outcomes 2008 - cleveland clinic · dear colleague: on behalf of cleveland clinic, i am pleased to...

Heart & Vascular Institute

2008Outcomes

2

Institute Overview

Sydell and Arnold Miller Family Heart & Vascular Institute 1

Surgical Overview

To promote quality improvement, Cleveland Clinic has created a series of Outcomes books similar to this one for many of its institutes. Designed for a physician 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 associated with improved outcomes. When process measures are unavailable, we may report volume measures; a volume/outcome relationship has been demonstrated for many treatments, particularly those involving surgical techniques.

In addition to our internal efforts to measure clinical quality, Cleveland Clinic 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.ohio.gov/healthStats/hlthserv/hospitaldata/hospperf.aspx)

Our commitment to providing accurate, timely information about patient care will also 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 clevelandclinic.org/quality/outcomes.

Dear Colleague:

On behalf of Cleveland Clinic, I am pleased to present our 2008 Outcomes books. The primary purpose of our annual Outcomes book initiative is to promote quality improvement at Cleveland Clinic, thereby optimizing the care we provide to our patients. Measuring and reporting outcomes reflects our organizational commitment to accountability, transparency and results.

Each year, external stakeholders are requiring hospitals to report more and more quality and patient safety data. We view our Outcomes books as voluntary supplements to the required public reporting and an opportunity to share selected innovations with colleagues across the country.

Designed for the physician reader, each book in the annual series focuses on care provided by one of our patient-centered clinical institutes. We hope you find the content informative.

Sincerely,

Delos M. Cosgrove, MD CEO and President

what’s insideChairman’s Letter 4

Introduction 5

World’s Most Advanced Cardiovascular Care Facility 6

Institute Overview 8

Quality and Outcomes Measures

Surgical Overview 10

Ischemic Heart Disease 13

Cardiac Rhythm Disorders 21

Valve Disease 25

Aortic Disease 34

Adult Congenital Heart Disease 44

Hypertrophic Obstructive Cardiomyopathy 46

Heart Failure and Transplant 48

Lung and Heart-Lung Transplant 54

Peripheral Arterial Disease 56

Venous Disease 58

Cerebrovascular Disease 59

Thoracic Surgery 60

Preventive Cardiology 64

Cardiothoracic Anesthesiology 68

Surgical Quality Improvement 70

Patient Experience 73

Innovations 76

Selected Publications 84

Staff Directory 92

Contact Information 100

Institute Locations 101

Cleveland Clinic Overview 104

Institute Resources 105

Resources for Physicians 106

Chairman’s Letter

4

Thank you for your interest in the Sydell and Arnold Miller Family Heart & Vascular Institute 2008 Outcomes. This represents the 11th year we have shared our clinical outcomes with physicians across the country.

The new Miller Family Pavilion, opened in fall 2008, brings together medical, surgical and support functions under one roof to improve collaboration, increase access, reduce wait times and enhance the overall patient experience (see page 6 for more information).

The structure of the Miller Family Heart & Vascular Institute integrates multiple specialties for specific diseases, thereby creating a synergy among medical professionals with similar clinical, research and educational interests, centering on patient care. The Institute structure will help further the innovation and research that is revolutionizing the prevention, diagnosis and treatment of cardiovascular 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 Miller Family Heart & Vascular Institute structure will help us to make the best choices and to carry out these therapies effectively.

Bruce W. Lytle, MDChairman, Miller Family Heart & Vascular Institute

Cleveland Clinic is recognized as the national leader in the clinical care of patients with cardiovascular

disease. Cleveland Clinic heart, vascular and thoracic specialists continue to provide leading-edge innovations

in patient care therapies and clinical research.

The Sydell and Arnold Miller Family Heart & Vascular Institute at Cleveland Clinic is composed of 153 staff

physicians, 42 fellows and 874 full-time nurses in cardiovascular medicine, thoracic surgery, cardiovascular

surgery and vascular surgery. Our cardiovascular specialists also collaborate with 39 cardiothoracic and

vascular surgery staff anesthesiologists.

BlueBerg (r11i01) by Iñigo Manglano-Ovalle

The four-story Great Hall links the Miller Family Pavilion to the Glickman Urological Institute and features the 30-foot BlueBerg (r11i01) sculpture by artist Iñigo Manglano-Ovalle. This ceiling sculpture represents an actual iceberg that drifted into the Labrador Sea. Photo ©Thom Sivo Photography

5Sydell and Arnold Miller Family Heart & Vascular Institute

Introduction

Outcomes 20086

With one million square feet of space, the newly constructed Miller Family Pavilion houses the largest and most advanced cardiovascular care facility in the world. The Miller Family Heart & Vascular Institute moved to its new home in fall 2008, tripling the space dedicated to heart and vascular services at Cleveland Clinic.

By bringing medical, surgical and support functions together under one roof, we are improving collaboration, increasing access, reducing wait times and enhancing the overall patient experience.

Building Features

16 operating rooms, including:•

− 1 robotic surgery suite

− 2 endovascular surgery suites

128 exam rooms•

10 catheterization suites, including electrophysiology labs • and two bi-plane labs

79 procedure rooms •

278 private patient rooms •

110 ICU beds, including four specialized ICUs: coronary • ICU, heart failure ICU and two surgical ICUs

28-bed recovery unit for same-day procedures •

Advanced cardiac imaging facilities •

− 1 cardiac MRI scanner

− 1 64-slice cardiac CT scanner

− 1 256-slice cardiac CT scanner

Rooftop pavilion with open views of the city •

In 2008, Cleveland Clinic was ranked No. 1 in the nation for heart care and heart surgery (14 years in a row) by U.S. News & World Report.

World’s Most Advanced Cardiovascular Care Facility


The Miller Family Pavilion houses the largest and most advanced cardiovascular care facility in the world.

“We evaluate every step in the process of care and make sure everything works together in a very synchronized and team-like manner. When a multidisciplinary team works together with the same shared goal, quality is better.”

— Bruce W. Lytle, MD Chairman, Miller Family Heart & Vascular Institute

8 Outcomes 2008

Institute Overview

Heart & Vascular Institute Overview 2008 Patient Visits 303,464 Admissions 11,792Beds 416 Coronary Intensive Care 24 Heart Failure Intensive Care 10 Cardiac, Vascular and Thoracic Surgery Intensive Care 76 Private Patient Rooms 278 Same-Day Recovery 28

Surgical ProceduresCardiac SurgeryCardiac Surgeries 3,606Valve Surgeries 2,355Coronary Artery Bypass Grafting (CABG - Isolated and Concomitant) 1,367Surgeries for Hypertrophic Cardiomyopathy 168Adult Congenital Heart Surgeries 56Robotically Assisted Cardiac Surgeries 213

Transplant SurgeryHeart Transplants 60Lung Transplants 57

Thoracic SurgeryGeneral Thoracic Surgeries 1,472Esophageal Surgeries 296Airway Surgeries 324

Vascular SurgeryVascular Surgeries (Open and Endovascular) 5,243Venous Surgeries 435Arteriovenous Access Surgeries 468


In 2008, patients traveled

from 50 states to

Cleveland Clinic for their

cardiovascular care.

Patients from 89 countries

came to Cleveland Clinic for their

cardiovascular care in 2008.

Aorta SurgeryOpen Ascending Aorta and Aortic Arch Repairs 610Open Descending Aorta and Thoracoabdominal Repairs 100Open Abdominal Aortic Aneursym Repairs 96Endovascular Descending Aorta and Thoracoabdominal Repairs 182Endovascular Abdominal Aortic Aneurysm Repairs 149

Non-Surgical Procedures Interventional Cardiology Diagnostic Cardiac Catheterizations 8,721Percutaneous Coronary Interventions 1,991 Percutaneous Aortic Valvuloplasties 77 Percutaneous Mitral Valvuloplasties 20

Percutaneous ASD and PFO Closures 77 Vascular Intervention Interventional Carotid Procedures 61 Interventional Vascular Procedures 1,510

Electrophysiology Electrophysiology Ablations 1,122 Ablations for Atrial Fibrillation 697 Device Implants 1,240 Device Lead Extractions 304 Diagnostic and Cardiac Imaging Echocardiograms (Echos) 53,791Cardiac Computed Tomography (CT) Scans 7,115Cardiac Magnetic Resonance Imaging (MRI) Scans 2,430Nuclear Cardiology Tests Tc-99m SPECT Studies 5,032 Rubidium PET Myocardial Perfusion 432 FDG PET Myocardial Viability 357 MUGA 187Stress Tests 10,674

Surgical Overview

Outcomes 200810

Main Campus and AffiliatesThoracic and Cardiac Surgery Volume (N = 12,068)

The Department of Thoracic and Cardiovascular Surgery and its affiliates perform a high volume and variety of procedures. In 2008, the department and its affiliates performed 12,068 cardiovascular and thoracic surgical procedures. It has been demonstrated that improved clinical outcomes are linked to centers with high surgical volumes.

1998 2000 2002 2004 2006 2008

14,00014,000VolumeVolume

12,00012,000

10,00010,000

8,0008,000

6,0006,000

4,0004,000

2,0002,000

00

Main CampusAffiliates

Surgical Overview

Cleveland Clinic has one of the nation’s most experienced cardiac surgery programs and performs a variety of cardiac operations. Isolated valve and combined valve operations accounted for 49 percent of the total cardiac surgical volume in 2008.

Of the 3,606 cardiac

surgeries performed for

acquired heart disease at

Cleveland Clinic’s main

campus, 27 percent

(N = 989) were

reoperations, which are generally more complex and entail greater risk

than primary operations

(N = 2,608). Extensive

experience with

reoperations benefits

patients and can ensure

improved outcomes.

* Cleveland Clinic main campus volume only, excluding affiliate volume

10

Distribution of Cardiac Surgeries at Main Campus (N = 3,606*)

25.5% Other Cardiac Surgeries (N = 917)25.5% Other Cardiac Surgeries (N = 917)

4.4% Combined CABG Surgeries (valve excluded) (N = 160)4.4% Combined CABG Surgeries (valve excluded) (N = 160)

1.7% Heart Transplants (N = 60)1.7% Heart Transplants (N = 60)3.2% Isolated Great Vessel Surgeries (N = 116)3.2% Isolated Great Vessel Surgeries (N = 116)16.2% Isolated CABG Surgeries (N = 584)16.2% Isolated CABG Surgeries (N = 584)

26% Isolated Valve Surgeries (N = 931)26% Isolated Valve Surgeries (N = 931)

23% Combined Valve Surgeries (N = 838)23% Combined Valve Surgeries (N = 838)

100%100%

49%49%

2008


Cardiac Surgery Hospital Mortality

Hospital mortality for all cardiac surgeries in 2008 was 2.8 percent, despite high patient acuity. Patient acuity of 6.9 represents one of the highest cardiac surgery acuity levels in the country.

0

6

4

2

8

1998 2000 2002 2004 2006 2008

2.8% Mortality

6.9 Patient Acuity

1998 2000 2002 2004 2006 2008

6,0006,000

4,0004,000

VolumeVolume

2,0002,000

00

Vascular Surgery Volume

The 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.

Cleveland Soul by Jaume Plensa

“Every second, every moment, our experiences are tattooed on our skin.”

This sculpture is located in the main lobby of the Miller Family Pavilion. The image of a body comprised of text is a metaphor for Plensa’s belief that the psyche is imprinted with human experiences.

2008

Outcomes 200812

88

66

44

22

00≤49 50-59 60-69 ≥8070-79

1,093 1,420 2,646 1,8463,025

Mortality (%)

AgeCC N =

CC Vascular Surgery MortalityNational TeachingHospital Mortality

Vascular Surgery Volume - Open and Endovascular Repair (N = 5,243)

Our treatment approach over the past nine years has transitioned from traditional, open surgical repair to endovascular intervention, revolutionizing the management of patients with vascular disease. Endovascular surgery has a much lower prevalence of acute morbidity and mortality and offers faster recovery than open surgery.

Vascular Surgery Hospital Mortality

The cumulative hospital mortality average at Cleveland Clinic was 3.2 percent from 2002 to 2008, compared with the 5.6 percent adjusted national teaching hospital mortality*.

*Data Source: Solucient

100%100%

58% Endovascular Surgery (N = 3,048)

42% Open Surgery (N = 2,195)

2008

Surgical Overview (continued)

Whispering by Jaume Plensa

This wall sculpture made of stainless steel is located off the main lobby of the Miller Family Pavilion. Phrases about healing and humanity written by famous philosophers,

artists and historical figures hang vertically, inviting viewers to engage with the artwork.Photo ©Thom Sivo Photography

2002-2008

Sydell and Arnold Miller Family Heart & Vascular Institute

Cardiac Catheterization Laboratory Procedures (N = 11,719)

As a regional and national referral center, Cleveland Clinic performs percutaneous coronary interventions (PCI) for patients with simple and complex ischemic disease. In 2008, 11,719 diagnostic and PCI procedures were performed in the Cath Lab.

PCI Outcomes for Adjunctive Medications (N = 1,991)2008

100

80

0Aspirin Statins

Before Procedure

β-Blockers Aspirin ACE Statins Thienopyridines

At Discharge

β-Blockers

60

40

20

PercentOther*Cleveland Clinic

43,287 stents have

been placed at

Cleveland Clinic

since 1992.

Receiving timely and appropriate adjunctive care before and after PCI procedures is recognized by the ACC as an important performance measure. Compared with the average high-volume interventional center, Cleveland Clinic physicians administer these medications more frequently.

60

50

0Age

(>75 years)Heartfailure

Prior heartattack

Diabetes Renalinsufficiency

Severe LVdysfunction

Multi-vesseldisease

Prior bypasssurgery

40

30

20

10

PercentOther*Cleveland Clinic

Intravascular

ultrasound

(IVUS) is used

to obtain detailed

images of the walls

of the blood vessels

and provides an

accurate picture

of the extent

and location of

atherosclerotic

plaque. Adjunctive

IVUS was

used with 435

procedures in

2008.

Ischemic Heart Disease

Data based on one-year rolling average.

PCI Procedures (N=1,991)2008

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

Cleveland Clinic patients undergoing PCI procedures more often have multi-vessel disease, diabetes, prior heart attack and prior bypass surgery than patients at other comparable hospitals.

*Comparable ACC- NCDR (American College of Cardiology National Cardiovascular Data Registry Cath PCI RegistryTM) Hos-pitals (>500 PCI Procedures/Year)


Outcomes 200814 Outcomes 2008

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

4

3

0Mortality Emergent CABG Blood Transfusions Major Vascular

Complications

2

1

Percent

Other*Cleveland Clinic

Leapfrog Survey – Acute Myocardial Infarction (AMI)January – December 2007

Leapfrog Survey – Angioplasty – Procedural Quality & CostsJanuary – December 2007

The Leapfrog Group encourages transparency and easy access to healthcare information. Participation in the annual Leapfrog Hospital Quality and Safety Survey is voluntary. Cleveland Clinic’s acute myocardial infarction and angio-plasty - procedural quality and costs ratings appear above.

*Source: www.leapfroggroup.org

Progress toward meeting Leapfrog Standards* One bar = willing to report data Two bars = some progress Three bars = substantial progress Four bars = fully meets standards

After adjustment for complexity and severity of illness, mortality for PCI procedures and prevalence 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).

Ischemic Heart Disease (continued)

PCI Complications (N = 1,991)2008

Door to Balloon Time (N = 1,991)2008

*Reportable cases (N=38) of patients with STEMI who were admitted through our Emer-gency Department and had a primary PCI procedure **Comparable ACC-NCDR Hospitals (>500 PCI Proce-dures/Year)

Door to balloon time is the time from arrival in the Emergency Department to PCI balloon inflation for patients with ST-elevation acute myocardial infarction (STEMI). The ACC/AHA practice guidelines recommend a goal of 90 minutes or less from the patient’s arrival in the Emergency Department to balloon inflation for PCI procedures unless there is uncertainty about diagnosis or delays associated with informed choice.

80

100

60

0Cleveland Clinic* Other** ACC/AHA Goal

40

20

Minutes

Sydell and Arnold Miller Family Heart & Vascular Institute 15Sydell and Arnold Miller Family Heart & Vascular Institute 15

100

80

0100 20 30 40 50 60 70

60

40

20

Percent

Months after Treatment

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

2008 Percent

Cardiac death 0.4

Non-cardiac death 0.1

Q-wave MI 0.3

Non-Q-wave MI 2.9

Emergent CABG 0.1

Blood transfusions 2.5

Percent

Cardiac death 3.3

Non-cardiac death 1.3

Reinfarction 0.7

Emergent CABG 1.0

Blood transfusions 8.8

Cleveland Clinic is investigating

the benefits and risks of

stem cell therapies

for patients with acute

myocardial infarction (MI) and

ischemic cardiomyopathy. This

research, funded by the NIH,

includes three randomized

clinical trials that are currently

enrolling (TIME, LATETIME

and FOCUS). Other

industry-based stem cell trials

are also enrolling.

Complications of PCI Procedures Performed to Treat Acute MI

200838,427percutaneous coronary

interventional (PCI)

procedures have been

performed at Cleveland

Clinic since 1992.

Freedom from Target Vessel Revascularization after PCI in the Drug-Eluting Stent Era

2004-2008

At Cleveland Clinic, the need for further revascularization in patients who had a prior PCI procedure remains remarkably low (8 percent at five years).

Diagnostic Cardiac Catheterization Complications

The composite rate of procedural complications was 0.01 percent in 2008 for 9,605 diagnostic catheterizations (including 884 isolated right heart catheterization procedures). There were no acute myocardial infarction (MI), stroke and death, and only 0.01 percent of patients required emergent coronary artery bypass graft (CABG) surgery.

2003 2004 2005 2006

0%

2007 2008

0.050.05

0.040.04

PercentPercent

0.030.03

0.020.02

0.010.01

00


Support for LV DysfunctionCleveland Clinic utilizes the latest support devices for

patients with left ventricular dysfunction, including:

• Intra-aortic Balloon Pump (IABP): Percutaneous mechanical circulatory support for the treatment of cardiogenic shock, heart failure, acute myocardial infarction and support during high-risk PCI procedures.

• TandemHeart® PTVA® System: Percutaneous centrifugal left ventricular assist device that provides temporary support for patients in cardiogenic shock as a bridge to other circulatory support devices, or to recovery.

• Impella 2.5 Cardiac Assist Device: Catheter-based cardiac assist device that provides partial circulatory support for up to six hours.

Coronary

angiography was

pioneered at Cleveland Clinic in 1958 by

F. Mason Sones, MD,

in whose honor the

Cardiac Catheterization

Laboratory is named.

This technique made

it possible to visualize

blocked vessels in

real time.

Impella 2.5 Cardiac Assist Device, ABIOMED, Inc.

Outcomes 200816


Hospital Compare: Acute Myocardial Infarction (AMI)

Hospital Compare is a consumer-oriented website hosted by the Centers for Medicare & Medicaid Services (CMS) in collaboration with the Hospital Quality Alliance (HQA). Hospitals that have agreed to public reporting submit process-of-care data showing how consistently they provide recommended care to adult patients, irrespective of payer. (These results also are posted on The Joint Commission’s website.) Thirty-day risk-adjusted all-cause mortality is an outcome based on Medicare claims and enrollment information. Cleveland Clinic’s acute myocardial infarction care performance appears below.

