2011 Outcomes...Hospital Mortality – Isolated Procedures (N = 1,426) 2011 Hospital Mortality – Combined Procedures (N = 347) 2011 10 88 00 CABGA ortic Valve Replacement Mitral

Heart & Vascular Institute

&

2011Outcomes

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 volumes 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

necessarily mean we 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 (qualitycheck.org)

• Centers for Medicare & Medicaid Services (CMS) Hospital Compare

(hospitalcompare.hhs.gov)

• Ohio Department of Health (ohiohospitalcompare.ohio.gov)

• Cleveland Clinic Quality Performance Report (clevelandclinic.org/QPR)

Our commitment to providing accurate, timely information about patient care also

will help patients and referring physicians make informed healthcare decisions.

We hope you find these data valuable, and we invite your feedback. Please send

comments and suggestions to us at [email protected]. To view

all our Outcomes books, please visit Cleveland Clinic’s Quality and Patient Safety

website at clevelandclinic.org/outcomes.

Dear Colleague:

Welcome to Cleveland Clinic’s 2011 Outcomes books. They include data on clinical outcomes, patient volumes, innovations and publications. Cleveland Clinic pioneered the collection and annual publication of outcomes data. This initiative has become part of the national discussion on lowering costs and improving the quality of healthcare.

Cleveland Clinic uses data to manage outcomes across the full continuum of care. Clinical services are delivered through patient-centered institutes, each based around a single disease or organ system. Institutes combine medical and surgical services, along with research and education, under unified leadership. Each institute defines quality benchmarks for its specialty services and reports longitudinal progress.

Cleveland Clinic Outcomes books are available in print and online. Additional data are available through our online Quality Performance Report (clevelandclinic.org/QPR). The site offers data in advance of national and state public reporting sites in key areas, including heart attack, heart failure, stroke and infection prevention.

We hope you will find this information useful.

Sincerely, Delos M. Cosgrove, MD CEO and President

Prefer an e-version?

Visit clevelandclinic.org/OutcomesOnline, and we’ll remove you from the hard-copy mailing list and email you when next year’s books are online.

Innovations 82

Selected Publications 90

Staff Directory 98

Contact Information 107

Institute Locations 108

Improving Quality, Safety and the Patient Experience 111

About Cleveland Clinic 115

Cleveland Clinic Resources 117

Institute Resources 118

what’s insideChairman’s Letter 04

Introduction 05

Institute Overview 06

Quality and Outcomes Measures

Surgical Overview 08

Ischemic Heart Disease 13

Cardiac Rhythm Disorders 21

Valve Disease 26

Aortic Disease 34

Hypertrophic Obstructive Cardiomyopathy 44

Congenital Heart Disease 46

Pericardial Disease 50

Heart Failure and Transplant 52

Lung and Heart-Lung Transplant 56

Peripheral Vascular Diseases 58

Venous Disease 60

Cerebrovascular Disease 61

Thoracic Surgery 62

Preventive Cardiology and Rehabilitation 68

Anesthesia 74

Surgical Quality Improvement 76

Patient Experience 78

Thank you for your interest in the Sydell and Arnold Miller Family Heart & Vascular Institute 2011 Outcomes. This is the 14th edition of our annual publication. We are pleased to provide this resource to physicians throughout the United States. Rapid changes in healthcare, coupled with mounting economic pressures, are impacting the U.S. healthcare system and creating changes in patient care. In these times, superior outcomes are more important than ever. Scientific evidence supports the assertion that, over time, better outcomes lead to reduced healthcare costs. Outcomes need to be viewed as important not only for the health of our patients, but as a way to provide efficient and value-added care.

As a leader in national healthcare, Cleveland Clinic continues to combine cutting-edge technology with quality improvements to refine and improve the care we deliver to our patients.

The outcomes reflected in this book are not our destination, but an illustration of the continuous journey we are on to improve the everyday health of our patients.

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

Chairman’s Letter

Outcomes 20114

Cleveland Clinic is the national leader in caring for patients with cardiovascular disease. Cleveland

Clinic heart, vascular and thoracic specialists offer established and innovative treatments, research

and education. They coordinate care with referring physicians to ensure that every patient has the

best outcome and experience.

Heart, vascular and thoracic care at Cleveland Clinic is centered at the Sydell and Arnold Miller

Family Pavilion. In this advanced facility, 213 staff physicians, 110 residents and fellows, and 1,200

full-time nurses devote their full energies to cardiovascular medicine, thoracic and cardiovascular

surgery, and vascular surgery services. Comprehensive care includes collaboration with 47

cardiothoracic anesthesiologists and the support of Cleveland Clinic’s 2,700 staff physicians in 120

medical and surgical specialties and subspecialties.

5Sydell and Arnold Miller Family Heart & Vascular Institute

Introduction

5

6

Heart & Vascular Institute Overview 2011Patient Visits 404,395 Admissions 13,131Beds 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 4,148Valve Surgeries 2,816Coronary Artery Bypass Grafting (Isolated and Concomitant) 1,355Surgeries for Hypertrophic Cardiomyopathy 183Congenital Heart Surgeries (Adult and Pediatric) 757Robotically Assisted Cardiac Surgeries 160

Transplant SurgeryHeart Transplants 54Lung Transplants 111

Thoracic SurgeryGeneral Thoracic Surgeries 1,380Esophageal Surgeries 247

Vascular SurgeryVascular Surgeries (Open and Endovascular) 2,729Venous Surgeries 302Arteriovenous Access Surgeries 228

Outcomes 2011

The data reported in the Institute Overview reflect volumes at Cleveland Clinic’s main campus only. Data in other areas of the book may reflect volumes for main campus and other Cleveland-area Cleveland Clinic hospitals. A complete list of these hospitals can be found In the Institute Locations section of this book, which begins on Page 108.

Institute Overview

In 2011, patients traveled from all

50 states to Cleveland Clinic for their cardiovascular care.

Patients from 84 countries

came to Cleveland Clinic for their

cardiovascular care in 2011.

Sydell and Arnold Miller Family Heart & Vascular Institute 7

Aorta SurgeryOpen Ascending Aorta and Aortic Arch Repairs 816Open Descending Aorta and Thoracoabdominal Repairs 110Open Abdominal Aortic Aneursym Repairs 59Endovascular Descending Aorta and Thoracoabdominal Repairs 210Endovascular Abdominal Aortic Aneurysm Repairs 87

Cardiovascular Medicine Procedures Interventional Cardiology Diagnostic Cardiac Catheterizations 8,997Interventional Cardiac Procedures 1,821 Percutaneous Aortic Valvuloplasties 202 Percutaneous Mitral Valvuloplasties 23 Percutaneous Atrial Septal Defect and Patent Foramen Ovale Closures 59 Vascular Intervention Interventional Carotid Procedures 97Interventional Vascular Procedures 1,005 Electrophysiology Electrophysiology Ablations 1,370 Ablations for Atrial Fibrillation 775 Device Implants 1,351 Leads Extracted 460 Diagnostic and Cardiac Imaging Echocardiograms* 68,157Cardiac Computed Tomography (CT) Scans 7,434Cardiac Magnetic Resonance Imaging (MRI) Scans 4,876Nuclear Cardiology Tests Tc-Myoview-Rest 4,046 Tc-Myoview-Stress 3,932 Rubidium Heart (PET) 469 FDG Heart (PET) 450 MUGA 128 N-13 Ammonia Heart 214Stress Tests 6,152

7

Surgical Overview

8

Thoracic and Cardiac Surgery Volume

2002 – 2011

Cleveland Clinic surgeons performed 12,169 cardiovascular and thoracic surgical procedures in 2011. This includes procedures at our main campus and Cleveland Clinic hospitals within the greater Cleveland area. For a complete list of these hospitals, please refer to the Institute Locations section that begins on Page 108 of this book.

2002 2004 2006 20082003 2005 2007 20102009

14,00014,000VolumeVolume

12,00012,000

10,00010,000

8,0008,000

6,0006,000

4,0004,000

2,0002,000

00

Other Cleveland Clinic Hospitals Main Campus

2011

Outcomes 2011

Surgical Overview

The majority of surgical procedures performed in 2011 were cardiac surgery at Cleveland Clinic’s Miller Family Heart & Vascular Institute at the main campus.

Surgical Procedure Volume by Type and Location (N = 12,169)

16.3% Other Cleveland Clinic Hospitals Thoracic (N = 1,985)16.3% Other Cleveland Clinic Hospitals Thoracic (N = 1,985)

34.1% Main Campus Cardiac (N = 4,148)34.1% Main Campus Cardiac (N = 4,148)

11.3% Main Campus Thoracic (N = 1,380)11.3% Main Campus Thoracic (N = 1,380)

25.1% Other Cleveland Clinic Hospitals Cardiac (N = 3,056)25.1% Other Cleveland Clinic Hospitals Cardiac (N = 3,056)

13.2% Other Cleveland Clinic Hospitals Other (N = 1,600)13.2% Other Cleveland Clinic Hospitals Other (N = 1,600)

100%100%

2011

27 % of the 4,148 cardiac

surgeries performed

at Cleveland Clinic’s

main campus in 2011

were reoperations.

The complexity and

risk associated with

reoperations, or

“redos,” are greater

than with primary

(first-time) operations.

