.2467

clevelandclinic.org

LocationsCleveland Clinic Heart & Vascular Institute physicians see patients at the locations below. Please inquire about availability of specific services at each location when calling.

Main Campus

9500 Euclid Avenue Cleveland, OH 44195

216.444.2200 or toll-free 866.223.2273

Cleveland Clinic Family Health Centers

Beachwood Family Health and Surgery Center

26900 Cedar Road Beachwood, OH 44122

216.839.3000 or toll-free 866.318.2491

Cardiovascular medicine, vascular surgery

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Independence Family Health Center

5001 Rockside Road Crown Centre II Independence, OH 44131

216.986.4000

Vascular surgery

Lorain Family Health and Surgery Center

5700 Cooper Foster Park Road Lorain, OH 44053

440.204.7400 or 800.272.2676

Pediatric cardiovascular medicine, vascular surgery

Strongsville Family Health and Surgery Center

16761 SouthPark Center Strongsville, OH 44136

440.878.2500 or 800.239.1098

Cardiovascular medicine, vascular medicine, vascular surgery

Westlake Family Health Center

30033 Clemens Road Westlake, OH 44145

440.899.5555 or 800.599.7771

Cardiovascular medicine, thoracic and cardiovascular surgery

Willoughby Hills Family Health Center

2570 SOM Center Road Willoughby Hills, OH 44094

440.943.2500 or 800.807.2888

Cardiovascular medicine, vascular surgery

Cleveland Clinic Wooster

1740 Cleveland Road Wooster, OH 44691

330.287.4500 or 800.451.9870

Adult and pediatric cardiovascular medicine

Heart & Vascular Institute Regional Centers

Cape Fear Valley Health System

Cardiothoracic Surgery 1638 Owen Drive Fayetteville, NC 28304

910.609.4000 capefearvalley.com

The Chester County Hospital

Cardiothoracic Surgery, 2nd Floor 701 E. Marshall Street West Chester, PA 19390

610.738.2690 cchosp.com

Cleveland Clinic in Florida

2950 Cleveland Clinic Boulevard Weston, Florida 33331

954.659.5320 clevelandclinic.org/florida

Cardiovascular medicine, vascular medicine, cardiothoracic surgery, thoracic surgery

EMH Regional Medical Center

Gates Medical Building, Suite 101 630 East River Street Elyria, OH 44035

440.284.1504 emh-healthcare.org

Cardiothoracic surgery

Euclid Hospital

18901 Lake Shore Boulevard Euclid, OH 44119

216.531.9000 euclidhospital.org

Cardiovascular medicine

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Fairview Hospital

Cardiothoracic Surgery, Fairview Physicians’ Center 18101 Lorain Avenue Cleveland, OH 44111

216.476.7310 fairviewhospital.org

Cardiothoracic surgery, vascular surgery

Hillcrest Hospital

Hillcrest Hospital Atrium 6780 Mayfield Road, Suite 400 Mayfield Heights, OH 44124

440.449.9300 hillcresthospital.org

Cardiothoracic surgery, vascular surgery

LakeWest Hospital

LakeWest Medical Building, Suite 280 36000 Euclid Avenue Willoughby, OH 44094-4662

440.918.4640 lhs.net

Cardiothoracic surgery

Marymount Hospital

12300 McCracken Road Garfield Heights, OH 44125

216.587.4280 marymount.org

Vascular surgery

McLeod Heart & Vascular Institute

Cardiothoracic Surgery 555 East Cheves Street Florence, SC 29506

843.777.2000 mcleodhealth.org

MetroHealth Medical Center

Cardiothoracic Surgery 2500 MetroHealth Drive Cleveland, OH 44109

216.778.4304 metrohealth.org

Rochester General Hospital

Cardiothoracic Surgery 1445 Portland Avenue Rochester, NY 14621

585.544.6550 rochestergeneralhospital.org

Locations (continued)

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9500 Euclid Avenue, Cleveland OH 44195,

© The Cleveland Clinic Foundation 2008, 7/08

Cleveland Clinic is a nonprofit multispecialty academic medical center. Founded in 1921, it is dedicated to providing quality specialized care and includes an outpatient clinic, a hospital with more than 1,000 staffed beds, an education institute and a research institute.

www.clevelandclinic.org/heart

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