* Benchmark source: www.hospitalcompare.hhs.gov, discharges July 2007 - June 2008

AMI: Aspirin at Arrival (N = 148)

Discharges January – December 2008

AMI - Aspirin Prescribed at Discharge (N = 610)


0 20 40 60 80 100

Percent of Patients

NationalAverage*

ClevelandClinic

71

83

0 20 40 60 80 100

NationalAverage*

ClevelandClinic

90

98.3

Percent of Patients

AMI: Beta-Blocker Prescribed at Discharge (N = 552)


0 20 40 60 80 100

NationalAverage*

ClevelandClinic

93

99

Percent of Patients


Outcomes 200818



0 20 40 60 80 100

NationalAverage*

ClevelandClinic

90

96

Percent of Patients

AMI: ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) (N = 102)


AMI: Adult Smoking Cessation Advice/Counseling (N = 220)


0 20 40 60 80 100

NationalAverage*

ClevelandClinic

94

99

Percent of Patients

AMI: Primary PCI Received within 90 Minutes of Hospital Arrival (N = 19)


0 20 40 60 80 100

NationalAverage*

ClevelandClinic

72

79

Percent of Patients

AMI: Risk-Adjusted All-Cause 30-Day Mortality (N = 161)

Discharges July 2006 – June 2007

0

5

10

15

20

Percent

National Average*

16.816.1

Cleveland Clinic

ACE = Angiotensin Converting Enzyme ARB = Angiotensin Receptor Blocker


* Benchmark source: www.hospitalcompare.hhs.gov, discharges July 2007 - June 2008* Benchmark source: www.hospitalcompare.hhs.gov, discharges July 2007 - June 2008


*Reference: Higgins TL et al. Stratification of morbidity and mortality outcome by preoperative risk factors in coronary artery bypass patients. A clinical severity score. JAMA. 1992 May 6;267(17):2344-8. Erratum in: JAMA 1992 Oct 14;268(14):1860.

1998 2000 2002 2004 2006 2008

44

33

22

11

00

3.25 Severity Score

1.2% Mortality

Mortality (%)Mortality (%) Severity Score*

Surgical Treatment for Ischemic Heart Disease

Primary Isolated CABG Procedures (N = 485)

Primary isolated coronary artery bypass grafting (CABG) refers to a patient’s first CABG when performed without any other procedure. In 2008, Cleveland Clinic surgeons performed 485 primary isolated CABG procedures, and mortality was 1.2 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 procedures on high-risk patients with greater mean severity scores, yet mortality remains low.

Leapfrog Survey – CABG Surgery Quality and CostsJanuary – December 2007

The Leapfrog Group encourages transparency and easy access to healthcare information. Participation in the annual Leapfrog Hospital Quality and Safety Survey is voluntary. Cleveland Clinic’s acute myocardial infarction and Angioplasty - Surgical Quality and Costs ratings appear above.


Progress toward meeting Leapfrog Standards* One bar = willing to report data Two bars = some progress Three bars = substantial progress Four bars = fully meets standards

Outcomes 200820

Isolated CABG Volume and Mortality

2008

Isolated CABG includes primary operations and reoperations. Nearly 20 percent of Cleveland Clinic’s isolated CABG procedures were reoperations in 2008. Reoperations are associated with higher morbidity and mortality. Cleveland Clinic’s expertise in cardiac surgery has led to a high percentage of referrals for reoperative CABG.

83% Primary Operations (N = 485)

83% Primary Operations (N = 485)

17% Reoperations (N = 99)17% Reoperations (N = 99)

100%100%

Isolated CABG

2008 Volume Hospital Mortality (%)

584 1.7


Primary Isolated CABG Mortality

2008

Increased age is a known risk factor for cardiovascular disease and contributes to the complexity of CABG surgical cases. In 2008, Cleveland Clinic achieved very low mortality in all age groups.

80% Single ITA (N = 373)

5% Single ITA + Radial (N = 24)

2% Bilateral ITA + Radial (N = 8)

13% Bilateral ITA (N = 62)

Arterial Grafts2008

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

Primary Isolated CABG Mortality (N = 485)

Age Mortality (%)

< 50 years (N = 54) 0.0

50-59 years (N = 104) 1.9

60-69 years (N = 167) 1.2

70-79 years (N = 114) 1.7

≥ 80 years (N = 46) 0.0


Cardiac Rhythm Disorders

Pulmonary Vein Antrum Isolation Procedures (PVAI)

PVAI is an effective treatment option for patients with symptomatic atrial fibrillation that is not responsive to antiarrhythmic medications. A single ablation procedure is completely curative in approximately 75 to 80 percent of patients with paroxysmal (intermittent) atrial fibrillation. A single procedure is less likely to cure patients who have been in atrial fibrillation constantly for months or years or who have extensive scarring in the atrium because of other heart disease. Nonetheless, patients with long-standing atrial fibrillation have a 50 to 70 percent chance of cure, depending on their underlying heart disease and other factors, but they are more likely to require more than one ablation procedure.

PVAI Procedure Volume (N = >4,300) and Outcomes for Paroxysmal Atrial Fibrillation 2004-2008

Success Rate* 75-80%

Complications

Stroke 0.6%

Severe Pulmonary Vein Stenosis 1.0%

Other 2.0%

*PVAI success rate is defined as a restored sinus rhythm without dependency on medications to control heart rhythm for at least six months post-procedure. The success rate for a single ablation procedure depends on several factors. The highest cure rate is achieved in patients with paroxysmal atrial fibrillation in whom atrial fibrillation stops on its own within one to three days. Some patients require more than one ablation procedure to achieve good long-term results. Ultimately, ablation of atrial fibrillation can be achieved successfully in 90 percent of patients with paroxysmal atrial fibrilla-tion who undergo one or more ablation procedures.

Comprehensive Atrial Fibrillation Treatment

Cleveland Clinic is expert at catheter-based treatments to effectively cure atrial fibrillation. The Center for Atrial Fibrillation offers comprehensive, state-of-the-art technologies to tailor treatment for each patient.

Cleveland Clinic electrophysiologists offer specialized approaches to diagnose and treat a wide range of arrhythmias.

Ablation of Ventricular Tachycardia

Cleveland Clinic is a national referral center for patients with ventricular arrhythmias, performing more than 400 ablation procedures for this condition from 2003 through 2008.

The overall benefit achieved in 93 percent of patients reflects Cleveland Clinic’s experience and use of advanced technology for these difficult procedures.

Ablation Procedure Volume (N = 71) and Outcomes for Ventricular Tachycardia 2008

Success Rate* 81%

*All ventricular tachycardias were eliminated in 81 percent of patients, and the procedure was partially successful in another 12 percent. Partial success means at least one tachycardia was ablated in patients who had multiple tachycardias.

Rotational angiography of the left atrium used to facilitate pulmonary vein isolation procedures


Left Atrial Appendage OcclusionCleveland Clinic physicians and

researchers have collaborated in

developing an occlusion 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 under

way in the U.S. and Europe. The

device has been used in more than

70 patients with excellent results,

and we expect full-scale clinical

release in 2010.

Cardiac Rhythm Disorders (continued)

Atrial Fibrillation Surgical Procedure Volume (N = 355)

2008

Surgical techniques for atrial fibrillation (AF) include a minimally invasive “keyhole” approach and the classic Maze procedure for patients who require stand-alone ablation. The choice of operation depends upon the patient’s condition; the left atrial appendage is routinely removed. In 2008, Cleveland Clinic cardiovascular surgeons performed 355 procedures to treat atrial fibrillation. The majority of surgical ablation procedures were performed during other cardiac procedures, as shown in the chart below.

100%100%

17.5% AF + Other Cardiac Surgery (N = 62) 4.2% AF + CABG (N = 15)1.7% Isolated AF Procedures (N = 6)

21.1% AF + Valve Surgery + CABG (N = 75)

55.5% AF + Valve Surgery (N = 197)

31% Bipolar Radiofrequency31% Bipolar Radiofrequency

1% Unipolar Radiofrequency1% Unipolar Radiofrequency

15% Cut-and-Sew Incision Method 15% Cut-and-Sew Incision Method

53% Cryoablation 53% Cryoablation

100%100%

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 Procedures (N = 355)

2008

CT scan from clinical trial showing

clip implanted in patient

Left atrial appendage clip with applier


Device Implants (N = 1,240)

Device Lead Extractions

Year # Extraction # Leads % Clinical % Major Procedures Extracted Success* Complications

2008 250 451 99.1 0.8

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

Average 291 523 99.6 0.3

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

Prevalence of infection

was 0.25 percent for 787 primary device

implants in 2008

(excluding device

replacements.)

2008 Volume

ICDs 705

Pacemakers 492

BiV Pacemakers and BiV ICDs 257

Loop Recorders 22

2008 Volume and Outcomes

The Electrophysiology Lab utilizes the latest device technology, including pacemakers, implantable cardiac defibrillators (ICDs), biventricular (BiV) pacemakers and biventricular ICDs.

Cleveland Clinic electrophysiologists perform the largest volume of lead extraction procedures in the world.

Sometimes, patients develop uncommon conditions that require the removal of device leads, such as infections, 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 of all the tools available for lead extraction, including rotating mechanical tip sheaths, electrosurgical energy, snares, mechanical sheaths and excimer laser energy. With these tools and techniques, almost all leads can be safely removed without opening the chest or heart.

Outcomes 200824

Cardiac Rhythm Disorders (continued)

The ability to remotely evaluate devices broadens patients’ access to care.

10,000

8,000

6,000

4,000

2,000

02007 20082004 2005 2006

Volume

ICDPacemaker

7,884 Holter recordings performed

in 2008

24,095 Transtelephonic arrhythmia

transmissions received in 2008

6,670 Transtelephonic device

transmissions received in 2008

Device Clinic Evaluations (N = 10,756)2008 Volume

Pacemaker Evaluations 4,855

ICD Evaluations 5,901

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

8,000

6,000

4,000

2,000

02007 20082004 2005 2006

Volume

2008 Volume

Remote Pacemaker Transmissions 373

Remote ICD Transmissions 6,702

Remote Device Evaluations (N = 7,075)

24 Outcomes 2008


Valve Disease

Distribution of Isolated and Combined Valve Operations (N = 1,769)

Nearly one-third (N = 505) of isolated and combined valve surgeries performed at Cleveland Clinic in 2008 were reoperations. Cleveland Clinic has expertise in performing complicated valve reoperations.

*Isolated valve surgery means valve surgery was performed without concomitant procedures to treat any other type of heart disease.

14% Combined Valve Reoperations (N = 247)14% Combined Valve Reoperations (N = 247)

15% Isolated Valve Reoperations (N = 258)15% Isolated Valve Reoperations (N = 258)

38% Isolated Primary Valve Surgeries (N = 673)38% Isolated Primary Valve Surgeries (N = 673)

33% Combined Primary Valve Surgeries (N = 591)33% Combined Primary Valve Surgeries (N = 591)100%100%

29%29%

2,5002,500

2,0002,000

1,5001,500

1,0001,000

500500

001998 2000 2002 2004 2006 2008

VolumeVolume Cleveland Clinic continues to perform the largest number of valve surgeries in the United States. In 2008, Cleveland Clinic surgeons performed 2,355 valve surgeries, including 1,737 primary operations and 618 reoperations.

Valve Surgery Volume

49%Valve surgeries

represented 49

percent of our

total cardiac

surgical volume

in 2008.

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 2008

0.2

Minimally Invasive Isolated Valve Surgery* Volume (N = 463) and Mortality

2008

Outcomes 200826

Valve Disease (continued)

Isolated Aortic Valve Replacement Mortality

Mortality for isolated aortic valve replacement at Cleveland Clinic in 2008 was 1.3 percent, significantly lower than The Society of Thoracic Surgeons’ (STS) benchmark of 2.7 percent.

*Based on data from January to June 2008 **Based on data from January to December 2008

0

1

3

4

2

2006

1.3% Cleveland Clinic**

2.7% STS benchmark*

2002 2003 20052004

Mortality (%)

20082007

1,5001,500

1,0001,000

500500

00

AV SparingAV RepairAV Replacement

AV SparingAV RepairAV Replacement

2008

Volume

2002 20042003 2006 20072005

Aortic Valve Surgery Volume

Cleveland Clinic performs the largest volume of aortic valve operations in the nation. In 2008, 1,321 aortic valve operations were performed. Eighty-eight percent were valve replacements (N = 1,157), seven percent were valve repairs (N = 94), and five percent were valve-sparing operations (N = 70).

Leapfrog Survey – Aortic Valve ReplacementJanuary – December 2007

The Leapfrog Group aims to reduce preventable medical mistakes and improve the quality and affordability of healthcare. Participation in the annual Leapfrog Quality and Safety survey is voluntary. Cleveland Clinic’s aortic valve replacement rating appears above.


Progress toward meeting Leapfrog Standards*

One bar = willing to report data

Two bars = some progress

Three bars = substantial progress

Four bars = fully meets standards


Valve Replacement Prostheses

Bioprostheses (biological tissue valves) are the prostheses of choice for most aortic and mitral valve replacement procedures. Bioprostheses are durable and allow most patients to avoid lifetime use of anticoagulants after surgery. In 2008, 1,234 bioprosthetic valves, 190 mechanical valves and 66 allograft valves were used.

0

1,2001,000

800600400200

1,400

1998

Volume

2000 2002 2004 2006 2008

Mechanical

Bioprostheses

Allografts

Mitral Valve Repair Surgery Volume

In 2008, 1,229 mitral valve surgeries were performed at Cleveland Clinic; 73 percent were valve repairs (N = 896), and 27 percent were valve replacements (N = 333).

1,0001,000

800800

200200

001998

Volume

2000 2002 2004 2006 2008

600600

400400

Outcomes 200828

Isolated Mitral Valve Repair Hospital Mortality

1998 2000 2002 2004 2006 2008

33Mortality (%)Mortality (%)

22

11

00

1.3% STS benchmark*

0.3% Cleveland Clinic**

* Based on data from January to June 2008 ** Based on 1 hospital death from January to December 2008

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 allografts (human cryopreserved valves). Cleveland Clinic heart surgeons have vast experience treating infective endocarditis, with excellent outcomes.

Infective Endocarditis Surgical Treatment Volume and Hospital Mortality

In 2008, Cleveland Clinic performed 339 primary isolated mitral valve repairs with 0.3 percent hospital mortality, significantly lower than The Society of Thoracic Surgeons’ (STS) benchmark of 1.3 percent.


150150

120120

9090

6060

3030

002004 2005 20072006 2008

Volume (N = 125)2525

2020

1515

1010

55

00

ReoperationMortality (%)

Primary

Infective endocarditis

causes bacterial or

fungal growths on the

heart valves that may

lead to perforation

and rupture

resulting in valve regurgitation.It is a life-threatening

condition that requires

prompt diagnosis and

treatment.

29

Minimally Invasive Valve Treatments

The Miller Family Heart & Vascular Institute is a worldwide leader in the development and use of minimally invasive valve surgery. Minimally invasive techniques encompass a variety of methods, including the use of very small incisions, robotic heart surgery and percutaneous procedures. Minimally invasive techniques are associated with reduced trauma and shorter recovery times.

More than 50 percent of isolated valve surgeries were performed using a minimally invasive approach in 2008.

84 percent of isolated mitral valve procedures were performed with a minimally invasive technique in 2008. Minimally invasive surgery reduces blood loss, trauma and length of hospital stay.

From 1995 through 2008,

6,629 minimally invasive heart surgeries were performed at Cleveland Clinic.

Procedure 2008 Volume Hospital Mortality (%)

Minimally invasive isolated aortic valve procedures 170 0

Minimally invasive isolated mitral valve procedures 292 0

Outcomes 200830

Access ports


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

00

300300

2006 2007 2008

100100

200200

00

33

11

22

VolumeVolume Mortality (%)

Isolated Mitral Valve Robotic Repair Procedure Volume and Hospital Mortality

Robotically Assisted Valve Surgeries

The volume of robotic mitral valve repairs has steadily increased since 2006; 213 robotic valve surgeries were performed in 2008 with 0 percent hospital mortality and greater than 99 percent success.

Cleveland Clinic performs the nation’s largest volume of robotically assisted mitral valve surgeries among major academic hospitals.

In 2008, robotic

surgery for isolated

mitral valve repair

reduced length of stay by 50 percent compared with

traditional nonrobotic

surgical techniques.

More than 30 percent

of patients who had

robotic isolated mitral

valve repair surgery

were discharged in three days or less in 2008.

The average length of

stay for robotic isolated

mitral valve repair was

five days in 2008,

compared with 10 days

for non-robotic isolated

mitral valve repair.

Hospital mortality for

both groups was

0.3 percent in 2008.


Percutaneous Valve Treatments

Cleveland Clinic remains a national leader in development and application of percutaneous valve approaches.

Critically ill patients and others who are not candidates for traditional valve replacement surgery because of comorbid conditions may be candidates for percutaneous aortic valvuloplasty. Many patients with severe, symptomatic aortic valve stenosis who underwent this procedure were successfully bridged to surgical aortic valve replacement.

Percutaneous Aortic Valvuloplasty Volume and Hospital Mortality

00

8080

2006

Volume

2007 2008

6060

4040

2020

00

2020

1515

1010

55

Mortality (%)

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

In 2008, Cleveland Clinic performed 16 transfemoral and 6 transapical aortic valve replacements in clinical trials.

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.

Percutaneous Aortic Valve Replacements

Transcatheter Aortic Valve Implantation

Less invasive transcatheter approaches for valve replacement/implantation are becoming a viable alternative for patients who are not considered surgical candidates because of age or significant comorbidities. Preoperative CT imaging is essential for appropriate planning of percutaneous aortic valve procedures.

CT image of the infrarenal abdominal aorta and iliac arteries. Size, tortuosity and calcification of the iliac arteries influence planning of the procedures.

Surface rendering of the root with the origin of the coronary arteries.

Cutplane through the aortic root. Virtual endoscopic view onto the aortic valve.

CT images of the aortic root

Outcomes 200832



Percutaneous Mitral Valvuloplasty Volume and Hospital Mortality

Percutaneous Mitral Valve Repair Procedures

Mitral Valvuloplasty for Mitral Stenosis

3D image of the MitraClipTM with double orifice mitral valve

3030

2020

1010

00

3030

2020

1010

002002 2003 2004 2005 2006 2007 2008

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 treatment of choice.

Percutaneous mitral valve repair is being investigated as an alternative treatment option for select patients with mitral valve regurgitation.

One repair technique involves the transcatheter delivery of a small metal clip (MitraClip™ Cardiovascular Repair System, Evalve, Inc.) introduced from the groin to immobilize the prolapsing segment of the mitral valve. Cleveland Clinic has performed 24 such procedures with 0 percent procedural mortality.

Cleveland Clinic is also participating in the PTOLEMY-2 (Percutaneous Transvenous Mitral Annuloplasty) study to evaluate the safety and efficacy of the Viacor PTMA® (Percutaneous Transvenous Mitral Annuloplasty) system, which modifies the valve annulus to reduce symptomatic functional mitral regurgitation in heart failure patients.