9

Main Campus

2011

Cardiac Surgery Hospital Mortality (N = 4,148)

Among the top U.S. hospitals for cardiac surgery, Cleveland Clinic’s volume was the highest, with the best-quality outcomes (lowest O/E mortality ratio).

O/E = Observed/expected

Observed mortality = Actual mortality

Expected mortality = Predicted number of deaths based on severity of illness.

Cleveland Clinic is the national leader in cardiac surgery volumes. In 2011, Cleveland Clinic performed 32 percent more open heart surgeries than the next leading U.S. hospital.

Source: University HealthSystem Consortium (UHC) Comparative Database, 2011 discharges.


Open Heart Surgery Volume Comparisons (N = 4,740)

2009 – 2011

ClevelandClinic

Top U.S. Hospitals

A B C D E F

5,0005,000

4,0004,000

3,0003,000

VolumeVolume

2,0002,000

1,0001,000

00

200920102011

5,0005,000

4,0004,000

3,0003,000

2,0002,000

1,0001,000

00

1.21.2

1.01.0

0.80.8

0.60.6

0.40.4

0.20.2

2011 Volume2011 Volume Mortality Index (O/E ratio)

FEDCBAClevelandClinic

Top U.S. Hospitals

Sydell and Arnold Miller Family Heart & Vascular Institute

10

Hospital Mortality – Isolated Procedures (N = 1,426) 2011

Hospital Mortality – Combined Procedures (N = 347) 2011

1010

88

00CABG Aortic Valve

ReplacementMitral ValveReplacement

Mitral ValveRepair

0%

0.3O/E Ratio = 0.14 0.23 0

ObservedSTS Expected

66

44

22

Percent

1212

1010

88

00Aortic ValveReplacement

+ CABG

Mitral ValveReplacement

+ CABG

Mitral Valve Repair+ CABG

0.09O/E Ratio = 0.32 0.46

ObservedSTS Expected

66

44

22

Percent

Source: Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database 2011.

Abbreviations: CABG, coronary artery bypass graft.

Source: Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database 2011.

Abbreviations: CABG, coronary artery bypass graft.

The observed mortality for all isolated procedures in 2011 was lower than the expected mortality, resulting in low O/E mortality ratios. Isolated procedures are those performed without any other surgical procedure.

Combined surgical procedures involve more than one treatment at the time of surgery and are generally more complex than isolated procedures. Despite the increased complexity, Cleveland Clinic had a low O/E mortality ratio in 2011 for combined procedures.

Outcomes 2011

Surgical Overview (continued)

11

Vascular Surgery Volume (N = 6,605)Main Campus and Other Cleveland Clinic Hospitals

2002 – 2011 Cleveland Clinic surgeons performed 6,605 vascular surgical procedures in 2011. This includes procedures at our main campus and Cleveland Clinic hospitals within the greater Cleveland area. For a complete list of these hospitals, please refer to the Institute Locations section that begins on Page 108 of this book.

Pulmonary procedures accounted for the majority of major thoracic surgical procedures at Cleveland Clinic in 2011. Our surgeons treat patients with a variety of conditions of varying complexity.

In 2011, Cleveland Clinic performed 1,380 thoracic surgeries.

2007 – 2011

2011

General Thoracic Surgery Volume (N = 1,380)

Major Thoracic Surgery by Type (N = 1,380)

20112007 2008 2009

2,0002,000

1,5001,500

500500

1,0001,000

00

VolumeVolume

2010

2003 2005 20072002 2004 2006 2008 2009 2010

8,0008,000

6,0006,000

4,0004,000

VolumeVolume

2,0002,000

002011

Other Cleveland Clinic HospitalsMain Campus


10% Mediastinum/Diaphragm (N = 138)10% Mediastinum/Diaphragm (N = 138)

39% Pulmonary (N = 536)39% Pulmonary (N = 536)

18% Esophagus (N = 248)18% Esophagus (N = 248)

15% Pleura (N = 207)15% Pleura (N = 207)

8% Lung Transplant (N = 108)8% Lung Transplant (N = 108)10% Other (N = 143)10% Other (N = 143)

100%100%

12

The hospital mortality average for vascular surgery at Cleveland Clinic (CC) from 2007 to 2011 was 2.16 percent. This is nearly three times lower than the adjusted average of 5.96 percent at national teaching hospitals.

Vascular Surgery by Approach (N = 6,605)

The majority of vascular procedures in 2011 were performed using an endovascular approach. The use of endovascular surgery reduces patient morbidity and mortality and results in a shorter recovery time.

Hospital Mortality — Vascular Surgery

Source: Solucient

2011

2007 – 2011

100%100%

53% Endovascular Surgery (N = 3,486)

47% Open Surgery (N = 3,119)

1010

88

66

44

22

00≤ 49920

50–591,131

60–692,040

≥ 801,328

70–792,303

Mortality (%)

AgeCC N =

CCNational Teaching Hospitals

Outcomes 2011

Surgical Overview (continued)

12

Cardiac Catheterization Laboratory Procedures (N = 10,818)

Cleveland Clinic is a regional and national referral center for percutaneous coronary intervention (PCI). In 2011, we performed more than 10,000 procedures for patients with simple and complex ischemic disease.

Data comparisons represent Cleveland Clinic’s outcomes with patients at hospitals included in the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) Cath-PCI Registry® for hospitals that perform > 500 PCIs/year. All comparison data are based on a one-year rolling average. Therefore, there may be differences compared with totals reported elsewhere in this book.

Use of Adjunctive Medications Before and After PCI (N = 1,833)2011

100

95

80Aspirin on Admission

Before Procedure

Statins Thienopyridines

At Discharge

Aspirin

90

85

PercentCleveland ClinicComparable ACC-NCDR Hospitals

One of the ACC-NCDR key performance measures is the use of appropriate adjunctive medications before and after PCI procedures. Compared with the average high-volume interventional center, Cleveland Clinic exceeds the rate of administration for all these medications.

60

50

0Age

(> 75 years)Prior MIAcute Care

TransferPrior Heart

FailurePrior CABG Severe LV

DysfunctionMultivessel

DiseaseDiabetes

40

30

20

10

Percent Comparable ACC-NCDR HospitalsCleveland Clinic

Ischemic Heart Disease

Risk Factors Among Patients Undergoing PCI Procedures (N = 1,833)2011

In many cases, patients who had PCI procedures at Cleveland Clinic in 2011 had more complex medical backgrounds than patients at comparable hospitals.

13

Abbreviations: CABG, coronary artery bypass grafting; LV, left ventricular; MI, myocardial infarction.


14

4

3

0Risk-Adjusted Mortality Major Vascular Complications

2

1

Percent

Comparable ACC-NCDR HospitalsCleveland Clinic

Patients who had PCI procedures at Cleveland Clinic in 2011 had fewer complications (mortality, major vascular complications) than patients at comparable hospitals.

Ischemic Heart Disease (continued)

PCI Complications2011

Door-to-Balloon Time (N = 55)*2011

*A total of 55 patients treated for myocardial infarc-tion at Cleveland Clinic’s ED met the ACC-NCDR reporting criteria for a primary diagno-sis of STEMI. Among these patients, time for reperfusion was 58 minutes. The rate at comparable hospitals was 62 minutes.

The American College of Cardiology/American Heart Association (ACC/AHA) practice guidelines recommend PCI balloon inflation within 90 minutes of arrival in the emergency department (ED) for patients with ST-elevation myocardial infarction (STEMI). Early reperfusion reduces the risk of morbidity and mortality.

80

100

6260

0Cleveland Clinic Comparable ACC-NCDR

Hospitals ACC/AHA Goal

40

20

Minutes

58

90

4

3

0Cleveland Clinic O/E RatioComparable ACC-NCDR

Hospitals

2

1

Percent

ExpectedObserved

PCI Mortality2011

The observed rates of mortality for patients who had PCI procedures at Cleveland Clinic in 2011 were lower than expected, resulting in a favorable O/E ratio.

Outcomes 2011

15

Surgical Treatment for Ischemic Heart Disease

CABG Volume (N = 1,355)2011

CABG Volume, Primary and Reoperations2011

CABG + Other, Mortality2011

Cleveland Clinic’s mortality rate for patients who had CABG plus another procedure was less than half of the expected rate, despite the fact that nearly one quarter of all these operations were reoperations, which are generally more complex with increased risk.

77% Primary Operations77% Primary Operations

23% Reoperations 23% Reoperations

100%100%

Procedure Volume

Isolated 527

CABG + Other 828

In 2011, Cleveland Clinic performed 1,355 coronary artery bypass grafting (CABG) procedures. A total of 527 were isolated procedures (performed without any other operation), and 828 were performed in combination with another procedure.

Primary procedures (patients’ first CABG) accounted for the majority of all CABG surgeries.

00

66

Cleveland Clinic Expected

22

44

PercentPercent

Primary Reoperation

44

PercentPercent

33

22

11

00

ExpectedCleveland Clinic

Source: University HealthSystem Consortium 2011 discharges.Source: University HealthSystem Consortium 2011 discharges.


16

★★★

★★


Cleveland Clinic is among

the 15 percent of hospitals

that achieved an overall

three-star rating from

The Society of Thoracic

Surgeons (STS) for CABG

surgery. The rating reflects

the highest quality of

cardiac surgery.

*Based on data comparisons from January 2011 through December 2011.

Primary (N = 459) Reoperation (N = 68)

44

PercentPercent

33

22

11

00

Expected

0%

Observed

Isolated CABG Procedures Mortality

In 2011, Cleveland Clinic surgeons performed 527 isolated CABG procedures with lower-than-expected mortality.

Source: University HealthSystem Consortium 2011 discharges.

Source: Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database, 2011.

STS CABG Quality Ratings*

Overall

Use of Internal Mammary Artery

Medications

Avoidance of Mortality

Avoidance of Morbidity

5

4

0Q1 Q3 Q4Q2

3

2

1

Percent

Cleveland ClinicSTS Expected

0% 0% 0%

Isolated CABG Mortality – Primary and Reoperation

Because of our expertise, we often receive referrals for reoperations. These are associated with greater morbidity and mortality than are primary procedures. Despite increased risks, overall mortality for isolated CABG remained low.

Outcomes 2011Outcomes 2011

17

Primary Isolated CABG: Age-Related Risk of Mortality

2011 Age Observed Mortality (%) Expected Mortality (%)

< 50 years (N = 50) 0.0 1.0

50–59 years (N = 113) 0.9 1.0

60–69 years (N = 165) 0.6 1.2

70–79 years (N = 98) 1.0 2.7

≥80years(N=33) 0.0 4.0

Total (N = 459) 0.6 1.6

5

4

0Q1 Q3 Q4Q2

3

2

1

Percent


0% 0% 0% 0%

Isolated CABG: Additional Outcomes

In addition to mortality, other outcomes for isolated CABG at Cleveland Clinic contributed to the achievement of a Three-Star STS quality rating.


Age contributes to the complexity of CABG surgical cases. The majority of patients who had primary isolated CABG surgery in 2011 at Cleveland Clinic were age 60 and older.

Deep Sternal Wound Infection2011

Throughout 2011, Cleveland Clinic maintained a 0 percent incidence of deep sternal wound infection following isolated CABG surgery.


18

20

0Q1 Q3 Q4Q2

15

10

5

Percent


20

0Q1 Q3 Q4Q2

15

10

5

Percent


10

0Q1 Q3 Q4Q2

8

6

4

2

Percent


Ventilator Time > 24 Hours

Cleveland Clinic continues to work toward reducing the number of patients who require a ventilator for more than 24 hours after isolated CABG surgery. Reduced ventilator time leads to better outcomes and increased patient satisfaction.

In-Hospital Reoperation

Cleveland Clinic’s rate of in-hospital reoperation after CABG surgery was consistently below the expected rate throughout 2011.

Postoperative Stroke

Cleveland Clinic continues to work toward reducing the incidence of stroke after isolated CABG surgery.





Outcomes 2011

Acute Myocardial Infarction (AMI) Appropriateness of Care – National Hospital Quality Measures

2010 – 2011

This composite metric, based on eight acute myocardial infarction hospital quality process measures developed by the Centers for Medicare and Medicaid Services (CMS), shows the percentage of patients who received all the recommended care for which they were eligible. Cleveland Clinic has set a target of UHC’s 90th percentile.

19

0

60

40

20

80

100Percent

98.6 97.0 99.3

Cleveland Clinic UHC Top Decile*

2010 20112011

Cleveland Clinic, 2010

Cleveland Clinic, 2011

UHC Top Decile, 2011*

10

0Q1 Q3 Q4Q2

8

6

4

2

Percent


0%

100

0Q1 Q3 Q4Q2

80

60

40

20

Percent

Postoperative Renal Failure

In 2011, we improved the rate of postoperative renal failure following CABG surgery.

Process Measures

Cleveland Clinic achieved and maintained 100 percent compliance with all Society of Thoracic Surgeons (STS) process measures in 2011. These include the use of a peri-operative beta blocker; beta blocker, statin, and aspirin at discharge; and use of an internal mammary artery during isolated CABG surgery.



Source: University HealthSystem Consortium (UHC) Clinical Database. https://www.uhc.edu


0

5

10

15

20

25

30

Percent

National Average*

19.722.1

Cleveland Clinic

AMI All-Cause 30-Day Mortality (N = 385)

July 2008 – June 2011

Source: www.hospitalcompare.hhs.gov

AMI All-Cause 30-Day Readmission (N = 662)

July 2008 – June 2011

0

5

10

15

20

25

30

Percent

National Average*

15.515.0

Cleveland Clinic

Source: www.hospitalcompare.hhs.gov

Acute Myocardial Infarction (AMI) – National Hospital Quality Measures (continued)

Cleveland Clinic’s AMI risk-adjusted all-cause 30-day mortality rate is slightly below the national average; the difference is not statistically significant. Our AMI risk-adjusted readmission rate is higher than the national average; that difference is statistically significant. To reduce this rate, transition-of-care strategies are being developed and deployed at Cleveland Clinic. These include predischarge needs assessment, improved discharge processes (patient education, relay of discharge information to receiving providers) and postdischarge follow-up, including continued clinical management support.

20

The Centers for Medicare and Medicaid Services (CMS) calculates two AMI outcome measures: all-cause mortality and all-cause readmission rates. Each are based on Medicare claims and enrollment information. Cleveland Clinic’s performance appears below.


Outcomes 2011


1,5001,500

PacemakersNon-CRT

PacemakersNon-CRT

PacemakersCRT

PacemakersCRT

ICDsNon-CRT-D

ICDsNon-CRT-D

ICDsCRT-DICDs

CRT-DAblations

PVAIAblations

PVAIAblations

VTAblations

VTAblations

OtherAblations

OtherCardioversionsCardioversions Other

ProceduresOther

Procedures

VolumeVolume

1,2001,200

900900

600600

300300

00

Cardiac Rhythm Disorders

Cleveland Clinic electrophysiologists use specialized approaches to diagnose and treat a wide variety of arrhythmias. In 2011, we performed more than 4,000 procedures. The total number of procedures includes some that are not detailed in the graph below.*

EP Laboratory Procedures (N = 4,605)2011

Pulmonary Vein Antrum Isolation (PVAI) Procedures

Pulmonary vein antrum isolation (PVAI) essentially disconnects the pathway of the abnormal heart rhythm and prevents atrial fibrillation. A total of 6,488 ablations for atrial fibrillation were performed at Cleveland Clinic from 2004 through 2011.

PVAI 775

PVAI Volume

2011

*Other procedures include EP Study, ICD Testing, Temporary Pacer, Loop Recorders, and EP Specials (endomyocardial biopsy, esophageal pacing, right heart catheterization, venography and other).

Abbreviations: CRT, cardiac resynchronization therapy; CRT-D, cardiac resynchronization therapy-defibrillator; ICD, implantable cardioverter defibrillator; PVAI, pulmonary vein antrum isolation; VT, ventricular tachycardia.

22

PVAI Complications2011

In 2011, the overall risk of serious complications was 1.9 percent.*

Complications Number Percent

Pericardial Tamponade / Pericardiocentesis 4 0.5

Pericardial Tamponade / Surgical 1 0.1

Transient Ischemic Attack (TIA) 1 0.1

Cerebrovascular Accident (CVA) 1 0.1

Arterial Dissection 1 0.1

Pseudoaneurysm 1 0.1

Pulmonary Edema 1 0.1

Urinary Tract Infection (UTI) / Bacteremia 1 0.1

Diaphragmatic Paralysis 2 0.3

Gastroparesis 1 0.1

Pacemaker Lead Dislodged 1 0.1

Total 15 1.9

Cardiac Rhythm Disorders (continued)

Success Rates of PVAI

Success is defined as a restored sinus rhythm without dependency on medications for at least 12 months after the procedure. This is influenced by a number of factors, including the length of time the patient has been in atrial fibrillation (AF) and the presence or absence of underlying heart disease.

In a recent study of 831 patients who underwent pulmonary vein isolation at Cleveland Clinic, 81 percent of patients with paroxysmal AF were arrhythmia-free while off antiarrhythmic drugs (AADs) at 12 months post-ablation. Paroxysmal AF is defined as AF that terminates within days without cardioversion. A total of 7.8 percent of this patient population had AF after one year post-ablation (late-recurrence AF).

The success rate is lower for patients with persistent or long-standing persistent AF (65 percent for a single ablation procedure), and is affected by the presence of valvular heart disease or other underlying problems.

A total of 161 patients who had early recurrence of AF had a repeat ablation procedure. At 14 months after this ablation, 78.9 percent were arrhythmia-free while off AAD. Of the 27 patients who had late-recurrence AF and a repeat ablation, 74.1 percent were arrhythmia-free while off AAD at 17 months post-second ablation.

Reference: Hussein AA, Saliba WI, Martin DO, Bhargava M, Sherman M, Magnelli-Reyes C, Chamsi-Pasha M, John S, Williams-Andrews M, Baranowski B, Dresing T, Callahan T, Kanj M, Tchou P, Lindsay BD, Natale A, Wazni O. Natural history and long-term outcomes of ablated atrial fibrillation.Circ Arrhythm Electrophysiol. 2011 Jun;4(3):271-8. Epub 2011 Apr 14.

Outcomes 2011

The majority of patients who have a PVAI procedure at Cleveland Clinic return within 3 to 4 months for follow-up imaging to assess for PV stenosis. Because of the time from treatment to follow-up, at the time of publication of this book, we are unable to report the 2011 data for rates of PV stenosis. In 2010, we performed 693 PVAI ablation procedures. Three of these patients were treated for PV stenosis, which equates to an incidence of 0.43 percent.