Balloon inflationBefore After

1,2001,200

1,0001,000

800800

00

Volume

20022000 2004 2006 2008

600600

400400

200200

Open Ascending/Arch Repair (N = 612) Open Ascending/Arch Repair (N = 612)

Open Descending/ThoracoabdominalRepair (N = 100)Open Descending/ThoracoabdominalRepair (N = 100)Endo Descending/ThoracoabdominalRepair (N = 182)Endo Descending/ThoracoabdominalRepair (N = 182)Open Abdominal Repair (N = 96)Open Abdominal Repair (N = 96)

Endo Abdominal Repair (N = 149)Endo Abdominal Repair (N = 149)

Outcomes 200834

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. In 2008, 1,139 aortic surgeries were performed.

Stratified Results

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

Aortic Surgery Volume and Distribution

Aortic Disease

ArchAscending

Descending thoracic aorta

Abdominal aorta

Thoracoabdominal aorta

43,199 – estimated number

of patients who die

annually from aortic

disease, according

to the Centers for

Disease Control and

Prevention. This

is greater than the

number of people

who die annually

from breast cancer,

homicides, pancreatic

cancer, colon cancer,

prostate cancer

and motor vehicle

accidents.

Svensson LG, Rodriguez ER. Aortic organ disease epidemic, and why do balloons pop? Editorial. Circulation. 2005 Aug 23;112(8):1082-1084.


Open Ascending Aorta and Arch Disease Surgery Volume

The number of elective and urgent/emergent proximal aortic repairs was 612 in 2008. Elective surgeries on the proximal aorta with or without aortic valve repair or replacement are increasingly being performed through a minimally invasive approach.

800800

400400

200200

001998 2000 2002 2004 2006 2008

600600

Volume

Elective Ascending Aorta and Arch Surgery Volume, Stroke and Mortality

Emergent Ascending Aorta and Arch Surgery Volume and Mortality

Cleveland Clinic’s

Acute Aortic Treatment Center provides

rapid transport, treatment

and follow-up for

patients with aortic

dissection and impending

aneurysm rupture.

The Center’s multi-

disciplinary treatment

team includes vascular

and cardiothoracic

physicians and surgeons

with expertise in aortic

emergencies.

Call 877.379.CODE

(2633) to expedite the

transfer of patients with

acute aortic syndromes.

Hospital mortality for emergent ascending aorta and arch surgery has remained low. In 2008, 335 emergent ascending aorta and arch procedures were performed, nearly one-third for acute aortic dissection.

In 2008, 277 elective ascending aorta and arch surgeries were performed. Stroke and hospital mortality remained low.

00

250250300300350350

150150200200

1001005050

00

3535

2020

3030

1515

2525

1010

Volume Volume Hospital Mortality (%)

1998 2000 2002 2004 2006 2008

5

00

500500

300300

400400

200200

100100

00

1010

66

88

44

Volume Volume Stroke (%)Hospital Mortality (%)

1998 2000 2002 2004 2006 2008

2

Outcomes 200836

Aortic Disease (continued)

Aortic Arch Repairs

Aneurysms involving the aortic arch represent one of the most complex types of aneurysms to treat because involvement of vessels supplying the cerebral circulation increases the risk of stroke. In 2008, 101 elective and 106 emergent arch operations were performed.

Elective Arch Operations Emergent and Urgent Arch Operations

Aortic Arch Hybrid Repair

In select patients, traditional operative techniques to repair lesions involving the aortic arch are potentially dangerous, while purely endovascular approaches are limited by the presence of vessels supplying the brain. Hybrid repairs combine techniques to provide the durability advantage of open surgery and the many advantages of less-invasive endovascular repair. New hybrid open/endovascular operating suites allow both stages of these procedures to be completed in one setting.

Figure 1

Aortic Arch Aneurysm

Stent Graft

Brachiocephalic Reconstruction

Conduit for Device Delivery

Figure 2

00

150150

9090

6060

3030

120120

00

1515

99

1212

66

VolumeVolumeStroke (%)Hospital Mortality (%)

2000 2002 2004 2006 2008

3

00

125125

7575

5050

2525

100100

00

2525

1515

2020

1010

VolumeVolumeStroke (%)Hospital Mortality (%)

2000 2002 2004 2006 2008

5


Descending Thoracic Aortic Disease

Aortic dissections or ruptured aneurysms commonly occur in the descending thoracic aorta (DTA) and require rapid evaluation and treatment. Cleveland Clinic’s team of aortic physicians has pioneered techniques for both surgical and endovascular repair.

DTA Repair Distribution (N = 367)

DTA Hospital Mortality (N = 367)

This CT scan shows a DTA reconstruction after placement of a stent graft.

23.4% Open Elective (N = 86)23.4% Open Elective (N = 86)

9.3% Open Emergent (N = 34)9.3% Open Emergent (N = 34)

44.1% Endo Elective (N = 162)44.1% Endo Elective (N = 162)

23.2% Endo Emergent (N = 85)23.2% Endo Emergent (N = 85)100%100%

2525

2020

1515

1010

55

00Emergent

Open

2006 - 20072008

Elective

Mortality (%)

Emergent

Endo

Elective

Mortality for elective endovascular repairs of the DTA decreased to 1.6 percent in 2008. The highest risk patients with emergent indications for repair were previously relegated to hospice care only. Our expertise with endovascular therapies has allowed us to offer this patient population a feasible treatment option, but comorbid-related risks still remain an issue in the emergent setting.

2006-2008

2006-2008

Outcomes 200838

Aortic Imaging

Cleveland Clinic’s state-

of-the-art CT imaging

equipment significantly

reduces radiation exposure during

thoracic aorta imaging.

Computed tomography imaging is a critical component of novel surgical and transcatheter treatments of aortic disease. However, its use is associated with radiation exposure and potential long-term side effects. Recent studies show substantial variability of radiation exposure among hospitals.

Recent advances in imaging technology, including wide-detector scanners, dual-source CT, low-tube voltage scanning and prospective triggering, are associated with a significant reduction in radiation dose. Using state-of-the-art equipment and optimized scan protocols, Cleveland Clinic imaging specialists carefully balance image quality and radiation exposure for each patient.

Adapted from: Gerber TC et al. Ionizing radiation in cardiac imaging: a science advisory from the American Heart Association Committee on Cardiac Imaging of the Council on Clinical Cardiology and Committee on Cardiovascular Imaging and Intervention of the Council on Cardiovascular Radiology and Intervention. Circulation 2009 Feb 24;119(7):1056-65.

Based on study data published between 1980 and 2007; coronary CTA data from studies published since 2005. Dose data may not reflect newest scanners and protocols.

Representative Effective Range of Reported Examination Dose (mSv) Effective Dose Values (mSv)

Chest X-ray 0.1 0.05-0.24

CT chest 7 4-18

Invasive coronary angiogram 7 2-16

Coronary CTA (64-slice with tube modulation) 9 8-18


3D reconstruction of aorta from 1-mm axial CT slices.

3D workstation depiction of lumen of blood flow of aorta.

Straightened view of aorta, improving accuracy of measurement for endovascular graft planning.

Center Line Flow of an Aortic Aneursym


Distribution of TAA Surgeries

Thoracoabdominal Aortic (TAA) Surgeries

Diseases of the thoracoabdominal aorta (TAA) are the most difficult to treat because of their complexity, as well as the risk of major complications and mortality. The expertise of Cleveland Clinic surgeons in both open and endovascular TAA approaches allows treatment plans to be tailored for each patient.

8080

6060

4040

2020

00Type I Type II

EndovascularOpen

Type III Type IV

Percent

Studies have shown that

elective endovascular

treatment of descending

thoracoabdominal aortic

aneurysms compares favorably with open

surgical techniques. Please see

page 41 for more information.

Type I aneurysms involve most or all of the descending thoracic aorta to the level of the renal arteries.

Type IV aneurysms involve the upper half or all of the abdominal aorta.

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 II aneurysms involve most or all of the descending thoracic aorta, with abdominal extension to below the renal arteries.

Crawford Classification of Aortic Aneurysms

Reference: Greenberg RK, Lu Q, Roselli EE, et al. Contemporary analysis of descending thoracic and thoracoabdominal aneurysm repair: a comparison of endovascular and open techniques. Circulation. 2008 Aug 19;118(8):808-817.

2006-2008

40 Outcomes 2008


Thoracoabdominal Aortic Aneurysm (TAAA) Surgery Volume and Distribution (N = 385)

TAAA Surgery Mortality

5050

4040

3030

2020

1010

00

Elective TAAA Emergency

OpenEndovascular

Percent

Open

Mortality for endovascular branch vessel procedures was 5.5 percent from 2006 to 2008. The majority of emergency TAAA procedures still require an open approach.

Cleveland Clinic treats

the world’s largest

volume of patients

with thoracoabdominal

aneurysms using

endovascular stent-grafts.

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.

From 2006 to 2008, 385 procedures were performed to treat thoracoabdominal aneurysms.

43% Open Surgeries (N = 166)43% Open Surgeries (N = 166)

57% Endovascular Branch Vessel Grafts (N = 219)57% Endovascular Branch Vessel Grafts (N = 219)

100%100%

Thoracoabdominal Aneurysm Stent-Graft

2006-2008

2006-2008

Leapfrog Survey – Abdominal Aortic Aneurysm Repair Quality January – December 2007

The Leapfrog Group encourages transparency and easy access to healthcare information. Participation in the annual Leapfrog Hospital Quality and Safety Survey is voluntary. Cleveland Clinic’s abdominal aortic aneurysm repair surgery rating appears above.








In a 2008 Cleveland Clinic study published in Circulation, we compared the results of 352 patients who had endovascular aneurysm repair of descending or thoracoabdominal aortic aneurysms (TAAA) with those of 372 patients who had open repair, focusing on mortality and spinal cord injury. Results showed similar prevalence of paraplegia and 30-day and 12-month mortality, regardless of repair technique.

The highest risk for death and spinal cord injury was most closely correlated with the extent of the aneurysm, regardless of repair technique; patients with type II TAAA had the highest risk, and patients who had aneurysms confined to the thoracic aorta had the lowest risk.

Based on our research, endovascular repair of extensive aneurysms can produce similar results to open surgical techniques, even in patients who are older and have more comorbidities.

Endovascular Treatment Approaches for Complex Aortic Diseases

Adapted from: Greenberg RK, Lu Q, Roselli EE, et al. Contemporary analysis of descending thoracic and thoracoabdominal aneurysm repair: a comparison of endovascular and open techniques. Circulation. 2008 Aug 19;118(8):808-817.70

80

90

100

4

Open Surgery (N = 372)

Endovascular Surgery (N = 352)Log-rank p value: 0.6

0 1 3

Years after Surgery

2

Survival (%)

65

Anterior and lateral views of a 3D reconstruction of a type II TAAA treated with a branched endovascular graft. The celiac and superior mesenteric branches (white arrows) are attached to the aortic graft as a side arm and oriented in the direction of the mesenteric vessel.

Outcomes 200842


Open Abdominal Aortic Aneurysm Repair

Abdominal Aortic Aneurysms (AAA)

Aside from the ascending aorta, the abdominal aorta is the most frequent site for aneurysm formation.

Cleveland Clinic uses endovascular and open surgery techniques to treat patients with AAA.

From 2006 to 2008, mortality for elective AAA endovascular repair was 1.7 percent and mortality for elective AAA open repair was 2.5 percent. This patient cohort includes those who have an AAA below the level of the renal arteries as well as those with aneurysms adjacent to the renal arteries.

AAA Procedure Volume and Distribution (N = 715)

From 2006 to 2008, 715 AAA repair surgeries were performed, and the majority were endovascular (endo and fenestrated grafts) repairs.

37% Open (N = 267)37% Open (N = 267)

63% Endovascular (N = 448)63% Endovascular (N = 448)

100%100%

Open AAA Repair Volume and Distribution (N = 267)

From 2006 to 2008, 267 open AAA repairs were performed.

2006-2008

2006-2008

13% Emergent (N = 34)13% Emergent (N = 34)

87% Elective (N = 233)87% Elective (N = 233)100%100%

Open aneurysm repair

is becoming more

complicated due to

infection, presence of

dissection and other

anatomic factors that

increase surgical

risks. Despite these

risks, the aortic

surgeons at Cleveland

Clinic continue to

maintain a large volume of open repairs with

superior results.


Mortality for patients with

juxtrarenal aneurysms

treated with fenestrated

graft procedures (N = 61)

was 0 percent from

2006 to 2008.

Endovascular AAA Repair Volume and Distribution (N = 448)

Of the 422 elective endovascular AAA repair procedures performed from 2006 to 2008, 61 fenestrated graft procedures were performed to repair juxtrarenal aneurysms.

Endovascular AAA Repair Mortality

2020

1616

1212

88

00Elective Emergent

44

Percent

Even in the setting of acute aortic aneurysm emergencies, mortality was low at 15 percent.

5.8% Emergent (N = 26)5.8% Emergent (N = 26)

94.2% Elective (N = 422)94.2% Elective (N = 422)100%100%

Open AAA Repair Mortality

4040

3030

2020

1010

00Elective

(N = 233)Emergent(N = 34)

Percent

From 2006 to 2008, mortality for elective AAA open repair was 2.5 percent, and mortality for emergent open repair of ruptured AAAs was 35 percent.

2006-2008

2006-2008

2006-2008

Outcomes 200844

Adult Congenital Heart Disease

2008 Volume

Total Adult Congenital Heart Disease Patient Visits 798

New Referral Visits for Adult Congenital Heart Disease 250

The Adult Congenital Heart Disease Clinic collaborates with pediatric and adult cardiologists, interventional cardiologists and cardiovascular surgeons to provide expert care to this specialized patient population.

Treatment for tetralogy of Fallot, the most common form of cyanotic congenital heart disease and the second most common referral to the Adult Congenital Heart Disease Clinic, demonstrates our multi-disciplinary approach. In addition to pulmonic valve repair and replacement, we continue to offer novel approaches to safely repair aortic aneurysms, including valve-sparing techniques and state-of-the-art surgical and percutaneous electrophysiologic therapies for this patient population.

We are also pioneering a medical approach to treating regurgitant pulmonic valves through continued recruitment in the Cleveland Clinic-based PINOT NOIR (Pulmonic INsufficiency imprOvemenT with Nitric Oxide Inhalational Response) trial.

Adult Congenital Heart Disease

Collateral vessels can be successfully closed using a minimally invasive transcatheter approach and occlusion devices such as the Amplatzer® Vascular Plug.

The many long-term complications of tetralogy of Fallot, including heart enlargement from unrecognized aorta disease due to aortopulmonary collateral vessels, are diagnosed and treated in the Adult Congenital Heart Disease Clinic.


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

Pulmonary Artery ReopeningThese images show a successful percutaneous reopening

of the pulmonary artery, which had likely been nearly

completely occluded for years, in a patient with repaired

tetralogy of Fallot and worsening cyanosis.

Interventional Procedures for Adult Congenital Heart Disease2008 Volume and Outcomes

Congenital/Pulmonary Hypertension Cases 216

Vasodilator Challenges 72

Complex Congenital Cases 135

Complex Congenital Interventions 78

Success Rate 100%

30-Day Mortality 0%

Percutaneous Closure Procedures2008 Volume and Outcomes

Percutaneous ASD Closures 19

Percutaneous PFO Closures 58

Success Rate* 99%

30-day Mortality 1%

Patients Requiring Repeat Procedure 1%

Adult Congenital Heart Surgery2008 Volume and Mortality

Adult Congenital Heart Surgeries* 56

Mortality 0%

* Including coarctation repair, ASD patch repair, VSD repair, Fontan procedure, vascular ring, septal defect repair, aortic valve repair and replacement, pulmonic valve replacement, Tetralogy of Fallot with pulmonary atresia repair, right ventricle to pulmonary artery conduit surgery, Blalock-Taussig shunt, and subaortic stenosis repair.

Note the 2008 volume is lower than the volume reported in 2007 due to changes in the reporting guidelines for congenital surgeries.

Hypertrophic Obstructive Cardiomyopathy

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.

Patient Volume

2008

Total HOCM Outpatient Visits 712

New HOCM Patients 190

200

150

0

100

50

1998 2000 2002 2004 2006 2008

Volume

Surgical Volume and Outcomes

2008

Isolated Myectomy and Concomitant Myectomy Procedures 168

Hospital Mortality 0.6%

Since 1967,

1,691 septal myectomies

have been

performed at

Cleveland Clinic.

Disarray of heart muscle cell pattern that occurs with HOCM. This irregular, disorganized cell pattern may interrupt the electrical signals in the ventricles, leading to ventricular arrhythmia.

Illustration of normal, organized, parallel heart muscle cell pattern. Septal Myectomy

Outcomes 200846

Cleveland Clinic has one of the largest surgical practices for treating HOCM. In 2008, Cleveland Clinic surgeons performed 168 septal myectomy surgeries. Of those, 154 were for patients with HOCM. Hospital mortality has been consistently low.

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

Outflow Tract Obstruction Without Septal Hypertrophy

Severe outflow tract obstruction can occur without septal hypertrophy, especially in young patients. Advanced imaging with MRI and stress echocardiography can identify this anomaly, and in most cases it can be treated with subvalvular repair.

Septal Myectomy and Concomitant Procedure Distribution (N = 168)2008

HOCM is an uncommon but serious problem, especially when associated with mitral valve dysfunction. In 2008, 42 percent of septal myectomies were performed in conjunction with a valve procedure.

Papillary muscles directed toward septum

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

100%100%

8.9% Septal Myectomy + Coronary Artery Bypass (N = 15)5.4% Septal Myectomy + Valve Surgery + Coronary Artery Bypass (N = 9)

36.3% Septal Myectomy + Valve (N = 61)

31.5% Isolated Septal Myectomy (N = 53)

17.9% Septal Myectomy + Other (N = 30)



Heart Failure and Transplant

Waiting List Mortality In 2008, Cleveland

Clinic’s waiting list

mortality (per year

on wait list) was

consistently lower than

the national median

wait list mortality of

0.18 percent.

Source: SRTR. Center and OPO-Specific Reports, January 2009. Ohio, Heart Centers, Cleveland Clinic. Table 4. www.ustransplant.org/csr/current/csrDefault.aspx

1,409 Number of adult heart

transplants performed

at Cleveland Clinic

since inception of the

Cardiac Transplant

Program in 1984.

100

Survival (%)

90

80

70

501 year

1/1/05 to 6/30/073 years

1/1/03 to 6/30/05

Expected*Observed

60

Time After Transplant

Heart Transplant Survival 2003-2007

The January 2009 report of the Scientific Registry of Transplant Recipients (SRTR) demonstrates that Cleveland Clinic achieved better-than-expected patient survival at one year and three years post-transplant.

Cleveland Clinic’s Cardiac Transplant Program remains the leading center in both Ohio and the Midwest, and is the third largest transplant program in the U.S.

Heart Transplant Volume and Distribution

*Expected based on risk adjustment Source: SRTR. Center and OPO-Specific Reports, January 2009. Ohio, Heart Centers, Cleveland Clinic. Table 11. www.ustransplant.org/csr/current/csrDefault.aspx

2006 2007 20082004 2005

Volume

0

80

60

40

20

Cleveland Clinic performed 60 adult heart transplants in 2008.

Sydell and Arnold Miller Family Heart & Vascular Institute 49Sydell and Arnold Miller Family Heart & Vascular Institute 49

5Median Months

4

3

2

0Cleveland

ClinicRegion

1

United States

Median (50th percentile) months to transplant for patients registered on wait list between 7/1/02 and 12/31/07. Our waiting times are consistently lower than the regional and national averages.