*All percentages were rounded, resulting in a (-.2) difference in the total percentage of complications.

23

Cleveland Clinic’s Center for

Atrial Fibrillation provides

customized catheter-based treatment that incorporates

comprehensive, state-of-the-art

technology to effectively cure

atrial fibrillation.


Ablation of Ventricular Tachycardia (N = 115)2011

Complete Success Rate* 79%

*All ventricular tachycardias were eliminated in 79 percent of patients, and the procedure was partially successful in another 15 percent. Partial success means at least one tachycardia was ablated in patients who had multiple tachycardias. A total of 6 percent of procedures were unsuccessful.

2011

In 2011, Cleveland Clinic cardiovascular surgeons performed 404 surgical procedures to treat atrial fibrillation (AF). These included minimally invasive “keyhole” and classic Maze procedures. The majority of these procedures were done in combination with other cardiac procedures. Overall hospital mortality was 1.2 percent (N = 5).

100%100%

7% AF + CABG (N = 29; Hospital Mortality, N = 0)7% AF + Other Procedures (N = 30; Hospital Mortality, N = 1) 1% Isolated AF Procedures (N = 4; Hospital Mortality, N = 1)

24% AF + Valve Surgery + CABG (N = 97; Hospital Mortality, N = 2)

61% AF + Valve Surgery (N = 244; Hospital Mortality, N = 1)

Atrial Fibrillation Surgical Procedure Volume (N = 404)

Cleveland Clinic is a national referral center for patients with ventricular arrhythmias. In 2011, we performed 115 ablations to correct ventricular arrhythmias.

Device Clinic Evaluations Volume (N = 30,513)2011

Pacemaker Evaluations 14,668

ICD Evaluations 15,845

Cardiac Rhythm Disorders (continued)Cardiac Rhythm Disorders (continued)

24 Outcomes 2011

Device Implants Volume (N = 1,351)

Device Lead Extractions

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

2011 270 460 100 0.0

2010 241 399 99 0.7

2009 263 443 98.1 1.1

2008 250 451 99.1 0.8

2007 249 445 99.8 0.4

2006 357 636 99.2 0.0

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

2011

ICDs 765

Pacemakers 586

Leads in Place > 1 Year or Requiring Extraction Technology

Cleveland Clinic physicians in the electrophysiology laboratory implanted 1,351 devices in 2011. This includes 382 implantable devices to provide cardiac resynchronization therapy to patients with heart failure.

Electrophysiologists at Cleveland Clinic perform the greatest number of lead extractions in the world. Many of our patients have complex conditions that result in referral to our physicians. Leads may need removal because of electrical malfunctions, blocked blood vessels or infection. In most cases, the leads can be removed without opening the chest or heart.

Cleveland Clinic was the first hospital in the country to integrate a patient database for pacemaker and implantable cardioverter defibrillator (ICD) follow-up with electronic medical records. This innovative approach to follow-up allows us to keep track of our patients’ health conditions regardless of their location. Remote monitoring is also associated with increased longevity and decreased need for in-person follow-up.

We use the MyChart® function in Epic, Cleveland Clinic’s electronic medical record system, to quickly notify patients of their device status.

12,000

9,000

6,000

3,000

02008 2009 2010 20112006 2007

Volume

2011

Remote Pacemaker Transmissions 3,176

Remote ICD Transmissions 7,969

Remote Device Evaluations Volume (N = 11,145)

1,000

800

600

400

200

0AutonomicReflex/HRV

BloodVolume

Tilt Table Hemodynamic

Volume

1.7average number of leads

extracted per procedure

87.3 monthsaverage lead age at removal

69.4 monthsmedian lead age at removal

25

Evaluation of Patients with Syncope2011

Cleveland Clinic electrophysiologists and neurologists work collaboratively to evaluate patients with unexplained loss of consciousness (syncope). Evaluation includes blood volume studies, tilt table testing, hemodynamic testing, and heart rate variability (HRV) and autonomic reflex testing.


Outcomes 201126

Valve Disease

Distribution of Isolated and Combined Valve Operations (N = 2,816)

The majority of valve operations performed at Cleveland Clinic in 2011 were combined primary procedures. However, reoperations accounted for 28 percent of all valve surgeries. These procedures are typically more complex and challenging than primary procedures.

16.7% Combined Valve Reoperations (N = 469)16.7% Combined Valve Reoperations (N = 469)

11.3% Isolated Valve Reoperations (N = 317)11.3% Isolated Valve Reoperations (N = 317)

29.5% Isolated Primary Valve Surgeries (N = 831)29.5% Isolated Primary Valve Surgeries (N = 831)

42.5% Combined Primary Valve Surgeries (N = 1,199)42.5% Combined Primary Valve Surgeries (N = 1,199)100%100%

28%28%

3,0003,000

2,0002,000

1,0001,000

0020082007 2009 2010

VolumeVolume

2011

In 2011, Cleveland Clinic surgeons performed 2,816 valve surgeries. This includes 2,030 primary operations and 786 reoperations. Cleveland Clinic continues to be the leader in the number of valve surgeries performed in the United States.

Valve Surgery Volume 2007 – 2011

2011

26

Cleveland Clinic recently

received The Society of

Thoracic Surgeons’ (STS)

prestigious three-star rating

for aortic valve replacement.

The rating is awarded to

hospitals across the country

that demonstrate the

highest quality of cardiac

surgery. Cleveland Clinic

was awarded the rating

based on data comparisons

from January 2009 through

December 2011.


Distribution of Isolated and Combined Valve Operations (N = 2,816)

★★★

Aortic Valve (AV) Surgery Volume (N = 1,739) 2007 – 2011

Cleveland Clinic performs the largest number of aortic valve operations in the nation. In 2011, we performed 1,739 aortic valve operations. Ninety-one percent were valve replacements (N = 1,553), 5 percent were valve repairs (N = 101) and 4 percent were valve-sparing operations (N = 85).

2,0002,000

1,0001,000

1,5001,500

500500

00

AV-SparingAV RepairAV Replacement

AV-SparingAV RepairAV Replacement

2009

Volume

2007 2008 2010 2011

The hospital mortality rate at Cleveland Clinic for patients who had an isolated aortic valve replacement in 2011 was 0.6 percent. This is significantly lower than The Society of Thoracic Surgeons’ (STS) benchmark of 3.5 percent. Hospital mortality rates for all other aortic valve replacement procedures were also lower than the STS benchmark.Source: Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database, 2011.

Isolated Aortic Valve Replacement Mortality (N = 1,553) 2011

00

66

Isolated

PrimaryReoperation

STS Expected

Combined

22

44

PercentPercent

27

Outcomes 201128

Valve Disease (continued)

Patients who had isolated aortic valve replacement surgery at Cleveland Clinic in 2011 had fewer complications than expected, according to The Society of Thoracic Surgeons’ (STS) benchmarks.

Isolated Aortic Valve Replacement Complications 2011

Mitral Valve Surgery Volume (N = 1,286) 2011

Cleveland Clinic is the nation’s leader in mitral valve surgery volume. Our surgeons performed 1,286 mitral valve surgeries in 2011. A total of 870 (68%) were repairs and 416 (32%) were replacements.

00

88

Deep SternalWound Infection

Post-OpStroke

Post-OpRenal Failure

Post-OpReoperation

(any)

Observed STS Expected

22

66

44

PercentPercent

1,0001,000

800800

600600

00

Volume

Replace Repair

400400

200200



Mitral Valve Surgery Volume – Repair vs. Replacement 2007 – 2011

Cleveland Clinic surgeons performed mitral valve repairs before it was the preferred treatment for patients with mitral valve disease. Valve repair, rather than replacement, is associated with better survival, improved lifestyle, better preservation of heart function, and lower risk of stroke and infection (endocarditis), and there is no need for anticoagulation therapy. The majority of mitral valve repairs at Cleveland Clinic are performed using a minimally invasive approach.

0

60

40

20

80Percent

20112007 2008 2009

Replacement

Repair

2010

29

*Isolated mitral valve repair based on STS data from Oct. 1, 2010 to Sept. 31, 2011

Primary Isolated Mitral Valve Surgery Hospital Mortality* 2011

In 2011, Cleveland Clinic had the country’s lowest mortality rate (0%) for primary isolated mitral valve repair. The mortality rate for patients who had a primary isolated mitral valve replacement was also well below The Society of Thoracic Surgeons’ (STS) benchmark.

00

66

Replace


Repair

0%

22

44

PercentPercent

Outcomes 201130

Infective endocarditis is a life-threatening disease. It causes bacterial or fungal growths on the heart valves that can lead to perforation, rupture and subsequent valve regurgitation. Prompt diagnosis and treatment are critical. Cleveland Clinic surgeons treat a variety of patients with infective endocarditis, including those with advanced disease and prosthetic valve endocardititis.

In 2011, we performed 128 surgical procedures to treat infective endocarditis and maintained low mortality rates.

Surgical Treatment of Infective Endocarditis

Volume and Hospital Mortality (N = 128)

2007 – 2011


Valve Replacement Prostheses Volume and Type 2007 – 2011

The majority (92.7%) of valve replacement procedures at Cleveland Clinic in 2011 involved bioprostheses (biologic tissue valves). Bioprostheses are preferred for most aortic and mitral valve procedures because they are durable and help most patients avoid lifelong anticoagulant therapy after surgery.

0

1,500

1,000

500

2,000Volume

2007 2008 2009 2010 2011

Mechanical

Bioprostheses

Allografts

180180

150150

120120

9090

6060

3030

002007 2008 2009 2010

Volume2424

2020

1616

1212

88

44

00

ReoperationMortality (%)

Primary

2011

Percutaneous Mitral Valvuloplasty Volume and Hospital Mortality 2007 – 2011

Many Cleveland Clinic patients with mitral valve stenosis are treated with percutaneous mitral valvuloplasty. The mortality rate is consistently 0 percent with this procedure, and patients experience a shorter recovery than those who have traditional surgery.

3030

2020

1010

00

3030

2020

1010

002007 2008 2009 2010 2011

Volume Mortality (%)


Robotically Assisted Mitral Valve Repair Volume

2007 – 2011

Robotically Assisted Valve Surgery (N = 160)

Cleveland Clinic performs more robotically assisted mitral valve surgeries than any major academic hospital in the United States.

Cleveland Clinic surgeons performed 160 robotically assisted mitral valve repairs in 2011.

00

300300

2007 2008 2009 2010

100100

200200

VolumeVolume

2011

0% Hospital MortalityThe hospital

mortality rate for

robotically assisted

valve surgeries

was 0 percent in

2011.

31

1515

1010

55

00Isolated

AVRAVR +CABG

Isolated MVR

MVR +CABG

Isolated MVRepair

0% 0%

MV Repair+ CABG

SeptalMyectomy

ObservedExpected

Percent

Outcomes 201132


Valve Surgery Mortality 2011

Cleveland Clinic is the nation’s leader in valve surgery volume and quality. Compared with comparable hospitals, mortality rates for valve surgery are far lower.

Percutaneous Valve TreatmentsCleveland Clinic remains dedicated to developing and using the best possible percutaneous methods to treat patients with valve disease. We are a national leader in these types of procedures.

Source: University HealthSystem Consortium (UHC) Comparative Database, January through November 2011 discharges.

Sources: 1. Kodali SK, O’Neill WW, Moses JW, et al. Early and Late (One Year) Outcomes Following Transcatheter Aortic Valve Implantation in Patients with Severe Aortic Stenosis (from the United States REVIVAL Trial). Am J Cardiol. 2011;107:1058-1064. 2. Svensson LG, Dewey T, Kapadia S, et al. United States Feasibility Study of Transcatheter Insertion of a Stented Aortic Valve by the Left Ventricular Apex. Ann Thorac Surg. 2008;86:46-55. 3. Leon MB, Smith CR, Mack M, et al. Transcatheter Aortic-Valve Implantation for Aortic Stenosis in Patients Who Cannot Undergo Surgery. N Engl J Med. 2010;363:1597-1607. 4. Smith CR, Leon MB, Mack MJ, et al. Transcatheter versus Surgical Aortic-Valve Replacement in HIgh-Risk Patients. N Engl J Med. 2011;364:2187-2198.

Transcatheter Aortic Valve Replacement Volume and 30-Day Mortality 2007 – 2011 In 2011, Cleveland Clinic performed 105

percutaneous aortic valve replacements. The procedure, also referred to as transcatheter aortic valve replacement (TAVR), is FDA-approved to treat patients who meet specific criteria. Cleveland Clinic continues to participate in the Placement of Aortic Transcatheter Valves (PARTNER) trial to assess use of this procedure to treat other patient populations.

00

120120Volume

2007 2008 2009 2010

8080

4040

00

1515

1010

55

Mortality (%)

2011

Expected Mortality (%)

Abbreviations: AVR, aortic valve replacement; CABG, coronary artery bypass grafting; MV, mitral valve; MVR, mitral valve replacement.


PARTNER II Trial Cleveland Clinic is

currently recruiting

patients for the second

arm of the Placement

of Aortic Transcatheter

Valves (PARTNER

II) trial. This phase

involves a randomized

study of patients who

have a moderately

high risk associated

with traditional surgery

to treat severe aortic

stenosis. Researchers

are studying the use

of percutaneous aortic

valve replacement in

this patient population.

The procedure is done

through the transfemoral

or left subclavian artery

or via a transapical

approach. Research also

includes an approach

through the ascending

aorta via a mini-J

incision.

Percutaneous Aortic Valvuloplasty Volume and Hospital Mortality

00

120120Volume

2007 2008 2009 2010

8080

4040

00

1515

1010

55

Expected Mortality (%)Mortality (%)

2011

Cleveland Clinic is a national leader in the development and use of percutaneous valve treatments.

A total of 1,173 aortic surgeries were performed at Cleveland Clinic in 2011. The majority were open procedures to repair the ascending aorta/arch.

1,5001,500

1,0001,000

500500

00

Volume

20052003 2007 2009 201020042002 2006 2008

Open Ascending/Arch Repair (N = 707) Open Ascending/Arch Repair (N = 707)

Open Descending/ThoracoabdominalRepair (N = 110)Open Descending/ThoracoabdominalRepair (N = 110)

Endovascular Descending/Thoracoabdominal Repair (N = 210)Endovascular Descending/Thoracoabdominal Repair (N = 210)

Open Abdominal Repair (N = 59)Open Abdominal Repair (N = 59)

Endovascular AbdominalRepair (N = 87)Endovascular AbdominalRepair (N = 87)

2011

Outcomes 201134

Cleveland Clinic uses a comprehensive, multidisciplinary approach to treat patients with aortic disease.

Using conventional, minimally invasive and endovascular techniques, our surgeons treat all sections of

the aorta, from the aortic valve to the blood supply to the pelvic vasculature.

Aortic Surgery Volume and Type (N = 1,173)2002 – 2011

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

or 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.

34


Open Ascending Aorta and Arch Disease Surgery Volume2007 – 2011 In 2011, Cleveland Clinic

performed 707 elective and emergency procedures to treat patients with problems of the ascending aorta and arch. Over time, the number of minimally invasive techniques performed has increased.

Elective Ascending Aorta and Arch Surgery Volume, Stroke and Mortality2007 – 2011

Emergency Ascending Aorta and Arch Surgery Volume and Mortality2007 – 2011

Patients who require emergency treatment of the ascending aorta and arch represent a challenging population. In 2011, we performed 209 of these procedures and maintained a low mortality rate of 7.2 percent.

Cleveland Clinic performed 498 elective ascending aorta and arch surgeries. Rates of stroke and mortality were 2 percent and 0.4 percent, respectively.

2011

800800

400400

200200

002007 2008 2009

600600

Volume

2010

00

250250300300350350

150150200200

1001005050

00

3535

2020

3030

1515

2525

1010

Volume Volume Hospital Mortality (%)

2007 2008 2009 2010

5

2011

00

500500

300300

400400

200200

100100

00

1010

66

88

44

Volume Volume Stroke (%)Hospital Mortality (%)

2007 2008 2009

2

2010 2011

Cleveland Clinic’s Acute Aortic Treatment Center provides rapid

transport, treatment and

follow-up for patients

with aortic dissection

and impending aneurysm

rupture. More than 4,500

patients were transported

by Cleveland Clinic’s Critical

Care Transport team in

2011. More than one-third

of the patients transported

were treated in the Miller

Family Heart & Vascular

Institute, and many had

acute aortic syndromes.

Call 877.379.CODE

(2633) to expedite the

transfer of patients with

acute aortic syndromes.

Outcomes 201136

Aortic Disease (continued)

Aortic Arch Aneurysm Repairs

In 2011, Cleveland Clinic surgeons performed 222 procedures to repair aortic arch aneurysms. Of these, 152 were elective and 70 were emergency surgeries. Aortic arch aneurysms are one of the most complicated conditions to treat. We use open and endovascular procedures that incorporate the use of fenestrations, branches or hybrid techniques. Despite the complexity of these procedures, the rate of death and stroke remained low.

Elective Arch Aneurysm Operations Volume, Stroke and Mortality 2007 – 2011

Emergency and Urgent Arch Aneurysm Operations Volume, Stroke and Mortality 2007 – 2011

00

200200

100100

5050

150150

VolumeVolumeStroke (%)Hospital Mortality (%)

20102007 2008 200900

2020

1515

1010

5

2011

00

2525

1515

2020

1010

VolumeVolumeStroke (%)Hospital Mortality (%)

5

20102007 2008 200900

150150

9090

6060

3030

120120

2011

3-D reconstruction of aortic arch aneurysm complicating a chronic aortic dissection.

3-D reconstruction of an aortic arch branch graft. There are branches for the innominate and left common carotid arteries. This technique allows treatment of very complex anatomy without opening the chest.

Outcomes 2011

Reference: Roselli EE, Sepulveda E, Pujara AC, Idrees J, Nowicki E. Distal landing zone fenestration facilitates endovascular elephant trunk completion and false lumen thrombosis. Annals of Thoracic Surgery. 2011 Dec;92(6):2277.

Reference: Roselli EE, Qureshi A, Idrees J, Lima B, Greenberg RK, Svensson LG, Pettersson G. Open, hybrid, and endovascular treatment for aortic coarctation and postrepair aneurysm in adolescents and adults. Ann Thorac Surg. 2012 Jun 15. [Epub ahead of print]


Novel Technique for Chronic Extensive Dissection with Aneurysm

Coarctation and Late Complications in Adults and Adolescents

A growing number of adults and adolescents are diagnosed with aortic coarctation after childhood. The number of patients who have late complications after treatment is also rising. Our multidisciplinary team has extensive experience using open, hybrid and endovascular procedures to treat patients in this population. During a 10-year study of 110 patients treated with these procedures, there was no incidence of hospital mortality.