Source: SRTR. Center and OPO-Specific Reports, January 2009. Ohio, Heart Centers, Cleveland Clinic. Table 6. www.ustransplant.org/csr/current/csrDefault.aspx

Reduced Waiting Time for Heart Transplant7/1/02 to 12/31/07

Source: SRTR. Center and OPO-Specific Reports, January 2009. Ohio, Heart Centers, Cleveland Clinic. Table 3. www.ustransplant.org/csr/current/csrDefault.aspx *Number of transplants per year of wait time. Based on data available as of 10/31/08. **Adjusted for age, blood type, medical urgency status, time on the waiting list and previous transplantation.

Transplant Rate Among Waitlist Patients7/1/06 to 6/30/08

2.0

1.5

1.0

0Observed

Transplant Rate*Expected

Transplant Rate**

.5

Percent

Cleveland ClinicRegionUnited States

The observed transplant

rate at Cleveland Clinic

is statistically higher than the

expected transplant rates

of the region and the

nation.

Outcomes 200850

Heart Failure and Transplant (continued)

Mechanical Circulatory Support (MCS) Devices

Strategies for Mechanical Circulatory Support

2008

50

40

02004 2005 2006 2007 2008

24N = 33 22 26 48

30

10

20

Volume

17% Destination Therapy17% Destination Therapy

83% Bridge to Transplant83% Bridge to Transplant100%100%

As a bridge to transplant, MCS devices allow patients to be discharged to an outpatient setting while awaiting transplant. In 2008, the majority of implanted devices were bridge to transplant.

Destination therapy provides long-term, permanent support in patients with end-stage heart failure who are not candidates for transplant.

Cleveland Clinic has nearly 20 years of experience with mechanical circulatory support (MCS) devices. In 2008, 48 MCS devices were implanted, including 41 left ventricular assist devices (LVAD), five total artificial hearts, and two right ventricular assist (RVAD) and LVAD combination devices. Access to and expertise with four support devices allows us to utilize the optimal device in each patient.

511MCS devices have

been implanted in 466

patients since 1990.

Image courtesy of Thoratec Corp.

Image courtesy of HeartWare, Inc.

HVAD™ Pump

Heartmate II LVAS


Survival to Transplant: Patients Who Received Bridge-to-Transplant MCS Devices

Survival after MCS Device Implant: Destination Therapy

100

80

60

40

20

03 Months 6 Months1 Month

Survival (%)

2008 (N = 40)2004 (N = 16)

100

80

60

40

20

03 Months 6 Months1 Month

Survival (%)

2008 (N = 8)2004 (N = 3)

*Numbers too

few formeaningful

analysis

Cleveland Clinic Earned VAD Advanced Certification

In December 2008, Cleveland Clinic earned advanced certification in Ventricular Assist Device (VAD) therapy from The Joint Commission. Cleveland Clinic is one of only two healthcare organizations in Ohio to earn this distinction.

This certification is based on a review of compliance with national standards, clinical guidelines and outcomes of care. The program is evaluated against Joint Commission standards through an assessment of the program’s processes, the program’s ability to evaluate and improve care within its own organization, and interviews with patients and staff.

52 Outcomes 2008

0 20

* Source: www.hospitalcompare.hhs.gov, discharges July 2007- June 2008

40 60 80 100

Percent of Patients

NationalAverage*

ClevelandClinic

73

83

0 20


40 60 80 100

NationalAverage*

ClevelandClinic

88

100

Percent of Patients

Heart Failure and Transplant (continued)

Hospital Compare: Heart Failure

Hospital Compare is a consumer-oriented website hosted by the Centers for Medicare & Medicaid Services in collaboration with the Hospital Quality Alliance. Hospitals that have agreed to public reporting submit process-of-care data showing how consistently they provide recommended care to adult patients, irrespective of payer. (These results also are posted on The Joint Commission’s website.) Thirty-day risk-adjusted all-cause mortality is an outcome based on Medicare claims and enrollment information. Cleveland Clinic’s heart failure care performance appears below.

Heart Failure - Discharge Instructions Provided (N = 847)


Heart Failure - Left Ventricular Systolic Function Evaluated (N = 980)


*Source: www.hospitalcompare.hhs.gov, discharges July 2007 - June 2008


0 20


40 60 80 100

NationalAverage*

ClevelandClinic

88

91

Percent of Patients0 20


40 60 80 100

NationalAverage*

ClevelandClinic

90

98

Percent of Patients

0

2

* Source: www.hospitalcompare.hhs.gov, discharges July 2006 - June 2007

4

6

8

10

12

Percent

National Average*

11

8

Cleveland Clinic

Heart Failure - Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (N = 383)


Heart Failure - Adult Smoking Cessation Advice/Counseling Given (N = 177)


Heart Failure - 30-Day Mortality (N = 255)

Discharges July 2006 – June 2007

ACE = Angiotensin Converting Enzyme ARB = Angiotensin Receptor Blocker

*Source: www.hospitalcompare.hhs.gov, discharges July 2007 - June 2008 *Source: www.hospitalcompare.hhs.gov, discharges July 2007 - June 2008

*Source: www.hospitalcompare.hhs.gov, discharges July 2006 - June 2007

Outcomes 200854

Lung and Heart-Lung Transplant

In 2008, Cleveland Clinic performed 29 double-lung transplants and 28 single-lung transplants. Cleveland Clinic’s lung transplant volume continues to increase; 63 lung transplants have been performed from 1/1/09 through 4/30/09.

Lung Transplant Procedures

8080Liver-LungHeart-LungDouble LungSingle Lung

Liver-LungHeart-LungDouble LungSingle Lung

6060

00

Volume

2002 20042003 2006 2007 20082005

4040

2020

Primary Disease of Lung Transplant Recipients (N = 61)

Source: Scientific Registry of Transplant Recipients. Center and OPO-Specific Reports, January 2009. Ohio, Lung Centers, Cleveland Clinic. Table 7. www.ustransplant.org/csr/current/csrDefault.aspx

Cleveland Clinic’s Lung Transplant Program is the leading program in Ohio and among the top programs nationally. Patients are referred from across the nation and internationally for lung and heart-lung transplantation.

52.5% Idiopathic Pulmonary Fibrosis (N = 32)52.5% Idiopathic Pulmonary Fibrosis (N = 32)

37.7% Emphysema/COPD (N = 23)37.7% Emphysema/COPD (N = 23)

4.9% Cystic Fibrosis (N = 3)4.9% Cystic Fibrosis (N = 3)4.9% Idiopathic Pulmonary Arterial Hypertension (N = 3)4.9% Idiopathic Pulmonary Arterial Hypertension (N = 3)

100%100%

7/1/07 to 6/30/08

Cleveland Clinic is on the forefront in utilizing

bridge-to-transplant technology for patients with end-stage pulmonary disease.

In 2008, 3 patients received lung transplants directly off of extracorporeal membrane oxygenation (ECMO).


Waiting List Mortality*

Lung Transplant Survival

Reduced Waiting Time for Lung Transplant

Median (50th percentile) months to transplant for patients registered on wait list between 7/1/02 and 12/31/07.

Cleveland Clinic’s waitlist mortality for lung transplant remains low.

1515

1010

55

00Cleveland Clinic Region United States

Median Months

Source: SRTR. Center and OPO-Specific Reports, January 2009. Ohio, Lung Centers, Cleveland Clinic. Table 3. www.ustransplant.org/csr/current/csrDefault.aspx

Cleveland Clinic lung transplant survival is comparable with the expected national experience.

*Expected based on risk adjustment. The difference between observed and expected survival is not statistically significant.



*The difference between observed and expected mortality is not statistically significant.

100Survival (%)

80

60

40

01 month

Time After Transplant

3 years1/1/03 to 6/30/05

1 year

Expected*Observed

20

1/1/05 to 6/30/07

2003-2007

7/1/02 to 12/31/07

7/1/06 to 6/30/08

1.0Mortality (%)

.8

.6

07/1/06 to 6/30/07

(N = 17)7/1/07 to 6/30/08

(N = 56)

Expected*Observed

.4

.2

Peripheral Arterial Disease

Lower Extremity Interventional Procedures (N = 2,252)

Our vascular surgeons and interventional cardiologists are skilled in performing procedures on the peripheral arteries, including angioplasty, atherectomy, stenting, thrombectomy and thrombolysis.

Lower Extremity Surgery Volume (N = 307) and Mortality

Our vascular surgeons specialize in performing peripheral artery bypass surgery and strive to use autologous vein grafts. In 2008, 149 lower extremity bypass surgeries were performed with a 0 percent 30-day mortality.

2008 Volume

Bypass 149

Thrombectomy 158

Lower Extremity Interventional Procedure Volume

2008

Angioplasty 1,193

Atherectomy 83

Stenting 751

Thrombolysis 225

Diagnostic Procedure Volume

2008

Non-invasive Vascular Ultrasounds 28,664

Phlebotests* 111

*Phlebotest is a comprehensive venous physiologic examination using air plethysmography and an automated positioning chair. The test is used to assess lower extremity venous obstruction, valvular incompetency and calf muscle pump dysfunction.

28,664non-invasive vascular

ultrasounds were

performed in 2008.

100%100%

13% Physiologic Testing

5% Evaluation of Mass 7% Renal/Mesenteric Duplex

9% Other*

49% Venous Duplex

17% Carotid Duplex and CIMT

Non-Invasive Vascular Lab Ultrasound Study Distribution (N = 28,664)

2008

CIMT = carotid intimal media thickness *Other = vein mapping, arterial mapping (mammary artery), arterial duplex and valvular incompetency

Outcomes 200856

2008 30-day Mortality (%)

Bypass 0

Lower Extremity Wound Clinic

There were 1,235 patients treated by specialists in the Lower Extremity Wound Clinic in 2008. These “before and after” photos demonstrate the treatment expertise and positive results that compliant patients were able to achieve.

This female patient, aged 74, is a heavy smoker with atherosclerosis and suspect plaque emboli to both feet. Wound management consisted of aggressive pain management, serial debridement and multiple topical treatments, including advanced composite dressings and skin substitutes. After about nine months of treatment at the Lower Extremity Wound Clinic, the wound healed as shown above.

This female patient, aged 71, had a history of peripheral arterial disease treated with intervention. Her wound management consisted of aggressive sequential wound debridement, including bone, IV antibiotic therapy and negative pressure wound therapy. After about four months of therapy at the Lower Extremity Wound Clinic, the wound healed and remains healed to date.

Before treatment After four months of treatment Before treatment After nine months of treatment

Fibromuscular Dysplasia

Fibromuscular dysplasia is an uncommon disorder characterized by abnormal cellular growth in the walls of medium and large arteries. This abnormal cellular growth may lead to a beaded appearance of the affected artery and narrowing (stenosis) in some cases.

From 2007 through 2008, 435 patients with a primary or secondary diagnosis of fibromuscular dysplasia were treated in the Miller Family Heart & Vascular Institute.

The classic “beads on a string” appearance is typical of medial fibroplasia, the most common type of FMD. In this case, there is mild to moderate narrowing of the artery.

The smooth, concentric narrowing (arrow) has the typical appearance of intimal fibroplasia. In this case, there is severe narrowing of the artery. The patient was treated with balloon angioplasty.

Fibromuscular Dysplasia (FMD) of the Right Renal Artery


Venous Disease

Cleveland Clinic vascular medicine physicians and vascular surgeons offer a full range of therapies for venous diseases.

Varicose Veins

Varicose veins are the most common venous disorder. Conservative therapy includes properly-fitting support stockings, skin care and a regular walking program. When this treatment regimen does not sufficiently treat the condition, determination of the precise venous abnormalities is essential in planning further therapy.

Comprehensive examinations using duplex ultrasound or the Phlebotest system are performed in the Non-invasive Vascular Laboratory. Based on the underlying pathology, treatment options include sclerotherapy, endovenous ablation with radiofrequency or laser energy sources, stab excision of varicosities and ligation of saphenous veins.

Venous Stasis Ulcers

The mainstay of venous stasis ulcer treatment is appropriate wound care and compression therapy. In addition, assessment of the cause of venous hypertension, and treatment using endoluminal therapy, angioplasty and stenting for proximal venous occlusion and endoscopic therapy for perforator incompetence are essential for promoting healing and optimizing long-term outcomes.

Endovenous Ablation Procedure

At Cleveland Clinic, endovenous ablation is the treatment of choice for valvular incompetency of the great saphenous vein. This minimally invasive procedure improves outcomes with less pain and bruising compared to vein stripping. During the procedure, radiofrequency or laser energy is applied to the inside of the diseased vein to ablate it.

Deep Vein Thrombosis (DVT)

DVT is usually treated with long-term anticoagulation, but studies suggest that the use of early thrombolysis decreases long-term complications. Consequently, thrombectomy is being used with increasing frequency at Cleveland Clinic for the treatment of DVT.

Pre-thrombolysis Post-thrombolysis

253endovenous ablations

were performed in 2008

Left to right: catheter inserted in vein, treated vein, and catheter withdrawn, closing vein.

At Cleveland Clinic,

extremity swelling

decreased in more than

60 percent of

patients with DVT who

underwent mechanical

thrombectomy in 2008.

Outcomes 200858

Cerebrovascular Disease

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

Cleveland Clinic

is investigating

innovative devices to treat

cerebrovascular diseases.

300300

200200

100100

00CarotidStenting

CarotidEndarterectomy

Cerebral VascularReconstruction

200620072008

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.

The Flow Reversal System may reduce the risk of debris reaching the brain during stent place-ment, thereby preventing stroke. Image used with permission of W.L. Gore and Associates.

*All procedures performed at Cleveland Clinic’s main campus

Embolic protection device. These devices, or filters, are placed to catch any particles that may dislodge during stent placement to treat patients at risk of stroke. Image courtesy of Abbott Vascular. ©2009 Abbott Laboratories. All rights reserved.

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

Carotid Stenting 397 0.0 2.5 0.3

Diagnostic Angiograms 670 0.3 1.2 0.0

Carotid Endarterectomy 440 2.0 3.0 0.9

2006-2008


60 Outcomes 2008

Thoracic Surgery

General Thoracic Surgery Volume and Mortality

In 2008, Cleveland Clinic thoracic surgeons performed 1,472 procedures with a low mortality of 0.9 percent. A high surgical volume translates into depth of clinical expertise.

Distribution of Thoracic Surgeries (N = 1,472)

1998 2000 2002 2004 2006 2008

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.

20% Esophagogastric (N = 296)20% Esophagogastric (N = 296)

22% Tracheobronchial (N = 324)22% Tracheobronchial (N = 324)

6% Other (N = 88)6% Other (N = 88)4% Lung Transplant (N = 57)4% Lung Transplant (N = 57)

23% Pulmonary (N = 339)23% Pulmonary (N = 339)

10% Mediastinum–Neck (N = 147)10% Mediastinum–Neck (N = 147)

15% Pleura (N = 221)15% Pleura (N = 221)

100%100%

2008


Distribution of Pulmonary Resections (N = 311)

Pulmonary Resection Mortality

Cleveland Clinic performed 311 pulmonary resections in 2008.

48% Lobectomy (N = 146)48% Lobectomy (N = 146)

39% Wedge (N = 124)39% Wedge (N = 124)

7% Segmentectomy (N = 21)7% Segmentectomy (N = 21)6% Pneumonectomy (N = 20)6% Pneumonectomy (N = 20)

100%100%

2008

44

33

22

11

002003 2004 2005 2006 2007 2008

Volume400400

300300

200200

100100

00

Mortality (%)

Leapfrog Survey – Esophageal Resection January – December 2007

The Leapfrog Group aims to reduce preventable medical mistakes and improve the quality and affordability of health care. Participation in the annual Leapfrog Quality and Safety survey is voluntary. Cleveland Clinic’s aortic valve replacement rating ap-pears above.

*Source:www.leapfroggroup.org






Outcomes 200862

Thoracic Surgery (continued)

Median Postoperative Length of Stay (Days)

00 22 44 66 88

Wedge Resection

Segmentectomy

Lobectomy

Pneumonectomy

00

44

33

1998

Percent

22

11

2000 2002 2004 20082006

Esophageal Surgery Operative Mortality

Major esophageal surgery includes resections for cancer and reoperative surgery for motility and reflux disorders. In 2008, 296 esophageal operations were performed with a low mortality of 2.4 percent.

Pulmonary Resection Length of Stay (N = 311)

Cleveland Clinic’s multidisciplinary care model results in shorter length of stay for patients.

2008


Distribution of Esophageal Surgeries by Indication (N = 296)

Esophageal Surgery Length of Stay (N = 296)

Median Postoperative Length of Stay (Days)

00 55 1010 1515

Fundoplication

Esophagectomy

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

SuperficialEsophageal Cancer

ESOPHAGECTOMY FOR SUPERFICIAL CANCER

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

45% Cancer (N = 133)45% Cancer (N = 133)

27% Reflux (N = 80)27% Reflux (N = 80)

25% Achalasia (N = 74)25% Achalasia (N = 74)

3% Other (N = 9)3% Other (N = 9)

100%100%

2008

2008

Outcomes 2008Outcomes 2008

Preventive Cardiology

2008 Volume

Prevention Outpatient Visits 5,453

Phase I Rehab 9,192

Phase II Rehab 4,332

Phase III Rehab 4,563

Primary Prevention, Statin-Tolerant Adults (N = 273*)

Secondary Prevention, Statin-Tolerant Adults (N = 277*)

160

120

80

200

1998 2000 2002 2004 2006 2008

90 mg/dL 2nd Follow-up

126 mg/dL Baseline

LDL Value

130

90

50

170

1998 2000 2002 2004 2006 2008


95 mg/dL Baseline

LDL Value

Preventive Cardiology and Rehabilitation tracks outcomes on numerous cardiovascular risk factors, including emerging nontraditional cardiac risk factors. The Cardiac Rehabilitation Program reports outcomes related to quality of life, functional capacity, blood pressure and compliance.

This graph represents median values of primary prevention for statin-tolerant adult patients in the Preventive Cardiology Program who had at least two follow-up visits in 2008.

This graph represents median values of secondary prevention for statin-tolerant adult patients in the Preventive Cardiology Program who had at least two follow-up visits in 2008.

The Women’s Cardiovascular Center provides

comprehensive cardiovascular

medical care to women, with

a focus on prevention. The

Center has special expertise

in preventive cardiology,

coronary artery disease,

vascular disease, heart

failure, pregnancy and

heart disease,

as well

as valve

disease.

The Center continues

to attract a significant

percentage of new patients to

the Cleveland Clinic for their

care. In 2008, patients from

22 states within the U.S.

were treated at the Center.

*The Preventive Cardiology Clinic works with referring physicians to help patients achieve their recommended goals. Patients are typically seen for an initial consultation and a limited number of follow-up visit(s) before returning to their primary care or referring physician. Data shown are for patients having at least two follow-up visits within the Preventive Cardiology Clinic in 2008.

64

The Weigh to a Healthy Heart is a 12-week comprehensive, medically-supervised group weight loss program with a focus on both cardiovascular disease prevention and weight loss.

Primary Prevention, Statin-Intolerant Adults (N = 196*)

Secondary Prevention, Statin-Intolerant Adults (N = 270*)

160

120

80

200

1998 2000 2002 2004 2006 2008


156 mg/dL Baseline

LDL Value

130

90

110

70

150

1998 2000 2002 2004 2006 2008


120 mg/dL Baseline

LDL Value

This graph represents median values of primary prevention for statin-intolerant adult patients in the Preventive Cardiology Program who had at least two follow-up visits in 2008.