Cleveland Clinic surgeons are internationally recognized as some of the best-trained surgeons to treat patients with extensive thoracic aneurysmal disease. We use a comprehensive, multidisciplinary approach that allows each patient to receive the best possible individual treatment.

Patients who survive an acute dissection that involves multiple segments of the aorta often require multiple major operations to eliminate the risk of rupture and death. A novel approach combining open “elephant trunk” repair with a fenestration procedure of the distal aorta provides a dependable endovascular solution to complete the repair in these complex cases.

First-stage elephant trunk and distal fenestration

Open repair of post-coarctation aneurysm

Hybrid “Frozen elephant trunk” repair of post-coarctation aneurysm

Endovascular repair of adult coarctation

Second-stage stent graft

Outcomes 201138

Extensive experience with both open and endovascular treatment options for patients with descending thoracic aortic disease allows us to offer life-saving therapy to patients. This includes even those who require high-risk emergency treatment. For elective repairs, the mortality was low at 2.4 percent for open repairs and 2.8 percent for endovascular repairs in 2011.


Advances in the Genetic Understanding of Disease

Understanding rare aortic disease is a major priority for Cleveland Clinic’s Aortic Team. We have demonstrated 100 percent success in treating patients with Takayasu arteritis using an endovascular approach to place stent grafts. The stent grafts remained patent throughout the follow-up period. Newer endovascular techniques have allowed us to use alternate treatment methods that may lead to better outcomes than traditional, open surgery to treat patients with this complex disease.

Qureshi MA, Martin Z, Greenberg RK. Endovascular management of patients with Takayasu arteritis; stents versus stent grafts. Semin Vasc Surg. 2011 Mar;24(1):44-52.

Descending Thoracic Aortic (DTA) Disease

From 2008 through 2011, Cleveland Clinic performed 612 DTA repairs. The majority of these procedures were endovascular repairs.

DTA Repair Volume and Type (N = 612)

DTA Repair Hospital Mortality (N = 612)

2008 – 2011

2008 – 2011

22% Open Elective (N = 137)22% Open Elective (N = 137)

9% Open Emergency (N = 56)9% Open Emergency (N = 56)

47% Endo Elective (N = 287)47% Endo Elective (N = 287)

22% Endo Emergency (N = 132)22% Endo Emergency (N = 132)100%100%

2020

1515

1010

55

00Emergency

Open

2008 – 20102011

Elective

Mortality (%)

Emergency

Endo

Elective

It is common for aortic dissections or ruptured aneurysms to occur in the descending thoracic aorta (DTA). These conditions require rapid evaluation and treatment. Cleveland Clinic surgeons treat patients with these conditions using both open and endovascular procedures.

38

Reference: Lima B, Nowicki ER, Blackstone EH, Williams SJ, Roselli E, Sabik JF III, Lytle BW, Svensson LG. Spinal cord protective strategies during descending and thoracoabdominal aortic aneurysm repair in the modern era: the role of intrathecal papaverine. J Thorac Cardiovasc Surg. 2012 Apr;143(4):945-952.e1. Epub 2012 Feb 15.


Protection of Spinal Function

The repair of thoracoabdominal aneurysms has historically been associated with a risk of spinal cord injury or paralysis. We have worked to evolve our techniques to protect the spinal cord. In cases of thoracoabdominal aneurysm repair, this means frequently staging the repair so the impact on the spinal cord is gradual, rather than sudden. Our results to date show this approach is successful. The rate of spinal cord injury with this technique is 3.38 percent in all cases of thoracoabdominal aneurysms treated with endovascular devices. This rate is lower than that reported by other centers. We have also incorporated advanced techniques to protect the spinal cord during open thoracoabdominal aortic repairs. This includes adding papaverine to the intrathecal space during surgery, which helped reduce the rate of paraplegia to 3.6 percent.

Group II Thoracoabdominal aneurysm with previous infrarenal repair that has kinked over time.

Stage I: Fenestrated device in place, excluding the largest portion of the aneurysm

Stage II: Thoracic component added to exclude the thoracic portion of the aneurysm.

Stage III: Iliac aneurysms treated with branch graft to complete the repair.


Outcomes 201140


Thoracoabdominal aneurysm stent graft

TAA Surgeries by Type

Thoracoabdominal Aortic (TAA) Surgeries

Our surgeons use both open and endovascular procedures to treat patients with diseases of the thoracoabdominal aorta (TAA). These are the most challenging aortic procedures.

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

2008 – 2011

5050

4040

3030

2020

00Type I Type II

EndovascularOpen

Type III Type IV

1010

Percent

40

Bifurcated-Bifurcated Device


Thoracoabdominal Aortic Aneurysm (TAAA) Surgery Volume and Type (N = 588)

TAAA Surgery Mortality

Despite the complexity of TAAA surgery, the mortality rates at Cleveland Clinic remain low. We continue to make improvements through the use of multimodality approaches. In 2011, the mortality rate for endovascular branch vessel procedures was 2.8 percent. The rate for open elective repairs was 3.13 percent. Emergency repairs require open surgery. The mortality rate for these procedures was 5.26 percent.

From 2008 through 2011, Cleveland Clinic surgeons performed 588 procedures to treat patients with TAAAs.

2008 – 2011

2008 – 2011

35% Open Surgeries (N = 207)35% Open Surgeries (N = 207)

65% Endovascular Branch Vessel Grafts (N = 381)65% Endovascular Branch Vessel Grafts (N = 381)

100%100%

5050

4040

3030

2020

1010

00

Elective TAAA Emergency

OpenEndovascular

2008 – 20102011

Percent

Open

41

Iliac aneurysms are common in patients with abdominal aortic aneurysms. This condition often limits the use of standard endografts for treatment. The goal of treatment with a bifurcated-bifurcated device is to eliminate the process of placing branched grafts into internal iliac arteries while allowing the preservation of blood flow to the pelvis.

Preserving pelvic blood flow is important because it contributes to spinal cord, buttock muscle and sexual function. Therefore, our patients have an improved quality of life after the repair.

Fewer components are needed to complete complex repairs when the bifurcated-bifurcated device is used. This results in a shorter operation and, ideally, a shorter recovery.

Outcomes 201142


Abdominal Aortic Aneurysms (AAA)

The abdominal aorta is second to the ascending aorta for aneurysm formation. Cleveland Clinic treats patients with AAAs both below and adjacent to the renal arteries. Our surgeons use both open and endovascular repair procedures.

AAA Procedure Volume and Type (N = 800)

Cleveland Clinic surgeons performed 800 AAA repair surgeries from 2008 through 2011. The majority of the procedures were endovascular repairs (endo and fenestrated grafts).

Open AAA Repair Volume and Type (N = 328)

Cleveland Clinic surgeons performed 328 open AAA repairs from 2008 through 2011. Although open repairs are associated with greater risk, we maintain high volumes and excellent outcomes.

2008 – 2011

2008 – 2011

41% Open (N = 328)41% Open (N = 328)

59% Endovascular (N = 472)59% Endovascular (N = 472)

100%100%

17% Emergency (N = 55)17% Emergency (N = 55)

83% Elective (N = 273)83% Elective (N = 273)100%100%

AAA ScreeningAneurysms can progress to a very

advanced state without any symptoms.

Often, they are diagnosed by accident.

Because of this, many studies support

population-based, one-time ultrasound

screening for patients at high risk (usually

those over age 65). Screening can detect

the condition before it becomes fatal.

Cleveland Clinic’s dedication to the care

of patients with aortic disease begins

before diagnosis. Our new aneurysm

screening program is designed to aid

the treatment of patients with aortic

aneurysms. In the near future, all patients

who are treated at Cleveland Clinic for

any medical condition will be screened

for aneurysms. This proactive approach

to care will help identify disease before it

becomes critical and

allow us to educate

patients about

their condition

and treatment

options.

42


Endovascular AAA Repair Volume and Type (N = 472)

Cleveland Clinic surgeons performed 472 endovascular AAA repair procedures in 2011. A total of 42 fenestrated grafts were used to repair juxtarenal aneurysms.

The mortality rate for elective endovascular AAA repair was 1.37 percent in 2011. The rate for emergency repairs was 0 percent.

Endovascular AAA Repair Mortality (N = 472)

Open AAA Repair Mortality (N = 328)2008 – 2011

2008 – 2011

2008 – 2011

4040

3030

2020

1010

00Elective

(N = 273)

2008 – 20112011

Emergency(N = 55)

0%

Percent

10% Emergency (N = 43)10% Emergency (N = 43)

90% Elective (N = 429)90% Elective (N = 429)100%100%

2020

1616

1212

88

00Elective

(N = 429)Emergency(N = 43)

0%44

Percent

2008 – 20102011

The mortality rate for patients who had elective AAA open repair was 4.35 percent in 2011. The mortality rate for emergency open repair of ruptured AAAs was 0 percent.

0 % Mortality rate for patients

with juxtarenal aneurysms

treated with fenestrated

graft procedures (N = 42)

from 2008 to 2011.

43

Hypertrophic Obstructive Cardiomyopathy

Hypertrophic obstructive cardiomyopathy (HOCM) is thickening of the lower chambers of the heart. The septal muscle, which divides the right and left chambers, is especially affected. The condition can impede blood flow from the heart to the aorta. Cleveland Clinic physicians use a comprehensive approach to diagnose and treat patients with HOCM. This approach includes a physical exam, EKGs, chest X-ray and MRI. Cleveland Clinic has a special interest in HOCM. We are actively screening patients and their family members for genetic abnormalities associated with the disease.

Patient Volume2011

Total HOCM Outpatient Visits 1,561

New Patients with HOCM 358

250

200

150

0

100

50

2007 20112008 2009 2010

Volume

Surgical Volume and Outcomes2011

Surgeries for HOCM 183

Hospital Mortality 0%

chest X-ray and MRI. Cleveland Clinic has a special interest in HOCM. We are actively screening patients and their family members for genetic abnormalities associated with the disease.

HOCM Surgeries2007 – 2011

44 Outcomes 2011

Cleveland Clinic is a national leader for HOCM surgery. In 2011, our surgeons performed 183 procedures to treat patients with HOCM. The overall mortality rate was 0 percent.

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

Surgical Procedure Distribution (N = 183)2011

Septal myectomy is used to treat patients with HOCM. Patients who require this procedure often require additional procedures.

9% Septal Myectomy + Coronary Artery Bypass +/- Other (N = 17)9% Septal Myectomy + Other (N = 16)4% Septal Myectomy + Valve Surgery + Coronary Artery Bypass +/- Other (N = 7)1% Valve +/- Other (N = 1)

38% Septal Myectomy + Valve +/- Other (N = 70)

100%100%

39% Isolated Septal Myectomy (N = 72)

02008

25

2007 2009 2010 2011

20

5

15

10

Volume

Maximal Intraventricular Septal Thickness ≤ 18 mmMaximal Intraventricular Septal Thickness > 18 mmMortality (%)

Papillary Muscle Reorientation/Realignment2007 – 2011

Septal Myectomy Mortality2011


6

4

00%

Percent

ExpectedObserved

2

Source: University HealthSystem Consortium (UHC) Comparative Database, 2011 discharges

Cleveland Clinic has excellent outcomes for patients who have a septal myectomy. In 2011, the expected mortality rate was 2 percent; however, our surgeons achieved a 0 percent mortality rate for this procedure.

Patients with HOCM who have outflow tract obstruction with minimal or mild hypertrophy may also have abnormal papillary muscle function. Cleveland Clinic surgeons use various techniques to repair the mitral valve and correct the condition. One technique, developed at Cleveland Clinic, involves reorienting papillary muscles that are abnormally positioned or excessively mobile.

46 Outcomes 2011

Congenital Heart Disease

Adult Congenital Cases 214

Complex Congenital Cases 119

Complex Congenital Interventions 37

Success Rate 100%

30-Day Mortality 0%

Percutaneous Interventional Procedures for Adult Congenital Heart Disease

Volume and Outcomes

2011

*Based on one complication, including stroke, myocardial infarction or need for surgery. Abbreviations: ASD, atrial septal defect; PFO, patent foramen ovale.

Percutaneous Closure Procedures

Volume and Outcomes

2011

Congenital Heart Disease

About 1 in 120 babies born each year in the United States has a congenital heart defect. One million people in the United States have congenital heart disease. In some cases, the disease is life-threatening at birth. However, some cases are not discovered for years. Cleveland Clinic has expertise in the diagnosis and treatment of patients with all forms of congenital heart disease. The newly opened Special Delivery Unit allows patients diagnosed in utero with complex heart conditions to receive immediate treatment after birth. The department is focused on achieving excellent outcomes in a family-centered care setting.

A total of 214 adult patients with congenital heart disease received interventional treatment in 2011. Although many of these cases were complex, we achieved a 100 percent success rate and 0 percent mortality.

In 2011, we performed 77 percutaneous closure procedures. The success rate was 99 percent with 0 percent mortality.

Percutaneous ASD Closures 25

Percutaneous PFO Closures 52

Successful Repair* 99%

30-Day Mortality 0%

Patients Requiring Repeat Procedure 0%

Adult Congenital Heart Disease Volume

2011

The Adult Congenital Heart Disease Center offers a collaborative approach to treatment. Cardiologists who specialize in pediatric care, adult care, intervention and cardiovascular surgery work together to create individual, expert treatment plans and care. In 2011, we saw 1,401 patients, including 460 new referrals.

Total Adult Congenital Heart Disease Patient Visits 1,401

New Referral Visits for Adult Congenital Heart Disease 460


Adult Congenital Heart Surgery Mortality2011

00

66

Cleveland Clinic Expected*

22

44

PercentPercent

Pediatric Congenital Surgery Volume and Type (N = 135)2011

2525

AortaAorta ArterialSwitch ±

VSD Repair

ArterialSwitch ±

VSD Repair

ASDRepairASD

RepairCompleteAV CanalRepair

CompleteAV CanalRepair

FontanFontan NorwoodNorwood OtherOther PDAClosure

PDAClosure

PulmonarySystemRepair

PulmonarySystemRepair

TOFRepairTOF

RepairTransplantTransplant Valve

SurgeryValve

SurgeryVSD

RepairVSD

Repair

VolumeVolume

2020

1515

1010

55

00

Cleveland Clinic’s Department of Congenital Heart Surgery offers a full range of comprehensive surgical treatments for adults with congenital defects. In 2011, our mortality rate was 0.2 percent, which is well below the expected rate for these procedures.

In 2011, Cleveland Clinic surgeons performed 135 pediatric congenital surgeries of varying complexity. The procedures within the majority “other” category include coarctation repair, truncus arteriosus repair, etc.

We continue our commitment to innovation in heart failure and transplant care. In 2011, we successfully implanted three Berlin Heart EXCOR® ventricular assist devices (Berlin Heart GmbH, Berlin) as a bridge to transplant for children with life-threatening conditions.

Source: University HealthSystem Consortium Discharges 2011

Abbreviations: ASD, atrial septal defect; AV, atrioventricular; PDA, patent ductus arteriosus; TOF, tetralogy of Fallot; VSD, ventricular septal defect.

48 Outcomes 2011

Congenital Heart Disease (continued)

Repair of Sinus Venosus ASD with Anomalous Pulmonary Veins

Cleveland Clinic surgeons have developed a new technique to treat patients with sinus venosus atrial septal defect with anomalous pulmonary veins. A total of 32 patients have undergone this procedure since 2000.

Pediatric Congenital Heart Surgery – Mortality 2011

In 2011, the rates of mortality for pediatric patients with congenital heart disease who had surgery were lower than expected. We continue to strive for the lowest possible mortality rates for all patients.

00

66

Cleveland Clinic Expected

22

44

PercentPercent

Source: University HealthSystem Consortium Discharges 2011


Treatment of a Coronary Fistula

Injection to the right coronary artery. This shows blood flow diverted to a fistula just proximal to the opening of the coronary artery from the aorta. It is draining to the pulmonary artery.

Within seconds, the fistula is occluded and no flow is seen beyond the device (arrow).

A guide wire is advanced into the fistula through a guide catheter.

After the intervention, reinjection of the right coronary artery demonstrates that flow remains normal in the right coronary artery and that blood flow is no longer being diverted in the direction of the fistula.

A telescoping technique is used to maintain a stable position so the occlusion device can be safely deployed.

The AMPLATZER(TM) Vascular Plug II (arrow) is deployed in the fistula.

50

Pericardial disease is more common than recognized. Often, patients are not aware of all the potential treatment options available. Cleveland Clinic’s Pericardial Center evaluates patients locally, nationally and internationally, and provides a focused, expert diagnosis and treatment plan. Our multispecialty approach includes cardiologists, surgeons and imaging specialists, which enhances collaboration in the management of these diseases.

Thickened pericardium

Outcomes 2011

Pericardial Disease

Pericardial disease includes a group of conditions that affect the pericardium, the double-layered sac that surrounds the heart. Cleveland Clinic’s Center for the Diagnosis and Treatment of Pericardial Disease is a multidisciplinary specialty treatment group dedicated to the diagnosis and treatment of patients with acute, recurrent and constrictive pericarditis. In 2011, we saw 1,016 patients.

The majority of patients seen in 2011 at Cleveland Clinic’s Center for the Diagnosis and Treatment of Pericardial Diseases had recurrent pericarditis. A total of 55 percent of pericardial syndromes were as-sociated with pericardial effusion.

Pericardial Disease Syndromes in Outpatient Clinic Volume, New and Consult (N = 430) 2011

Pericardial Disease: Patient Volume 2007 – 2011

Acute Pericarditis

Recurrent Pericarditis

Constrictive Pericarditis

EffusiveConstrictive

PericardialEffusion with Pericarditis

Pericardial Disease Syndromes

400400

300300

VolumeVolume

200200

100100

00

24

338

39 29

293

800800

1,0001,000

New ConsultEstablishedNew ConsultEstablished

400400

00

Volume

2007 2008 2009 2010 2011

200200

600600

2011430

586

Cardiac MRI showing a thickened and inflamed pericardium (arrows) that resolves with treatment. Before treatment (top) and after treatment (bottom).

Pericardial window surgery accounted for the majority of pericardial procedures in 2011. The procedure involves making an opening in the pericardium through a small chest incision. The fluid is drained and a diagnosis can be made. Pericardiectomy is the removal of a portion or all of the pericardium.