This graph represents median values of secondary prevention for statin-intolerant adult patients in the Preventive Cardiology Program who had at least two follow-up visits in 2008.

The average weight loss of program participants is

8 to 10 pounds, with marked improvements in lipid and glucose levels.

*The Preventive Cardiology Clinic works with referring physicians to help patients achieve their recommended goals. Patients are typically seen for an initial consultation and a limited number of follow-up visit(s) before returning to their primary care or referring physician. Data shown are for patients having at least two follow-up visits within the Preventive Cardiology Clinic in 2008.


Preventive Cardiology (continued)

Preventive Cardiology Pediatric Lipid Clinic (N = 80*)2008

This graph represents patients aged <18 years in the Preventive Cardiology Program who had at least two follow-up visits in 2008. The Pediatric Lipid Clinic offers expert medication and lifestyle management for patients with genetic dyslipidemia and their families.

*Volume is representative of low population of pediatric genetic dyslipidemia patients.

300

0HDL

250

LDL Triglycerides Total Cholesterol

200

50

150

100

Value (mg/dL)

53 44

260

100

191

111

151

2nd Follow-upBaseline

181

The Pediatric Cardiology and Metabolic Clinic is a multidisciplinary team of physicians, nurse practitioners, dietitians, behavioral health specialists and exercise physiologists who take a comprehensive approach to preventing the onset/progression of cardiovascular and metabolic conditions in high-risk pediatric and adolescent patients. Our patient population includes children and adolescents with:

• Significantly elevated lipid levels and genetic lipid disorders

• Metabolic abnormalities: Body mass index above the 85th percentile and ultrasound evidence of fatty liver or presence of other risk factors

• Rheumatological diseases including juvenile arthritis, vasculitis and others

Blood Test Identifies Increased Cardiovascular Risk in Patients with no Significant Heart Disease

Cleveland Clinic researchers demonstrated that the serum protein PON1 (paraoxonase) promotes potent anti-oxidant activity and is strongly linked to protection from heart attack, stroke and death. In the study, blood measurement of PON1 was shown to predict risk for adverse cardiac conditions in individuals with no known coronary artery disease and who had just undergone an elective cardiac catheterization showing no significant heart disease.Reference: Bhattacharyya T, et al. Relationship of paraoxonase 1 (PON1) gene polymorphisms and functional activity with systemic oxidative stress and cardiovascular risk. JAMA. 2008; 299(11):1265-1276.

Outcomes 200866


Cardiac Rehabilitation

Improvement in Exercise Capacity by Exercise Stress Test

2008

For every 1 MET increase in exercise capacity, there is an 8 to 12 percent reduction in mortality from coronary artery disease. In our cardiac rehabilitation participants, this translates to a 15 percent average reduction in mortality.

Cardiac Rehabilitation Improvement in Quality of Life Assessment (N = 644*)

2008

60

0

50

Cardiac Rehab Entry Cardiac Rehab Exit

40

10

30

20

Mental Summary Score Absolute ChangesPhysical Summary Score

*2008 data from the Short Form, 36-Item (SF36) Health Status Survey. Both the physical and emotional components of wellness improved after Cleveland Clinic patients participated in the 12-week cardiac rehabilitation program.SF36 is a validated quality of life measure used to track overall wellness in cardiac rehabilitation.

10

0Pre-Cardiac Rehab

Peak METs

METs

Post-Cardiac RehabPeak METs

8

2

6

4

Anxiety and depression often

affect patients with cardiovascular

disease, hindering their recovery

and motivation, as well as affecting

their quality of life and prognosis.

Up to 20 percent of cardiac

patients have signs and symptoms

of clinical depression.

The Cardiovascular Behavioral Health Clinic offers consultations

for depression/anxiety to patients

within the Preventive Cardiology

and Rehabilitation Program.

A psychiatrist on staff and on

site evaluates patients and

makes appropriate treatment

recommendations and referrals.

MET = Metabolic equivalent, or the ratio of the working metabolic rate to the resting metabolic rate

In 2008, the Cardiovascular Behavioral Health Clinic expanded to other sections of Cardiovascular Medicine.


Outcomes 200868

Cardiothoracic Anesthesiology

One of the Surgical Care Improvement Project pay for reporting measures is the 6 a.m. glucose following surgery. We have taken this a step further, reporting the percentage of patients who maintain all blood glucose readings within a desired therapeutic range.

One consequence of increasingly aggressive attempts at tight intraoperative blood glucose control in other institutions has been an increase in morbidity and mortality, possibly related to episodes of hypoglycemia. We have not observed morbidity attributed to hypoglycemia, but continue to track episodes of mild hypoglycemia to avoid this unintended consequence.

Cleveland 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 pain control modalities.

Postoperative Pain Control for Patients Who Had Thoracotomy and Laparotomy Procedures (N = 3,945)

Postoperative Glucose Control

Episodes of Mild Hypoglycemia

2008 48-Hour Pain Score

Glucose Control in Cardiac Surgery Patients (N = 3,352)Percent with All ICU Glucoses In Control (between 65 and 200 mg/dL)

Glucose Control in Cardiac Surgery Patients (N = 3,352)Percent with at Least One ICU Glucose < 65

00

100100

Non-Diabetic2,533N =

Percent

Diabetic819

All Patients3,352

6060

8080

4040

2020

00

5050

Non-Diabetic2,533

Percent

Diabetic819

All Patients3,352

3030

4040

2020

1010

N =

0 1 2 3 4 5 6 7 8 9 10

100100

7575

5050

2525

00

PercentPercent

Pain ScorePain Score

Cumulative Percent

2008

2008


Postoperative Normothermia

100100

8080

6060

4040

2020

002003 2004

<35.5 oC≥35.5 oC

2005 2006 2007 2008

Percent

Postanesthesia hypothermia (<35.5 °C) has been associated with a significant increase in morbid cardiac events in patients at risk. In other patient subsets, (gastrointestinal surgery) postoperative normothermia has been proposed as a pay for performance measure. This graph shows that the majority of our patients were normothermic upon arrival to the ICU.

Reference: Frank SM, et al. Perioperative maintenance of normothermia reduces the incidence of morbid cadiac events. A randomized clinical trial. JAMA 1997. Apr 9;277(14):1127-1134.

One outcomes measure collected from medical record review is the prevalence of postoperative nausea or vomiting. Management of postoperative nausea and vomiting is part of the department’s clinical quality improvement program. There has been a reduction in postoperative nausea and vomiting as a result of improved anesthesia management.

Postoperative Nausea and Vomiting Within 24 Hours after Vascular Surgery (N = 912)

Immediate Postoperative Core TemperatureCardiac (Excluding Bypass*), Thoracic ICU, Thoracic PACU

*Patients undergoing cardiopulmonary bypass have been excluded, given the complexity of optimal temperature management following bypass.

100100VomitingNausea OnlyNeither Nausea or Vomiting

VomitingNausea OnlyNeither Nausea or Vomiting

6060

00

Percent

1st

Quarter

2nd 3rd 4th

4040

2020

8080

2008

2008

Outcomes 200870

Hospital Compare: Surgical Care Improvement Project (SCIP)

SCIP - Prophylactic Antibiotic Received within 1 Hour Prior to Surgical Incision (N = 902)


Hospital Compare is a consumer-oriented website hosted by the Centers for Medicare & Medicaid Services (CMS) in collaboration with the Hospital Quality Alliance (HQA). Hospitals that have agreed to public reporting submit process-of-care data showing how consistently they provide recommended care to adult patients, irrespective of payer. (These results also are posted on The Joint Commission’s website.) Thirty-day risk-adjusted all-cause mortality is an outcome based on Medicare claims and enrollment information. Cleveland Clinic’s 2008 surgical care performance appears below.

SCIP - Prophylactic Antibiotic Discontinued within 24 Hours After Surgery End Time (N = 813)


Surgical Quality Improvement

0 20 40 60 80 100

NationalAverage*

ClevelandClinic

84

82

Percent of Patients

0 20 40 60 80 100

Percent of Patients

NationalAverage*

ClevelandClinic

86

95



SCIP - Appropriate Prophylactic Antibiotic Selection for Surgical Patients (N = 937)


SCIP - Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered (N = 677)


SCIP - Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis within 24 Hours Prior to Surgery to 24 Hours after Surgery (N = 677)


0 20 40 60 80 100

NationalAverage*

ClevelandClinic

81

95

Percent of Patients* Source: www.hospitalcompare.hhs.gov, discharges July 2007- June 2008

0 20 40 60 80 100

NationalAverage*

ClevelandClinic

84

96

Percent of Patients

0 20


40 60 80 100

NationalAverage*

ClevelandClinic

92

95

Percent of Patients

Outcomes 200872

National Surgical Quality Improvement Project - Vascular Surgery (N = 320)

The American College of Surgeons’ National Surgical Quality Improvement Project is a national program that objectively measures surgical outcomes. Based on a defined sampling and abstraction methodology, risk-adjusted 30-day outcomes are reported. Cleveland Clinic’s most recent vascular surgery results appear above.

30-Day Mortality 30-Day Morbidity* Surgical Site Infection0

10

20

30

Percent

ExpectedObserved

*Significantly different at 99% confidence interval

July 1, 2007 - June 30, 2008

SCIP - Surgery Patients with Appropriate Hair Removal (N = 1,386)


Surgical Quality Improvement (continued)

0 20 40 60 80 100

NationalAverage*

ClevelandClinic

95

94

Percent of Patients



Patient Experience

Excellent Very Good Good

2007 (N = 6,591)2008 (N = 6,667)

Fair Poor

PercentPercent

00

100100

6060

8080

4040

2020

Outpatient – Miller Family Heart & Vascular Institute

Rating of Outpatient Provider 2007-2008

Recommend Outpatient Provider 2007-2008

Overall Rating of Outpatient Care and Services 2007-2008


2007 (N = 6,591)2008 (N = 6,667)

Fair Poor

PercentPercent

00

100100

6060

8080

4040

2020


2007 (N = 6,591)2008 (N = 6,667)

Fair Poor

PercentPercent

00

100100

6060

8080

4040

2020

Cleveland Clinic has placed a renewed emphasis on improving the patient experience by establishing the role of Chief Experience Officer. Recognizing that patients seek more than solely a successful clinical outcome, the mission of the Office of Patient Experience is to create an environment that enhances the well-being of our patients, families and employees in a way that elevates Cleveland Clinic’s reputation as one of the world’s best hospitals.

In 2008, the Office of Patient Experience dedicated teams within the institutes to research and implement innovative patient- and family-based programs that support this mission.

Rooftop Pavilion

Source: Quality Data Management, a national hospital survey vendor

Inpatient – Miller Family Heart & Vascular Institute

With the support of the Centers for Medicare and Medicaid Services (CMS) and its partner organizations, the first national standard patient experience hospital survey (HCAHPS) was implemented in late 2006. Results collected for reporting are available at www.hospitalcompare.hhs.gov.

HCAHPS Overall Assessment 2007-2008

HCAHPS Domains of Care 2007-2008

Rate Hospital% respondents

choosing 9 or 10

Would Recommend% respondents choosing

‘Definitely Yes’

2007 (N = 2,247)2008 (N = 3,049)

PercentPercent

00

70%70% 72%72% 81%81% 82%82%100100

6060

8080

4040

2020

Source: Quality Data Management and Press Ganey, national hospital survey vendors

For comparison purposes, 2007 and Q1 2008 HCAHPS scores have been adjusted to account for a survey mode administration change as recommended by CMS.

Outcomes 200874

100

80

0

60

40

20

Percent

Percent Respondents choosing 'always' or 'yes'

Respondents choosing 'always' or 'yes'

DischargeInformation

Doctor Communication

Nurse Communication

PainManagement

RoomClean

CommunicationNew Medications

Responsivenessto Needs

2007 (N = 2,247)2008 (N = 3,049)

Quiet atNight

Source: Quality Data Management and Press Ganey, national hospital survey vendors

For comparison purposes, 2007 and Q1 2008 HCAHPS scores have been adjusted to account for a survey mode administration change as recommended by CMS.

Patient Experience

Inpatient Satisfaction, Vascular Surgery Anesthesia

2008

A question in the interview obtained during postoperative rounds on postoperative day two asks for the patient’s response to the statement “I was satisfied with my anesthesia care.” The percentages by calendar quarter of vascular surgery patients responding “Agree very much,” the highest rating, are shown here.

1st

(N = 67)2nd

(N = 84)3rd

(N = 63)4th

(N = 66)

Calendar Quarter 2008

Percent Very SatisifiedPercent Very Satisified

00

100100

6060

8080

4040

2020


The Cleveland Clinic Arts & Medicine Institute sponsors a variety of musicians who perform on the Rooftop Pavilion, located on the top floor of the Miller Family Pavilion, as well as in the building’s main lobby.

Innovations

New Generation Heart Assist Device

Cleveland Clinic continues to offer the newest mechanical

circulatory assist devices available to support patients

with advanced heart failure. We have implanted over 500

devices to date, including 48 in 2008. Cleveland Clinic is

participating in a bridge-to-transplant trial for the HeartWare®

Ventricular Assist System, which features the HVAD™ Pump,

a full output miniaturized device. This device is designed to

be implanted in the pericardial space, avoiding the abdominal

surgery generally required to implant other assist devices. This

less invasive implantation technique is expected to lead to

relatively short surgery time and faster recovery.

Images courtesy of HeartWare, Inc.

Outcomes 200876

Cleveland Clinic Innovation Center

Cleveland 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.

The Atrial Fibrillation Innovation Center

The Atrial Fibrillation Innovation Center (AFIC), a state-funded Wright Center of Innovation, now

operates under the GCIC, continuing its efforts to improve the diagnosis and treatment of atrial

fibrillation. AFIC has assembled a multidisciplinary team of accomplished laboratory and clinical

researchers at Ohio’s leading academic research institutions and operates a state-of-the-art

preclinical facility.


Global Cardiovascular Innovation Center

The Global Cardiovascular Innovation Center (GCIC) is a cardiovascular product development consortium made possible through a $60 million grant from the State of Ohio’s Third Frontier Project. GCIC is led by Cleveland Clinic and is linked with other Ohio-based, world-class academic healthcare facilities and economic development groups to promote the commercialization of new cardiovascular technology and the creation of new companies in Ohio.

2008 was a year of major accomplishment for the core GCIC initiatives – formation, expansion, attraction and retention of businesses in Ohio. GCIC awarded commercialization grants totaling $3.5 million to nine companies, bringing the total number of GCIC-funded projects to 31 with an investment of $10.5 million to date. Additionally, GCIC awarded its first grant to assist a foreign cardiovascular company in establishing operations in Ohio. GCIC portfolio companies reported significant growth, adding more than 50 incremental jobs and securing millions of dollars of outside funding.

Several Cleveland Clinic spinoff companies benefit from GCIC funding and support, including:

Clear Catheter Systems: Featuring clot-free indwelling drainage catheters for use after cardiac surgery.

Cleveland Heart: Featuring ventricular assist systems for patients with terminal heart failure who are unresponsive to conventional therapies.

Juventas Therapeutics: Featuring cell-based, regenerative therapies for treating heart attack and heart failure.

Navis Medical: Featuring guide wire technology for invasive peripheral vascular procedures that improves endovascular navigation and eliminates or reduces the need for multiple catheters and wires.

PrognostiX: Featuring molecular biomarkers such as an enzyme immunoassay for diagnosing and treating cardiovascular disease.

PeriTec Biosciences: Featuring peripheral vascular stents lined with peritoneal tissue for increased long-term patency.

Innovations (continued)

Robotically Assisted Cardiac Surgery

Robotically assisted cardiac surgery represents a novel, minimally

invasive approach for treating a variety of cardiac conditions with

the least amount of trauma to the patient. It is performed through

small incisions and ports on the right side of the chest, without

the need for dividing the breast bone. A dedicated cardiac robotic

surgical system is used in the laboratory at Cleveland Clinic to

further develop treatments for coronary artery disease, mitral

and aortic valve disease, atrial fibrillation and

hypertrophic cardiomyopathy.

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

Outcomes 200878

Remote Catheter Navigation

Cleveland Clinic electrophysiologists have been instrumental in the

development and clinical application of the Sensei™ Robotic Catheter

(Hansen Medical, Inc.) and Magnetic Navigation (Stereotaxis) Systems

to treat atrial and ventricular arrhythmias. These technologies have

helped improve the safety and effectiveness of complex catheter ablation

procedures.


Percutaneous Treatment for Aortic Valve Stenosis

Percutaneous aortic valve replacement continues to be investigated as an alternative treatment option for select patients with severe aortic valve stenosis who are high-risk surgical candidates. A transapical or transfemoral approach is used, and a compressed tissue heart valve on a balloon-mounted catheter is positioned directly in the diseased aortic valve. When the balloon is inflated, the position of the implant is secured.

Cleveland Clinic continues its participation 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. The one arm of the study for patients who are not surgical candidates has finished enrollment. At Cleveland Clinic, patients who underwent transcatheter aortic valve replacement have done particularly well.

Percutaneous repair of mitral and tricuspid valve regurgitation is being

investigated as an alternative to open surgical repair. The repair device

features an occluder that is suspended in or above the annulus of the

valve by an adjustable wire. The wire is anchored in the wall of the

atrium or other parts of the heart, including the left atrial appendage

or septum.

Percutaneous Repair of Mitral/Tricuspid Valve Regurgitation

These images show a balloon expandable aortic valve being placed inside of the native valve.

The occluder serves as a buttress against the native valve leaflets to ensure that they completely coapt, thereby eliminating the regurgitation.


In Vivo Video-Assisted Cardioscopy:

An Inside Look at the Heart

Three-Dimensional TEE for Catheterization Applications

Three-dimensional transesophageal echocardiography (TEE)

is now routinely used in the cardiac catheterization laboratory

to perform complex minimally invasive structural heart

disease interventions. Mitral valve repair with MitraClipTM,

paravalvular leak closure and mitral valvuloplasty are examples

of procedures that have become safer, faster and more

reproducible because of accurate, real-time three-dimensional

imaging.

Cardioscopy is a novel imaging technique that allows

visualization inside the beating heart. The technique uses

a specially designed heart-lung machine circuit, which

replaces the blood in the heart with a translucent oxygen-

carrying solution. A fiberoptic camera is used to view the

function and structure of the heart and heart muscle. This

experimental technology may serve as the future platform

for valvular interventions and ablation procedures on the

beating heart.

Paravalvular leak closure

Outcomes 200880

Cardioscope position 2



Clamp

Clamp

CPB

Endovascular Treatment Approaches for Complex Aortic Disease

The development of branched endovascular technologies to treat complex aortic disease has continued to evolve. These devices are now regularly being used as multiple component systems to treat aneurysms involving branched segments of the central vasculature, including the aortic arch, thoracoabdominal aorta and internal iliac arteries.

Thoracoabdominal aneurysm and right common iliac aneurysms: 7 centimeters and 3 centimeters in diameter, respectively.

Endovascular repair of type III TAA and RCIA aneurysm using a five-vessel branch device, including helical sidebranch to both the celiac artery and the right internal iliac artery.

Preventing the obstruction of surgical drainage

tubes inserted after heart, lung and trauma surgery

has important implications for both patient safety

and comfort. Cleveland Clinic researchers are

collaborating in the development of chest tube

drainage systems that feature proprietary drainage

tubes and clearing mechanisms. These drainage

systems will help clinicians manage bleeding and

clogging in a safer fashion, as well as increase

patient comfort and improve patient outcomes.

Improved Safety with New Chest Tube Drainage Design



Outcomes 200882

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.

Transcathether Valve Delivery System

One of the challenges of transcatheter valve procedures is compressing

the tissue valve for ease of delivery. A novel valve delivery system is being

investigated in which tissue valves are processed, sterilized, crimped

and preloaded into a catheter-based delivery system. The proprietary

stent design allows the valve to be crimped easily and provides secure

attachment to the annulus of the valve being replaced.


Advanced Technology Adds Flexibility for Interventional Cardiology and Hybrid Procedures

Siemens Healthcare’s Artis zeego® interventional imaging system used in the catheterization labs features fast, robotic positioning that enables unique park positions to provide better visualization and easier patient access. The system also features a flexible working height that improves operator comfort. This unique system is one of only 12 systems used for interventional applications in the U.S.

Image courtesy of Siemens Healthcare

During the Ross procedure for aortic valve disease, the patient’s native pulmonic valve is used to replace a diseased aortic valve, and an allograft valve is placed in the pulmonic valve position. Most often, failure of the Ross operation is caused by dilatation of the aortic root, making the valve leak. The allograft in the pulmonary position will degenerate over time, become stenotic and leak.

Reverse Ross Procedure

Patients who require repeat aortic valve surgery after a failed Ross procedure often face the possibility of receiving both prosthetic aortic and pulmonary valves, with the potential for complications and need for future reoperations. During the reverse Ross procedure, the pulmonic valve that was used in the aortic position can be removed, reconstructed and repositioned in its original pulmonic position. Then, a prosthetic valve conduit or allograft valve is used to replace the aortic valve. This Ross reversal surgery has been performed in nine recent patients at Cleveland Clinic with excellent immediate results, sparing these patients a two-valve problem.

84 Outcomes 2008

Akins CW, Miller DC, Turina MI, Kouchoukos NT, Blackstone EH, Grunkemeier GL, Takkenberg JJM, David TE, Butchart EG, Adams DH, Shahian DM, Hagl S, Mayer JE, Lytle BW. Guidelines for reporting mortality and morbidity after cardiac valve interventions. Ann Thorac Surg. 2008 Apr;85(4):1490-1495.

Antman EM, Hand M, Armstrong PW, Bates ER, Green LA, Halasyamani LK, Hochman JS, Krumholz HM, Lamas GA, Mullany CJ, Pearle DL, Sloan MA, Smith SC, Jr., Anbe DT, Kushner FG, Ornato JP, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 writing group to review new evidence and update the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction, writing on behalf of the 2004 writing committee [Erratum in: Circulation. 2008 Feb 12;117(6):e162]. Circulation. 2008 Jan 15;117(2):296-329.

Ballantyne CM, Raichlen JS, Nicholls SJ, Erbel R, Tardif JC, Brener SJ, Cain VA, Nissen SE, for the ASTEROID investigators. Effect of Rosuvastatin Therapy on Coronary Artery Stenoses Assessed by Quantitative Coronary Angiography. A Study to Evaluate the Effect of Rosuvastatin on Intravascular Ultrasound-Derived Coronary Atheroma Burden. Circulation. 2008 May 13;117(19):2458-66. Epub 2008 Mar 31.

Bavry AA, Bhatt DL. Appropriate use of drug-eluting stents: balancing the reduction in restenosis with the concern of late thrombosis. Lancet. Jun 21 2008;371(9630):2134-2143.

Bhattacharyya T, Nicholls SJ, Topol EJ, Zhang R, Yang X, Schmitt D, Fu X, Shao M, Brennan DM, Ellis SG, Brennan ML, Allayee H, Lusis AJ, Hazen SL. Relationship of paraoxonase 1 (PON1) gene polymorphisms and functional activity with systemic oxidative stress and cardiovascular risk. JAMA. Mar 19 2008;299(11):1265-1276.

Heart & Vascular Institute Selected Publications

This is a representative sample of publications authored by the Miller Family Heart & Vascular Institute in 2008.

Selected Publications

The Heart & Vascular Institute staff authored 725

publications in 2008. For a complete list, go to

www.clevelandclinic.org/quality/outcomes.

725 Publications

C5ResearchC5Research, Cleveland Clinic Coordinating Center for Clinical

Research, is an Academic Research Organization 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, site selection

and management, clinical events committee, data management,

statistics, research contracts and finance, quality assurance 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.


Bishop PD, Feiten LE, Ouriel K, Nassoiy SP, Pavkov ML, Clair DG, Kashyap VS. Arterial calcification increases in distal arteries in patients with peripheral arterial disease. Ann Vasc Surg. 2008 Nov;22(6):799-805.

Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Jr., Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O’Gara PT, O’Rourke RA, Otto CM, Shah PM, Shanewise JS. 2008 focused update incorporated into the 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). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008 Sep 23;52(13):e1-e142.

Brener SJ, Galla JM, Bryant R, 3rd, Sabik JF, 3rd, Ellis SG. Comparison of percutaneous versus surgical revascularization of severe unprotected left main coronary stenosis in matched patients. Am J Cardiol. Jan 15 2008;101(2):169-172.

Chen X, Zhang W, Laird J, Hazen SL, Salomon RG. Polyunsaturated phospholipids promote the oxidation and fragmentation of gamma -hydroxyalkenals: formation and reactions of oxidatively truncated ether phospholipids. J Lipid Res. Dec 29 2008;49(4):832-836.

Choi SH, Chae A, Miller E, Messig M, Ntanios F, DeMaria AN, Nissen SE, Witztum JL, Tsimikas S. Relationship between biomarkers of oxidized low-density lipoprotein, statin therapy, quantitative coronary angiography, and atheroma: volume observations from the REVERSAL (Reversal of Atherosclerosis with Aggressive Lipid Lowering) study. J Am Coll Cardiol. Jul 1 2008;52(1):24-32.

Desai MY, Kwon DH, Nair D, Mankad SV, Popovic Z, Decastro S, Nasser HJ, Patel A, Kuvin J, Pandian NG. Association of aortic atherosclerosis and renal dysfunction. J Am Soc Echocardiogr. 2008 Jun;21(6):751-5. Epub 2008 Jan 9.

Daimon M, Saracino G, Gillinov AM, Koyama Y, Fukuda S, Kwan J, Song JM, Kongsaerepong V, Agler DA, Thomas JD, Shiota T. Local dysfunction and asymmetrical deformation of mitral annular geometry in ischemic mitral regurgitation: A novel computerized 3D echocardiographic analysis. Echocardiography. 2008 Apr;25(4):414-423.

Dowdall JF, Greenberg RK, West K, Moon M, Lu Q, Francis C, Pfaff K. Separation of components in fenestrated and branched endovascular grafting--branch protection or a potentially new mode of failure? Eur J Vasc Endovasc Surg. 2008 Jul;36(1):2-9.

Eagleton MJ, Bishop PD, Bena JF, Nassoiy SP, Clair DG, Kashyap VS, Ouriel K. Calcium channel blockers and angiotensin-converting enzyme inhibitors may be associated with altered atherosclerotic plaque size and morphology. Vascular. 2008 May;16(3):171-178.

Eikelboom JW, Hankey GJ, Thom J, Bhatt DL, Steg PG, Montalescot G, Johnston SC, Steinhubl SR, Mak KH, Easton JD, Hamm C, Hu T, Fox KA, Topol EJ, CHARISMA Investigators. Incomplete inhibition of thromboxane biosynthesis by acetylsalicylic acid: determinants and effect on cardiovascular risk. Circulation. Oct 21 2008;118(17):1705-1712.

Ellis SG, Tendera M, de Belder MA, van Boven AJ, Widimsky P, Janssens L, Andersen HR, Betriu A, Savonitto S, Adamus J, Peruga JZ, Kosmider M, Katz O, Neunteufl T, Jorgova J, Dorobantu M, Grinfeld L, Armstrong P, Brodie BR, Herrmann HC, Montalescot G, Neumann FJ, Effron MB, Barnathan ES, Topol EJ, FINESSE I. Facilitated PCI in patients with ST-elevation myocardial infarction. N Engl J Med. May 22 2008;358(21):2205-2217.

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 reporting for

quality inititives, marketing statistics, presentations and publications

of new knowledge generated from analyses of clinical cohorts, novel

advanced clinical data management tools and statistical methodology,

and presentations and publications by medical students, residents,

and fellows.

Outcomes 200886

Epelman S, Tang WH, Chen SY, Van Lente F, Francis GS, Sen S. Detection of soluble angiotensin-converting enzyme 2 in heart failure: insights into the endogenous counter-regulatory pathway of the renin-angiotensin-aldosterone system. J Am Coll Cardiol. Aug 26 2008;52(9):750-54.

Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM 3rd, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO, Smith SC, Jr., Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Faxon DP, Halperin JL, Hiratzka LF, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura RA, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: Executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices). Circulation. 2008;117(21):2820-2840.

Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC, Jr., Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Anesth Analg. 2008 Mar;106(3):685-712.

Fonarow GC, Abraham WT, Albert NM, Stough WG, Gheorghiade M, Greenberg BH, O’Connor CM, Sun JL, Yancy CW, Young JB. Influence of beta-blocker continuation or withdrawal on outcomes in patients hospitalized with heart failure: findings from the OPTIMIZE-HF program. J Am Coll Cardiol. Jul 15 2008;52(3):190-199.

Fukuda S, Lever HM, Stewart WJ, Tran H, Song JM, Shin MS, Greenberg NL, Wada N, Matsumura Y, Toyono M, Smedira NG, Thomas JD, Shiota T. Diagnostic value of left ventricular outflow area in patients with hypertrophic cardiomyopathy: a real-time three-dimensional echocardiographic study. J Am Soc Echocardiogr. 2008 Jul;21(7):789-795.

Gillinov AM, Saltman AE. Surgical approaches for atrial fibrillation. Med Clin North Am. 2008 Jan;92(1):203-215.

Gillinov AM, Blackstone EH, Nowicki ER, Slisatkorn W, Al-Dossari G, Johnston DR, George KM, Houghtaling PL, Griffin B, Sabik JF 3rd, Svensson LG. Valve repair versus valve replacement for degenerative mitral valve disease. J Thorac Cardiovasc Surg. 2008 Apr;135(4):885-893.e2.

Gonzalez-Stawinski GV, Tan CD, Smedira NG, Starling RC, Rodriguez ER. Decay-accelerating factor expression may provide immunoprotection against antibody-mediated cardiac allograft rejection. J Heart Lung Transplant. 2008 Apr;27(4):357-361.

Gornik HL, Creager MA. Aortitis. Circulation. Jun 10 2008;117(23):3039-3051.

Gornik HL, Garcia B, Wolski K, Jones DC, Macdonald KA, Fronek A. Validation of a method for determination of the ankle-brachial index in the seated position. J Vasc Surg. 2008 Nov;48(5):1204-10. Epub 2008 Sep 30.

Greenberg RK, Lu Q, Roselli EE, Svensson LG, Moon MC, Hernandez AV, Dowdall J, Cury M, Francis C, Pfaff K, Clair DG, Ouriel K, Lytle BW. Contemporary analysis of descending thoracic and thoracoabdominal aneurysm repair: a comparison of endovascular and open techniques. Circulation. 2008 Aug 19;118(8):808-817.

Hazen SL. Oxidized phospholipids as endogenous pattern recognition ligands in innate immunity. J Biol Chem. 2008;283(23)15527-31. Epub. 2008 Feb 19.

Hiatt WR, Lincoff AM, Harrington RA. Acute pharmacological conversion of atrial fibrillation to sinus rhythm: is short-term symptomatic therapy worth it? A report from the December 2007 Meeting of the Cardiovascular and Renal Drugs Advisory Committee of the Food and Drug Administration. Circulation. Jun 3 2008;117(22):2956-2957.

Hoercher KJ, Nowicki ER, Blackstone EH, Singh G, Alster JM, Gonzalez-Stawinski GV, Starling RC, Young JB, Smedira NG. Prognosis of patients removed from a transplant waiting list for medical improvement: implications for organ allocation and transplantation for status 2 patients. J Thorac Cardiovasc Surg. 2008 May;135(5):1159-1166.



Kanderian AS, Gillinov AM, Pettersson GB, Blackstone E, Klein AL. Success of surgical left atrial appendage closure: assessment by transesophageal echocardiography. J Am Coll Cardiol. Sep 9 2008;52(11):924-929.

Kamdar AR, Meadows TA, Roselli EE, Gorodeski EZ, Curtin RJ, Sabik JF, Schoenhagen P, White RD, Lytle BW, Flamm SD, Desai MY. Multidetector computed tomographic angiography in planning of reoperative cardiothoracic surgery. Ann Thorac Surg. 2008 Apr;85(4):1239-1245.

Kaple RK, Murphy RT, DiPaola LM, Houghtaling PL, Lever HM, Lytle BW, Blackstone EH, Smedira NG. Mitral valve abnormalities in hypertrophic cardiomyopathy: echocardiographic features and surgical outcomes. Ann Thorac Surg. 2008 May;85(5):1527-1535.e2.

Kashyap VS, Pavkov ML, Bena JF, Sarac TP, O’Hara PJ, Lyden SP, Clair DG. The management of severe aortoiliac occlusive disease: endovascular therapy rivals open reconstruction. J Vasc Surg. 2008 Dec;48(6):1451-1457.e3.

Kashyap VS, Pavkov ML, Bishop PD, Nassoiy SP, Eagleton MJ, Clair DG, Ouriel K. Angiography underestimates peripheral atherosclerosis: lumenography revisited. J Endovasc Ther. 2008 Feb;15(1):117-125.

Khan MN, Jais P, Cummings J, Di Biase L, Sanders P, Martin DO, Kautzner J, Hao S, Themistoclakis S, Fanelli R, Potenza D, Massaro R, Wazni O, Schweikert R, Saliba W, Wang P, Al-Ahmad A, Beheiry S, Santarelli P, Starling RC, Dello Russo A, Pelargonio G, Brachmann J, Schibgilla V, Bonso A, Casella M, Raviele A, Haissaguerre M, Natale A. Pulmonary-vein isolation for atrial fibrillation in patients with heart failure. N Engl J Med. Oct 23 2008;359(17):1778-1785.

Kim ES, Carrigan TP, Menon V. Enrollment of women in National Heart, Lung, and Blood Institute-funded cardiovascular randomized controlled trials fails to meet current federal mandates for inclusion. J Am Coll Cardiol. Aug 19 2008;52(8):672-673.

King SB, 3rd, Smith SC, Jr., Hirshfeld JW, Jr., Jacobs AK, Morrison DA, Williams DO, Feldman TE, Kern MJ, O’Neill WW, Schaff HV, Whitlow PL, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW. 2007 Focused Update of the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention: a report of the

American College of Cardiology/American Heart Association Task Force on Practice Guidelines: 2007 Writing Group to Review New Evidence and Update the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention, Writing on Behalf of the 2005 Writing Committee. Circulation. Jan 15 2008;117(2):261-295.

Kirtane AJ, Ellis SG, Dawkins KD, Colombo A, Grube E, Popma JJ, Fahy M, Leon MB, Moses JW, Mehran R, Stone GW. Paclitaxel-eluting coronary stents in patients with diabetes mellitus: pooled analysis from 5 randomized trials. J Am Coll Cardiol. Feb 19 2008;51(7):708-715.

Koch CG, Li L, Sessler DI, Figueroa P, Hoeltge GA, Mihaljevic T, Blackstone EH. Duration of red-cell storage and complications after cardiac surgery. N Engl J Med. 2008 Mar 20;358(12):1229-1239.

Kwon DH, Kapadia SR, Tuzcu EM, Halley CM, Curtin RJ, Thamilarasan M, Smedira NG, Lytle BW, Lever HM, Desai MY. Long term outcomes of HCM patients at high risk for myectomy that underwent alcohol septal ablation. J Am Coll Cardiol Interv. August 2008, 1(4):432.

Kwon DH, Setser RM, Popovic ZB, Thamilarasan M, Sola S, Schoenhagen P, Garcia MJ, Flamm SD, Lever HM, Desai MY. Association of myocardial fibrosis, electrocardiography and ventricular tachyarrhythmia in hypertrophic cardiomyopathy: a delayed contrast enhanced MRI study. Int J Cardiovasc Imaging. 2008 Aug;24(6):617-25.

Lewis C, Zhu W, Pavkov ML, Kinney CM, Dicorleto PE, Kashyap VS. Arginase blockade lessens endothelial dysfunction after thrombosis. J Vasc Surg. 2008 Aug;48(2):441-446.

Lim P, Buakhamsri A, Popovic ZB, Greenberg NL, Patel D, Thomas JD, Grimm RA. Longitudinal Strain Delay Index by Speckle Tracking Imaging. A New Marker of Response to Cardiac Resynchronization Therapy. Circulation. 2008 Sep 9;118(11)1130-7. Epub 2008 Aug 25.

Marwick TH, Starling RC. The riddle of determining cardiac resynchro-nization therapy response a physiologic approach to dyssynchrony therapy. J Am Coll Cardiol. Oct 21 2008;52(17):1410-1412.

Mason DP, Thuita L, Alster JM, Murthy SC, Budev MM, Mehta AC, Pettersson GB, Blackstone EH. Should lung transplantation be performed using donation after cardiac death? The United States experience. J Thorac Cardiovasc Surg. 2008 Oct;136(4):1061-1066.

Outcomes 200888

Mason DP, Rajeswaran J, Murthy SC, McNeill AM, Budev MM, Mehta AC, Pettersson GB, Blackstone EH. Spirometry after transplantation: how much better are two lungs than one? Ann Thorac Surg. 2008 Apr;85(4):1193-1201.e2.

Mastracci TM, Garrido-Olivares L, Cina CS, Clase CM. Endovascular repair of ruptured abdominal aortic aneurysms: a systematic review and meta-analysis. J Vasc Surg. 2008. Jan;47(1):214-221.

Matsumura Y, Gillinov AM, Toyono M, Wada N, Yamano T, Thomas JD, Shiota T. Usefulness of left ventricular shape to predict the early recovery of left ventricular function after isolated aortic valve replacement for aortic valve stenosis. Am J Cardiol. 2008 Dec 1;102(11):1530-1534.

Mihaljevic T, Nowicki ER, Rajeswaran J, Blackstone EH, Lagazzi L, Thomas J, Lytle BW, Cosgrove DM. Survival after valve replacement for aortic stenosis: implications for decision making. J Thorac Cardiovasc Surg. 2008 Jun;135(6):1270-1278.

Mihaljevic T, Ootaki Y, Robertson JO, Durrani AK, Kamohara K, Akiyama M, Cingoz F, Ootaki C, Dessoffy R, Kopcak M, Liu J, Fukamachi K. Beating heart cardioscopy: a platform for real-time, intracardiac imaging. Ann Thorac Surg. 2008 Mar;85(3):1061-1065.

Miyazaki K, Colles SM, Graham LM. Impaired graft healing due to hypercholesterolemia is prevented by dietary supplementation with alpha-tocopherol. J Vasc Surg. 2008 Oct;48(4):986-993.

Morales JP, Greenberg RK, Lu Q, Cury M, Hernandez AV, Mohabbat W, Moon MC, Morales CA, Bathurst S, Schoenhagen P. Endoleaks following endovascular repair of thoracic aortic aneurysm: etiology and outcomes. J Endovasc Ther. 2008 Dec;15(6):631-638.

Mullens W, Abrahams Z, Francis GS, Skouri HN, Starling RC, Young JB, Taylor DO, Tang WH. Sodium nitroprusside for advanced low-output heart failure. J Am Coll Cardiol. Jul 15 2008;52(3):200-207.

Mullens W, Abrahams Z, Skouri HN, Francis GS, Taylor DO, Starling RC, Paganini E, Tang WH. Elevated intra-abdominal pressure in acute decompensated heart failure: a potential contributor to worsening renal function? J Am Coll Cardiol. Jan 22 2008;51(3):300-306.

Nair D, Carrigan TP, Curtin RJ, Popovic ZB, Kuzmiak S, Schoenhagen P, Flamm SD, Desai MY. Association of coronary atherosclerosis detected by multislice computed tomography and traditional risk-factor assessment. Am J Cardiol. Aug 1 2008;102(3):316-320.

Nicholls SJ. The complex intersection of inflammation and oxidation: implications for atheroprotection. J Am Coll Cardiol. Oct 21 2008;52(17):1379-80.

Nicholls SJ, Tuzcu EM, Brennan DM, Tardif JC, Nissen SE. Cholesteryl Ester Transfer Protein Inhibition, High-Density Lipoprotein Raising, and Progression of Coronary Atherosclerosis. Insights From ILLUSTRATE (Investigation of Lipid Level Management Using Coronary Ultrasound to Assess Reduction of Atherosclerosis by CETP Inhibition and HDL Elevation). Circulation. 2008 Dec 9;118(24):2506-14. Epub 2008 Nov 24.

Nicholls SJ, Tuzcu EM, Kalidindi S, Wolski K, Moon KW, Sipahi I, Schoenhagen P, Nissen SE. Effect of diabetes on progression of coronary atherosclerosis and arterial remodeling: a pooled analysis of 5 intravascular ultrasound trials. J Am Coll Cardiol. Jul 22 2008;52(4):255-262.

Nishimura RA, Carabello BA, Faxon DP, Freed MD, Lytle BW, O’Gara PT, O’Rourke RA, Shah PM. ACC/AHA 2008 guideline update on valvular heart disease: focused update on infective endocarditis: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2008 Aug 19;118(8):887-896.

Nissen SE. Limitations of computed tomography coronary angiography. J Am Coll Cardiol. Dec 16 2008;52(25):2145-47.

Nissen SE, Nicholls SJ, Wolski K, Nesto R, Kupfer S, Perez A, Jure H, De Larochelliere R, Staniloae CS, Mavromatis K, Saw J, Hu B, Lincoff AM, Tuzcu EM, PERISCOPE I. Comparison of pioglitazone vs glimepiride on progression of coronary atherosclerosis in patients with type 2 diabetes: the PERISCOPE randomized controlled trial. JAMA. Apr 2 2008;299(13):1561-1573.

Nissen SE, Nicholls SJ, Wolski K, Rodes-Cabau J, Cannon CP, Deanfield JE, Depres J-P, Kastelein JJP, Steinhubl SR, Kapadia S, Yasin M, Ruzyllo W, Gaudin C, Job B, Hu B, Bhatt DL, Lincoff AM, Tuzcu EM, STRADIVARIUS I. Effect of rimonabant on progression of atherosclerosis in patients with abdominal obesity and coronary artery disease: the STRADIVARIUS randomized controlled trial. JAMA. Apr 2 2008;299(13):1547-1560.



Patterson GA, Cooper JD, Deslauriers J, Lerut AEMR, Luketich JD, Rice TW. Pearson’s Thoracic & Esophageal Surgery. 3rd ed. Philadelphia, PA: Churchill Livingstone/Elsevier; 2008.

Pearson GD, Devereux R, Loeys B, Maslen C, Milewicz D, Pyeritz R, Ramirez F, Rifkin D, Sakai L, Svensson L, Wessels A, Van Eyk J, Dietz HC. Report of the National Heart, Lung, and Blood Institute and National Marfan Foundation Working Group on research in Marfan syndrome and related disorders. Circulation. 2008 Aug 12;118(7):785-791.

Penn MS, Mangi AA. Genetic enhancement of stem cell engraftment, survival, and efficacy. Circ Res. Jun 20 2008;102(12):1471-1482.

Pettersson GB, Crucean AC, Savage R, Halley CM, Grimm RA, Svensson LG, Naficy S, Gillinov AM, Feng J, Blackstone EH. Toward predictable repair of regurgitant aortic valves: a systematic morphology-directed approach to bicommissural repair. J Am Coll Cardiol. 2008 Jul 1;52(1):40-49.

Pinto DS, Stone GW, Shi C, Dunn ES, Reynolds MR, York M, Walczak J, Berezin RH, Mehran R, McLaurin BT, Cox DA, Ohman EM, Lincoff AM, Cohen DJ, ACUITY, Investigators. Economic evaluation of bivalirudin with or without glycoprotein IIb/IIIa inhibition versus heparin with routine glycoprotein IIb/IIIa inhibition for early invasive management of acute coronary syndromes. J Am Coll Cardiol. Nov 25 2008;52(22):1758-1768.

Pocock SJ, Lansky AJ, Mehran R, Popma JJ, Fahy MP, Na Y, Dangas G, Moses JW, Pucelikova T, Kandzari DE, Ellis SG, Leon MB, Stone GW. Angiographic surrogate end points in drug-eluting stent trials: a systematic evaluation based on individual patient data from 11 randomized, controlled trials. J Am Coll Cardiol. Jan 1 2008;51(1):23-32.

Popovic ZB, Kwon DH, Mishra M, Buakhamsri A, Greenberg NL, Thamilarasan M, Flamm SD, Thomas JD, Lever HM, Desai MY. Association between regional ventricular function and myocardial fibrosis in hypertrophic cardiomyopathy assessed by speckle tracking echocardiography and delayed hyperenhancement magnetic resonance imaging. J Am Soc Echocardiogr. Dec 2008;21(12): 1299-1305.

Rice TW, Blackstone EH. Surgical management of gastroesophageal reflux disease. Gastroenterol Clin North Am. 2008 Dec;37(4):901-919.

Robertson JO, Lober C, Smedira NG, Navia JL, Sopko N, Gonzalez-Stawinski GV. One hundred days or more bridged on a ventricular assist device and effects on outcomes following heart transplantation. Eur J Cardiothorac Surg. 2008 Aug;34(2):295-300.

Roselli EE, Pettersson GB, Blackstone EH, Brizzio ME, Houghtaling PL, Hauck R, Burke JM, Lytle BW. Adverse events during reoperative cardiac surgery: frequency, characterization, and rescue. J Thorac Cardiovasc Surg. 2008 Feb;135(2):316-323,323.e1-e6.

Rosengart TK, Feldman T, Borger MA, Vassiliades TA, Jr., Gillinov AM, Hoercher KJ, Vahanian A, Bonow RO, O’Neill W. Percutaneous and minimally invasive valve procedures: a scientific statement from the American Heart Association Council on Cardiovascular Surgery and Anesthesia, Council on Clinical Cardiology, Functional Genomics and Translational Biology Interdisciplinary Working Group, and Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2008 Apr 1;117(13):1750-1767.

Rudy Y, Ackermann MJ, Bers DM, Clancy CE, Houser SR, London B, McCulloch AD, Przywara DA, Rasmusson RL, Solaro RJ, Trayanova NA, Van Wagoner DR, Varro A, Weiss JN, Lathrop DA. Systems approach to understanding electromechanical activity in the human heart: a National Heart, Lung, and Blood Institute workshop summary. Circulation. Sep 9 2008;118(11):1202-11.

Sabik JF 3rd, Stockins A, Nowicki ER, Blackstone EH, Houghtaling PL, Lytle BW, Loop FD. Does location of the second internal thoracic artery graft influence outcome of coronary artery bypass grafting? Circulation. 2008 Sep 30;118(14 Suppl):S210-S215.

Saliba W, Reddy VY, Wazni O, Cummings JE, Burkhardt JD, Haissaguerre M, Kautzner J, Peichl P, Neuzil P, Schibgilla V, Noelker G, Brachmann J, Di Biase L, Barrett C, Jais P, Natale A. Atrial fibrillation ablation using a robotic catheter remote control system initial human experience and long-term follow-up results. J Am Coll Cardiol. Jun 24 2008;51(25):2407-2411.

Sarac TP, Altinel O, Bannazadeh M, Kashyap V, Lyden S, Clair D. Midterm outcome predictors for lower extremity atherectomy procedures. J Vasc Surg. 2008 Oct;48(4):885-890.

Sarac TP, Altinel O, Kashyap V, Bena J, Lyden S, Sruvastava S, Eagleton M, Clair D. Endovascular treatment of stenotic and occluded visceral arteries for chronic mesenteric ischemia. J Vasc Surg. 2008 Mar;47(3):485-491.e2.

Outcomes 200890

Schade AE, Gonzalez-Stawinski G. Immunomodulation via targeted inhibition of antigen receptor signal transduction. Cardiovasc Hematol Disord Drug Targets. 2008 Mar;8(1):1-6.

Schocken DD, Benjamin EJ, Fonarow GC, Krumholz HM, Levy D, Mensah GA, Narula J, Shor ES, Young JB, Hong Y. Prevention of Heart Failure. A Scientific Statement From the American Heart Association Councils on Epidemiology and Prevention, Clinical Cardiology, Cardiovascular Nursing, and High Blood Pressure Research; Quality of Care and Outcomes Research Interdisciplinary Working Group; and Functional Genomics and Translational Biology Interdisciplinary Working Group. Circulation. 2008 May 13;117(19):2544-65. Epub 2008 Apr 7.

Schoenhagen P, Tuzcu EM. Identifying patterns of atherosclerotic disease manifestation with coronary computed tomography. Impact on clinical management and outcome? Eur Heart J. Aug 27 2008.

Sehayek E, Hazen SL. Cholesterol absorption from the intestine is a major determinant of reverse cholesterol transport from peripheral tissue macrophages. Arterioscler Thromb Vasc Biol. Jul 2008;28(7):1296-1297.

Shishehbor MH, Amini R, Raymond RE, Bavry AA, Brener SJ, Kapadia SR, Whitlow PL, Ellis SG, Bhatt DL. Safety and efficacy of overlapping sirolimus-eluting versus paclitaxel-eluting stents. Am Heart J. Jun 2008;155(6):1075-1080.

Sipahi I, Tuzcu EM, Moon KW, Nicholls S, Schoenhagen P, Zhitnik J, Crowe T, Kapadia S, Nissen S. Do the extent and direction of arterial remodeling predict subsequent progression of coronary atherosclerosis? A serial intravascular ultrasound study. Heart. 2008 May;94(5):623-7. Epub 2007 Dec 10.

Svensson LG, Dewey T, Kapadia S, Roselli EE, Stewart A, Williams M, Anderson WN, Brown D, Leon M, Lytle B, Moses J, Mack M, Tuzcu M, Smith C. United States feasibility study of transcatheter insertion of a stented aortic valve by the left ventricular apex. Ann Thorac Surg. 2008 Jul;86(1):46-54; discussion 54-55.

Svensson LG, Kouchoukos NT, Miller DC, Bavaria JE, Coselli JS, Curi MA, Eggebrecht H, Elefteriades JA, Erbel R, Gleason TG, Lytle BW, Mitchell RS, Nienaber CA, Roselli EE, Safi HJ, Shemin RJ, Sicard GA, Sundt TM 3rd, Szeto WY, Wheatley GH 3rd. Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts. Ann Thorac Surg. 2008 Jan;85(1 Suppl):S1-S41.

Tang WH, Francis GS. The year in heart failure. J Am Coll Cardiol. Nov 11 2008;52(20):1671-1678.

Tang WH, Tong W, Jain A, Francis GS, Harris CM, Young JB. Evaluation and long-term prognosis of new-onset, transient, and persistent anemia in ambulatory patients with chronic heart failure. J Am Coll Cardiol. Feb 5 2008;51(5):569-576.

Tang WH, Tong W, Shrestha K, Wang Z, Levison BS, Delfraino B, Hu B, Troughton RW, Klein AL, Hazen SL. Differential effects of arginine methylation on diastolic dysfunction and disease progression in patients with chronic systolic heart failure. Eur Heart J. Aug 6 2008;29(20):2506-2513.

Torre-Amione G, Anker SD, Bourge RC, Colucci WS, Greenberg BH, Hildebrandt P, Keren A, Motro M, Moye LA, Otterstad JE, Pratt CM, Ponikowski P, Rouleau JL, Sestier F, Winkelmann BR, Young JB. Results of a non-specific immunomodulation therapy in chronic heart failure (ACCLAIM trial): a placebo-controlled randomised trial. Lancet. Jan 19 2008;371(9608):228-236.

Van Wagoner DR. Evaluating the impact of atrial dilatation on atrial calcium cycling. Eur Heart J. May 2008;29(9):1084-1085.

Van Wagoner DR. Oxidative Stress and Inflammation in Atrial Fibrillation: Role in Pathogenesis and Potential as a Therapeutic Target. J Cardiovasc Pharmacol. 2008 Oct;52(4):306-13. Epub 2008 Sep 10.

Van Wagoner DR, Nattel S. Insights into mechanisms linking cardiac hypertrophy and atrial fibrosis: Evidence for a role of histone deacetylase in atrial fibrillation pathophysiology and therapy. J Mol Cell Cardiol. 2008 Dec;45(6):707-8. Epub 2008 Sep 10.

Videtic GMM, Rice TW, Murthy S, Suh JH, Saxton JP, Adelstein DJ, Mekhail TM. Utility of positron emission tomography compared with mediastinoscopy for delineating involved lymph nodes in stage III lung cancer: insights for radiotherapy planning from a surgical cohort. Int J Radiat Oncol Biol Phys. 2008 Nov 1;72(3):702-706.

White HD, Ohman EM, Lincoff AM, Bertrand ME, Colombo A, McLaurin BT, Cox DA, Pocock SJ, Ware JA, Manoukian SV, Lansky AJ, Mehran R, Moses JW, Stone GW. Safety and efficacy of bivalirudin with and without glycoprotein IIb/IIIa inhibitors in patients with acute coronary syndromes undergoing percutaneous coronary intervention 1-year results from the ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) trial. J Am Coll Cardiol. Sep 2 2008;52(10):807-814.



Wilkoff BL, Auricchio A, Brugada J, Cowie M, Ellenbogen KA, Gillis AM, Hayes DL, Howlett JG, Kautzner J, Love CJ, Morgan JM, Priori SG, Reynolds DW, Schoenfeld MH, Vardas PE. HRS/EHRA Expert Consensus on the Monitoring of Cardiovascular Implantable Electronic Devices (CIEDs): description of techniques, indications, personnel, frequency and ethical considerations: developed in partnership with the Heart Rhythm Society (HRS) and the European Heart Rhythm Association (EHRA); and in collaboration with the American College of Cardiology (ACC), the American Heart Association (AHA), the European Society of Cardiology (ESC), the Heart Failure Association of ESC (HFA), and the Heart Failure Society of America (HFSA). Endorsed by the Heart Rhythm Society, the European Heart Rhythm Association (a registered branch of the ESC), the American College of Cardiology, the American Heart Association. Europace. Jun 2008;10(6):707-725.

Wilkoff BL, Williamson BD, Stern RS, Moore SL, Lu F, Lee SW, Birgersdotter-Green UM, Wathen MS, Van Gelder IC, Heubner BM, Brown ML, Holloman KK. Strategic programming of detection and therapy parameters in implantable cardioverter-defibrillators reduces shocks in primary prevention patients: results from the PREPARE (Primary Prevention Parameters Evaluation) study. J Am Coll Cardiol. Aug 12 2008;52(7):541-550.

Wu Z, Wagner MA, Zheng L, Parks JS, Shy JM 3rd, Smith JD, Gogonea V, Hazen SL. Corrigendum: The refined structure of nascent HDL reveals a key functional domain for particle maturation and dysfunction. Nat Struct Mol Biol. Jun 2008;15(6):651.

Yancy CW, Abraham WT, Albert NM, Clare R, Stough WG, Gheorghiade M, Greenberg BH, O’Connor CM, She L, Sun JL, Young JB, Fonarow GC. Quality of care of and outcomes for African Americans hospitalized with heart failure: findings from the OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure) registry. J Am Coll Cardiol. Apr 29 2008;51(17):1675-1684.

Anesthesiology Institute Selected PublicationsBakri MH, Nagem H, Sessler DI, Mahboobi R, Dalton J, Akca O, Roselli EE, Insler SR. Transdermal oxygen does not improve sternal wound oxygenation in patients recovering from cardiac surgery. Anesth Analg. 2008 Jun;106(6):1619-1626.

Duncan AI, Lowe BS, Garcia MJ, Xu M, Gillinov AM, Mihaljevic T, Koch CG. Influence of concentric left ventricular remodeling on early mortality after aortic valve replacement. Ann Thorac Surg. 2008 Jun:85(6):2030-2039.

Mamoun NF, Xu M, Sessler DI, Sabik JF, Bashour CA. Propensity matched comparison of outcomes in older and younger patients after coronary artery bypass graft surgery. Ann Thorac Surg. 2008 Jun;85(6):1974-1979.

Ovreiu M, Nair BG, Xu M, Bakri MH, Li L, Wazni O, Fahmy T, Petre J, Starr NJ, Sessler DI, Bashour CA. Electrocardiographic activity before onset of postoperative atrial fibrillation in cardiac surgery patients. Pacing Clin Electrophysiol. 2008 Nov;31(11):1371-1382.

Emergency Institute Selected PublicationsDiercks DB, Fonarow GC, Kirk JD, Jois-Bilowich P, Hollander JE, Weber JE, Wynne J, Mills RM, Yancy C, Peacock WF, IV. Illicit stimulant use in a United States heart failure population presenting to the emergency department (from the Acute Decompensated Heart Failure National Registry Emergency Module). Am J Cardiol. 2008 Nov 1;102(9):1216-1219.

Diercks DB, Fonarow GC, Kirk JD, Emerman CL, Hollander JE, Weber JE, Summers RL, Wynne J, Peacock WF, IV. Risk stratification in women enrolled in the Acute Decompensated Heart Failure National Registry Emergency Module (ADHERE-EM). Acad Emerg Med. 2008 Feb;15(2):151-158.

Maisel AS, Peacock WF, McMullin N, Jessie R, Fonarow GC, Wynne J, Mills RM. Timing of immunoreactive B-type natriuretic peptide levels and treatment delay in acute decompensated heart failure: an ADHERE (Acute Decompensated Heart Failure National Registry) analysis. J Am Coll Cardiol. 2008 Aug 12;52(7):534-540.

Peacock WF, IV, De Marco T, Fonarow GC, Diercks D, Wynne J, Apple FS, Wu AHB. Cardiac troponin and outcome in acute heart failure. N Engl J Med. 2008 May 15;358(20):2117-2126.

Staff Directory

Institute Leadership Bruce W. Lytle, MD∆, Chairman, Miller Family Heart & Vascular Institute

Daniel Clair, MD∆, Chairman, Vascular Surgery

Steven E. Nissen, MD∆, Chairman, Robert and Suzanne Tomsich Department of Cardiovascular Medicine

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

Quality Review Officers

Nicholas G. Smedira, MD∆, Miller Family Heart & Vascular Institute

Ravi N. Nair, MD, Cardiovascular Medicine

Sunita Srivastava, MD, Vascular Surgery

Lars G. Svensson, MD, PhD, Thoracic and Cardiovascular Surgery

Institute Patient Experience Officer

A. Marc Gillinov, MD∆

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

Gösta B. Pettersson, MD, PhD∆, Vice-Chairman

Cardiovascular Surgery

Eugene H. Blackstone, MD∆

A. Marc Gillinov, MD∆

Gonzalo Gonzalez-Stawinski, MD

Douglas R. Johnston, MD

Bruce W. Lytle, MD∆

Kenneth McCurry, MD

Tomislav Mihaljevic, MD∆

José L. Navia, MD

Edward Nowicki, MD

Eric E. Roselli, MD

Joseph F. Sabik III, MD

Nicholas G. Smedira, MD∆

Edward G. Soltesz, MD

Lars G. Svensson, MD, PhD

Thoracic Surgery

Thomas W. Rice, MD∆, Section Head

David P. Mason, MD

Sudish C. Murthy, MD, PhD

Cardiovascular Surgery Hospitalists

Jatinder Aujla, MD

Sumit Duggal, MD

Naveed Iqbal, MD

Raghunandan Muppidi, MD

Shiraz Nisar, MD

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

Mireille Moise, MD

Patrick O’Hara, MD

Timur Sarac, MD

Sunita Srivastava, MD

Outcomes 20089292

Robert and Suzanne Tomsich Departmentof Cardiovascular Medicine Steven E. Nissen, MD, Chairman

A. Michael Lincoff, MD, Vice-Chairman

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

E. Murat Tuzcu, MD, Vice-Chairman

Cardiac Electrophysiology and Pacing

Bruce D. Lindsay, MD, Section Head

Mandeep Bhargava, MD

Thomas Callahan IV, MD

Lon W. Castle, MD

Mina K. Chung, 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

Mark Niebauer, MD

Walid I. Saliba, MD

Richard Sterba, MD

Patrick J. Tchou, MD

Niraj Varma, 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

William James Stewart, MD

Maran Thamilarasan, MD *Joint appointment with Radiology

Clinical Cardiology

Ben Barzilai, MD, Section Head

Ajay Bhargava, MD

Caroline Casserly, MD, MBA

Michael Faulx, MD

Adam Grasso, MD, PhD

Heather L. Gornik, MD, RVT

Donald F. Hammer, MD

Joel B. Holland, MD

Julie Huang, MD

Fuad Y. Jubran, MD∆

∆Chair Holders


Staff Directory

Clinical Cardiology (continued)

Vidyasagar Kalahasti, MD

Richard Krasuski, MD

Steven E. Nissen, MD

Marc S. Penn, MD, PhD

Mehdi Razavi, MD∆

Curtis Rimmerman, MD∆

Michael B. Rocco, MD

Michael B. Rollins, MD

Terrence G. Tulisiak, MD

Donald A. Underwood, MD

Bennett Werner, MD

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

Maria Mountis, MD

Gustavo Rincon, MD

W.H. Wilson Tang, MD

David O. Taylor, MD

James B. Young, MD∆

Invasive Cardiology

Stephen Ellis, MD, Section Head

Christopher Bajzer, MD*

Corinne Bott-Silverman, 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, Section Head

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

Outcomes 20089494

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*

Carmel Celestin, MD

Carmen Fonseca, MD

Leslie Gilbert, MD

Marcelo Gomes, MD


Douglas Joseph, DO, RVT

Samir Kapadia, MD*

Soo Hyun Kim, 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

Research

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



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


Stanley L. Hazen, MD, PhD

Wael A. Jaber, MD

Douglas E. Joseph, DO, RVT

Venugopal Menon, MD

Stephen J. Nicholls, MD, PhD

∆Chair Holders


Staff Directory

Cardiothoracic AnesthesiologyMichael S. O’Connor, DO, MPH, Chairman, Cardiothoracic Anesthesiology

Colleen Koch, MD, MS, Vice-Chair, Cardiothoracic Anesthesiology

Michael Licina, MD, Vice-Chair, Cardiothoracic Anesthesiology

Ahmad Adi, MD

Andrej Alfirevic, MD

John Apostolakis, MD

C. Allen Bashour, MD, FACS, FCCP

M. Gregory Bourdakos, MD

Michelle Capdeville, MD

Gohar Dar, MD

Pierre deVilliers, MD

Andra Duncan, MD

Brian Fitzsimons, MD

Marius Gota, MD

Michael Hauser, MD

Steven Insler, DO

Brian Johnson, MD

Erik Kraenzler, MD

Tory McGrath, MD

Grzegorz Pitas, MD

Dominique Prud’Homme, MD

Shiva Sale, MD

Robert M. Savage, MD, FACC

Norman J. Starr, MD

Chad Wagner, MD

Lee Wallace, MD

Jean-Pierre Yared, MD

Anesthesiology, Cardiovascular Intensive Care Units

Jean-Pierre Yared, MD, Medical Director, Cardiovascular ICU, Director, Center for Critical Care Medicine


Gregory Bourdakos, MD

Gohar Dar, MD

Marius Gota, MD

Steven Insler, DO

Michael S. O’Connor, DO, MPH

Chad Wagner, MD

Thoracic Surgery Anesthesiology

Dominique Prud’Homme, MD, Section Head, Thoracic Anesthesiology

Ahmad Adi, MD

Andrej Alfirevic, MD

John Apostolakis, MD


M. Gregory Bourdakos, MD

Michelle Capdeville, MD

Gohar Dar, MD

Pierre deVilliers, MD

Andra Duncan, MD


Marius Gota, MD

Michael Hauser, MD

Steven Insler, DO

Brian Johnson, MD

Colleen Koch, MD, MS

Erik Kraenzler, MD

Michael Licina, MD

Tory McGrath, MD

Grzegorz Pitas, MD

Outcomes 20089696

Shiva Sale, MD

Robert M. Savage, MD, FACC

Norman J. Starr, MD

Chad Wagner, MD

Lee Wallace, MD

Vascular Surgery Anesthesiology

Theodore Marks, MD, Section Head, Vascular Surgery Anesthesiology

Maged Argalious, MD

Harendra Arora, MD

Jacek Cywinski, MD

Tracy Dovich, MD


Alexandru Gottlieb, MD

Robert Helfand, MD

Samuel Irefin, MD

Jia Lin, MD

Brian Parker, MD

M. Ramachandran, MD

Regional Medical Practice

Cleveland Clinic Avon Lake Family Health Center

Brett Butler, MD, Vascular Surgery

Cleveland Clinic Beachwood Family Health and Surgery Center

Leslie Gilbert, MD, Cardiovascular Medicine

Joel B. Holland, MD, Cardiovascular Medicine

Vikram Kashyap, MD, Vascular Surgery

Michael B. Rocco, MD, Cardiovascular Medicine

Sunita Srivastava, MD, Vascular Surgery

Emad Zakhary, MD, Vascular Surgery

Cleveland Clinic Brunswick Family Health Center

Joel Godard, MD, Cardiovascular Medicine

Cleveland Clinic Elyria Chestnut Commons Family Health Center

Daniel Clair, MD, Vascular Surgery

Mireille Moise, 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


Sean Lyden, MD, Vascular Surgery

Richard Sterba, MD, Pediatric Cardiology


Staff Directory

Cleveland Clinic Solon Family Health Center

Joseph Martin, MD, Cardiovascular Medicine

Mark Pace, DO, Cardiovascular Medicine

Cleveland Clinic Strongsville Family Health and Surgery Center

John R. Bartholomew, MD, Vascular Medicine

Matthew Eagleton, MD, Vascular Surgery

Joel Godard, MD, Cardiovascular Medicine

Tara Mastracci, MD, Vascular Surgery

Terrence G. Tulisiak, MD, Cardiovascular Medicine

Cleveland Clinic Westlake Family Health Center


Caroline Casserly, MD, MBA, Cardiovascular Medicine

Lon W. Castle, MD, Cardiovascular Medicine

Albert Chan, MD, Cardiovascular Medicine

Thomas B. Edel, MD, Cardiovascular Medicine

Robert D. Mosteller, MD, Cardiovascular Medicine

Ashoka Nautiyal, MD, Cardiovascular Medicine

Robert Reynolds, MD, Cardiovascular Medicine

Cleveland Clinic Willoughby Hills Family Health Center

Leslie Gilbert, MD, Cardiovascular Medicine

J. Michael Koch, MD, Cardiovascular Medicine

Kamal Riad, MD, Cardiovascular Medicine


Cleveland Clinic Wooster

Kenneth E. Shafer, MD, Cardiovascular Medicine

Richard Sterba, MD, Pediatric Cardiology

Bennett Werner, MD, Cardiovascular Medicine

Cleveland Clinic Hospitals

Euclid Hospital

J. Michael Koch, MD, Cardiovascular Medicine

Kamal Riad, MD, Cardiovascular Medicine

Fairview Hospital


Inderjit S. Gill, MD, Thoracic and Cardiovascular Surgery

Joseph A. Lahorra, MD, Thoracic and Cardiovascular Surgery

R. Thomas Temes, MD, Thoracic and Cardiovascular Surgery

Hillcrest Hospital

George Anton, MD, Vascular Surgery

Mark J. Botham, MD, Thoracic and Cardiovascular Surgery

Anthony Rizzo, MD, Vascular Surgery

Thomas G. Santoscoy, MD, Thoracic and Cardiovascular Surgery

Donna J. Waite, MD, Thoracic and Cardiovascular Surgery


Marymount Hospital

Javier Alvarez-Tostado, MD, Vascular Surgery

Neal 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

Outcomes 20089898

Affiliate Programs Thoracic and Cardiovascular Surgery

Cape Fear Valley Health System

Ali Husain, MD

Robert Maughan, MD

Chester County Hospital

Verdi DiSesa, MD

Martin LeBoutillier III, MD

Cleveland Clinic in Florida

W. Douglas Boyd, MD

Mercedes Dullum, MD

Keith Mortman, MD

EMH Regional Medical Center

Altagracia M. Chavez, MD

Michael S. Mikhail, MD

LakeWest Hospital

Rami Akhrass, MD

Mark Botham, MD

Thomas G. Santoscoy, MD

Donna J. Waite, MD

McLeod Heart & Vascular Institute

Fred Holland II, MD

Gregory Jones, MD

Robert Phillips Jr., MD

MetroHealth Medical Center

Rami Akhrass, MD

Inderjit S. Gill, MD

Joseph A. Lahorra, MD

R. Thomas Temes, MD

Rochester General Hospital

Eli Becker, MD

David Cheeran, MD

Ronald Kirshner, MD

South Pointe Hospital

Thomas G. Santoscoy, MD

Donna J. Waite, MD

Some physicians may practice in multiple locations. For a detailed list including staff photos, please visit clevelandclinic.org/staff.


Contact Information

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 (877.843.2781)

Cardiovascular Medicine Appointments/Referrals

216.444.6697 or 800.223.2273, ext. 46697

Vascular Surgery Appointments/Referrals

216.444.4508 or 800.223.2273, ext. 44508

Miller Family Heart & Vascular Institute Resource Center

For patient questions or concerns about heart and blood vessel 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

On the Web at clevelandclinic.org/heart

Additional Contact Information

General Information

216.444.2200

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]

Global Patient Services/International Center

Complimentary assistance for international patients and families

001.216.444.8184 or visit clevelandclinic.org/gps


866.293.7866

For address corrections or changes, please call

800.890.2467

Outcomes 2008100100

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

Main Campus

9500 Euclid Ave. Cleveland, OH 44195

216.444.2200 or 800.223.2273

Cleveland Clinic Family Health CentersAvon Lake Family Health Center

450 Avon Belden Road Avon Lake 44012

440.930.6800

Vascular surgery

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

Elyria Chestnut Commons Family Health Center

303 Chestnut Commons Dr. Elyria, OH 44035

440.366.9444 or 440.204.7900

Vascular surgery

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

Solon Family Health Center

29800 Bainbridge Road Solon, OH 44139

440.519.6800 or 800.648.0022

Cardiovascular medicine

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


Institute Locations

Institute Locations

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

Cleveland Clinic Health System

Euclid Hospital

18901 Lake Shore Blvd. Euclid, OH 44119

216.531.9000 euclidhospital.org

Cardiovascular medicine

Fairview Hospital

Cardiothoracic Surgery, Fairview Physicians’ Center 18101 Lorain Ave. 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

Marymount Hospital

12300 McCracken Road Garfield Heights, OH 44125

216.587.4280 marymount.org

Vascular surgery

Heart & Vascular Institute Regional Centers

Cape Fear Valley Health System

Cardiothoracic Surgery 1638 Owen Dr. Fayetteville, NC 28304

910.609.4000 capefearvalley.com

Outcomes 2008102102

The Chester County Hospital

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

610.738.2690 cchosp.com


2950 Cleveland Clinic Blvd. 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 St. Elyria, OH 44035

440.284.1504 emh-healthcare.org

Cardiothoracic surgery

LakeWest Hospital

LakeWest Medical Building, Suite 280 36000 Euclid Ave. Willoughby, OH 44094

440.918.4640 lhs.net

Cardiothoracic surgery

McLeod Heart & Vascular Institute

Cardiothoracic Surgery 555 East Cheves St. 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 Ave. Rochester, NY 14621

585.544.6550 rochestergeneralhospital.org


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 50 buildings on 166 acres in Cleveland, Ohio, includes a 1,000-bed hospital, outpatient clinic, specialty institutes and supporting labs and facilities. Cleveland Clinic also operates 15 family health centers; eight community hospitals; one affiliate hospital; a rehabilitation hospital for children; 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 late 2012.

At the Cleveland Clinic Lerner Research Institute, hundreds of principal investigators, project scientists, research associates and postdoctoral fellows are involved in laboratory-based, translational and clinical research. Total annual research expenditures exceed $244 million from federal agencies, non-federal societies and associations, endowment funds and other sources. 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.

Now in its fifth year of existence, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University offers all students full tuition scholarships. The program will graduate its first 29 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, please visit clevelandclinic.org.

Cleveland Clinic Overview

Outcomes 2008104104

Healing Services

The Miller Family Heart & Vascular Institute continues to offer a variety of complimentary services designed to support the well-being of our patients and their families. Our comprehensive treatment approach encompasses contributions from the Office of Patient Experience, Spiritual Care Department and the Healing Services Team. Touch therapies, including complimentary light massage therapy, Reiki and Healing Touch™, are offered at the patient’s bedside or in the Healing and Wellness Suite to naturally help patients relax and heal as they recover from medical or surgical interventions.

A new chapel, serving people of all faiths, and a Muslim prayer room have been added to the Miller Family Pavilion to meet patients’ and families’ spiritual needs.

Healing and Wellness Suites

The Miller Family Pavilion is the home of two new Healing and Wellness Suites, which are open to families 24 hours a day, every day. Patients and family members are encouraged to go to these rooms to take a quiet break from the daily hospital routine. Touch therapies are also offered in these suites by appointment.

Miller Family Heart & Vascular Institute Resource Nurses

866.289.6911 [email protected]

Dedicated, experienced resource nurses are available to answer thoracic and cardiovascular questions via phone, e-mail and online chat. This service is particularly helpful for patients and other individuals who do not have immediate access to a Cleveland Clinic cardiologist or surgeon. In 2008, there were 14,987 total contacts, including 6,108 phone calls, 3,907 e-mails and 4,972 online nurse chats.

Patient and Family Health & Education Center

800.223.2273 ext. 43771 [email protected]

The Patient and Family Health & Education Center opened in October 2008 in the Miller Family Pavilion and is a valuable resource for patients and visitors. Services include a library of education and health information materials; computer terminals with Internet access; audio and video education programs; and health education classes and screenings. There were 1,022 visitors to the Center, including 96 employees, from October through December.

Live Web Chat Events

In 2008 Cleveland Clinic hosted 29 live web chat events with experts from the Miller Family Heart & Vascular Institute. Online participants can post questions about specific thoracic and cardiovascular topics and receive answers from our team of experts, and transcripts are posted after the events. To view a list of chat transcripts, go to www.clevelandclinic.org/heart/webchat.

Institute Resources


Outcomes 2008

Online Services

Cleveland Clinic Secure Online Services

Cleveland Clinic uses state-of-the-art digital information systems to offer secure online services such as online medical second opinions, medical record access, patient treatment progress for referring physicians (see below), and imaging interpretations by our subspecialty trained radiologists. For more information, please visit eclevelandclinic.org.

MyChart

This secure online tool connects patients to their own health information from the privacy of their home any time, day or night. Some features include renewing prescriptions, reviewing test results and viewing medications, all online. For the convenience of physicians and patients across the country, MyChart now offers a secure connection to GoogleTM Health. Google Health users can securely share personal health information with Cleveland Clinic, and record and share the details of their Cleveland Clinic treatment with the physicians and healthcare providers of their choice. To establish a MyChart account, visit clevelandclinic.org/mychart.

DrConnect

Whether you are referring from near or far, DrConnect streamlines communication from Cleveland Clinic physicians to your office. This complimentary online tool offers 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 clevelandclinic.org/drconnect or email [email protected].

MyConsult Online Medical Second Opinion

This secure online service provides specialist consultations from our Cleveland Clinic experts and remote medical second opinions for more than 1,000 life-threatening and life-altering diagnoses. MyConsult is particularly valuable for people who wish to avoid the time and expense of travel. For more information, visit clevelandclinic.org/myconsult, email [email protected] or call 800.223.2273, ext 43223.

CME Opportunities: Live and Online

Cleveland Clinic’s Center for Continuing Education’s website, clevelandclinicmeded.com, offers hundreds of convenient, complimentary learning opportunities, from webcasts and podcasts to a host of medical publications including the Disease Management Project Online Medical Textbook, with more than 150 chapters. The site also offers a schedule of live CME courses, including international summits that focus on key areas of translational research. Many live CME courses are hosted in Cleveland, an economical option for business travel. Physicians can manage their CME credits by using the myCME Web Portal. Available 24/7, the site offers CME opportunities to medical professionals across the globe.

Resources for Physicians

106 Outcomes 2008106

Critical Care Transport Worldwide

Cleveland Clinic’s critical care transport team serves

critically ill and highly complex patients across the

globe. The transport fleet comprises mobile ICU

vehicles, helicopters and fixed-wing aircraft. The

transport teams are staffed by physicians, critical care

nurse practitioners, critical care nurses, paramedics and

ancillary staff, and are customized to meet the needs

of the patient. Critical care transport is available for

children and adults.

To arrange a transfer for STEMI (ST elevated myocardial

infarction), acute stroke, ICH (intracerebral hemorrhage),

SAH (subarachnoid hemorrhage) or aortic syndromes,

call 877.279.CODE (2633).

For all other transfers, call 216.444.8302 or

800.553.5056.


9500 Euclid Avenue, Cleveland, OH 44195

© The Cleveland Clinic Foundation 2009, 6/09

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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outcomes 2008 - cleveland clinic · dear colleague: on behalf of cleveland clinic, i am pleased to...

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