Pericardial Procedures (N = 136) 2011

43% Window (N = 58)43% Window (N = 58)

28% Pericardiocentesis (N = 38)28% Pericardiocentesis (N = 38)

29% Pericardiectomy (N = 40)29% Pericardiectomy (N = 40)100%100%

The most common cause for pericarditis in 2011 was idiopathic in nature.

Pericardial Disease Etiology 2011

4% Viral (N = 20)4% Viral (N = 20)2% Autoimmune (N = 7)2% Autoimmune (N = 7)

5% Other (N = 21)5% Other (N = 21)

67% Idiopathic (N = 298)67% Idiopathic (N = 298)

22% Postoperative Cardiac Surgery (N = 93)22% Postoperative Cardiac Surgery (N = 93)

100%100%

Pericardiocentesis is used to drain large pericardial effusions. This percutaneous procedure is used for patients whose condition develops postoperatively or from a viral or idiopathic cause. The procedure is guided by echocardiography, which helps improve outcomes.

51

Outcomes 2011

Heart Failure and Transplant

1,570 Number of heart

transplants performed

at Cleveland Clinic since

inception of the Cardiac

Transplant Program

in 1984.

100

Survival (%)

90

80

70

501 year N=1177/1/08 to 12/31/10

3 years N=1481/1/06 to 6/30/08

Expected*Observed

60

Time After Transplant

Heart Transplant Patient Survival

The survival rates among patients who have heart transplants at Cleveland Clinic exceeds the expected rates. Of the 150 transplant centers in the United States, Cleveland Clinic is one of only three that had better-than-expected one-year survival rates in 2011.

The Cardiac Transplant Program at Cleveland Clinic continues to be the leading center in Ohio and among the largest in the United States.

Heart Transplant Volume July 2007 – June 2011

*Expected based on risk adjustment Source: Scientific Registry of Transplant Recipients. Center and OPO-Specific Reports, March 2012. Ohio, Heart Centers, Cleveland Clinic. Table 11. www.srtr.org

2009 2010 20112007 2008

Volume

0

80

60

40

20

Cleveland Clinic performed 54 heart transplants in 2011.

52

20

15

10

0Observed Expected

5

Percent


Heart Failure and Transplant

Ventricular Assist Device Volume 2007 – 2011 80

40

60

02007 2008 2009 2010

N = 23 48 76 51201156

20

Volume

Bridge-to-TransplantDestination Therapy

LVAD In-Hospital Mortality 2007 – 2011

Cleveland Clinic continues to make improvements to reduce mortality rates among patients who are placed on mechanical circulatory support. The mortality rate among patients who have a left ventricular assist device (LVAD) has been drastically reduced over the past five years.

50

30

40

02007 2008 2009 2010 2011

20

10

Percent

Mechanical circulatory support (MCS) devices are used in patients with heart failure to preserve heart function until transplantation (bridge-to-transplant) or as a final treatment option (destination therapy). Cleveland Clinic has more than 20 years of experience with MCS devices for both types of therapy.

VAD Mortality 2011

The mortality rate among Cleveland Clinic patients placed on ventricular assist devices (VADs) was much lower than expected in 2011.

Source: University HealthSystem Consortium (UHC) Comparative Database, January through November 2011 discharges.

53

Heart Failure Appropriateness of Care

2010 – 2011

This composite metric, based on four heart failure hospital quality process measures developed by the Centers for Medicare and Medicaid Services (CMS), shows the percentage of patients who received all the recommended care for which they were eligible. Cleveland Clinic has set a target of UHC’s 90th percentile.

Heart Failure – National Hospital Quality Measures

0

60

40

20

Source: University HealthSystem Consortium (UHC) Clinical Databasehttps://www.uhc.edu

80

100

Percent

93.9 96.9 99.2 Cleveland Clinic, 2010 (N = 1,194)Cleveland Clinic, 2011 (N = 1,163)UHC Top Decile, 2011

Heart Failure and Transplant (continued)

Outcomes 201154


Heart Failure All-Cause 30-Day Mortality (N = 762)

July 2008 – June 2011

Heart Failure All-Cause 30-Day Readmission (N = 1,029)

July 2008 – June 2011

Heart Failure – National Hospital Quality Measures (continued)

The Centers for Medicare and Medicaid Services (CMS) calculates two heart failure outcome measures: all-cause mortality and all-cause readmission rates, each based on Medicare claims and enrollment information. Cleveland Clinic’s performance appears below.

* Source: hospitalcompare.hhs.gov

Cleveland Clinic’s heart failure risk-adjusted 30-day mortality rate is below the national average; the difference is statistically significant. Our heart failure risk-adjusted readmission rate is higher than the national average; that difference is also statistically significant. To further reduce this rate, a multidisciplinary team was tasked with improving transitions from hospital to home or post-acute care facility. Specific initiatives have been implemented in each of these focus areas: communication, education and follow-up.

0

5

10

15

20

25

30

Percent

National Average*

11.69.2

Cleveland Clinic0

5

10

15

20

25

30

Percent

National Average*

24.7

27.3

Cleveland Clinic

56 Outcomes 2011

Lung and Heart-Lung Transplant

Lung Transplant Procedures2007 – 2011

Primary Disease of Lung Transplant Recipients (N = 101)

Source: Scientific Registry of Transplant Recipients. March 2011. Ohio, Lung Centers, Cleveland Clinic. Table 7

Cleveland Clinic surgeons transplanted 111 lungs in 2011. Our Lung and Heart-Lung Transplant Program is the leader in Ohio and among the best programs in the country.

July 2010 – June 2011

160160Liver-LungHeart-LungDouble LungSingle Lung

Liver-LungHeart-LungDouble LungSingle Lung

00

Volume

2007 2009 20102008

4040

120120

8080

2011

53.5% Idiopathic Pulmonary Fibrosis (N = 54)53.5% Idiopathic Pulmonary Fibrosis (N = 54)

26.7% Emphysema/Chronic Obstructive Pulmonary Disease (N = 27)26.7% Emphysema/Chronic Obstructive Pulmonary Disease (N = 27)

9.9% Cystic Fibrosis (N = 10)9.9% Cystic Fibrosis (N = 10)6.9% Idiopathic Pulmonary Arterial Hypertension (N = 7)6.9% Idiopathic Pulmonary Arterial Hypertension (N = 7)3.0% Other (N = 3)3.0% Other (N = 3)

100%100%

In 2011,

51% of lung transplant patients were from outside the state of Ohio.


Ambulatory ECMO

Patients waiting for lung transplantation can become poorer candidates while waiting because of the use of extracorporeal membrane oxygenation (ECMO). This is a method used in very ill patients to add oxygen and remove carbon dioxide from the blood.

Traditionally, ECMO requires the patient to stay in bed. This causes the muscles to weaken, and patients become less likely to be eligible for transplantation.

Cleveland Clinic is aggressively developing ambulatory ECMO technology to improve transplant candidacy, save lives and improve outcomes.

Wait List Mortality

Lung Transplant Survival*

Waiting Time for Lung Transplant*

Patients awaiting lung transplantation have a shorter waiting time at Cleveland Clinic compared with hospitals throughout the region and the country.

The mortality rate among Cleveland Clinic patients waiting for a lung transplantation is lower than expected.

Patients who undergo lung transplantation at Cleveland Clinic live longer than the expected rate after three years.

* Expected survival rate based on risk adjustment. Statistically significant. Source: Scientific Registry of Transplant Recipients. March 2012, Ohio, Lung Centers, Cleveland Clinic. Table 10. srtr.org



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

2006 – 2010

July 2005 – December 2010

July 2009 – June 2011

100Survival (%)

80

60

40

01 Month

Time After Transplant

3 Years1/1/06 to 6/30/08

N = 152

1 Year

ExpectedObserved

20

7/1/08 to 12/31/10N = 302

88

44

22

00Cleveland Clinic Region United States

66

Median Months

1.0Mortality (%)

0.8

0.6

07/1/09 to 6/30/10

(N = 57)7/1/10 to 6/30/11

(N = 114)

Expected*Observed

0.4

0.2

In 2011,

98% of venous

duplex ultrasound

studies were

read in 24 hours;

100% of all other

vascular studies

were finalized

within 48 hours.

Peripheral Vascular Diseases

Lower Extremity Interventional Procedures

Cleveland Clinic’s team of vascular surgeons and interventional cardiologists perform a variety of procedures to treat patients with peripheral artery conditions. They are skilled at angioplasty, atherectomy, stenting, thrombectomy and thrombolysis.

47% Venous Duplex (N = 17,284)47% Venous Duplex (N = 17,284)

36% Arterial Duplex (N = 13,239)36% Arterial Duplex (N = 13,239)

17% Physiologic Testing (N = 6,252)17% Physiologic Testing (N = 6,252)

100%100%

Outcomes 201158

Lower Extremity Surgery Volume and Mortality (N = 303)

A total of 229 lower extremity bypass surgeries were performed in 2011. The 30-day mortality rate was 0 percent. Cleveland Clinic’s vascular surgeons have expertise in this area and strive to use autologous vein grafts.

All Cleveland Clinic vascular lab technologists are certified registered vascular technologists (RVTs). This exemplifies our commitment to quality patient care. Each year, we perform a high volume of ultrasounds.

The Noninvasive Vascular Laboratory provides service seven days a week to diagnose arterial and venous disorders throughout the vascular tree and for follow-up after revascularization procedures, such as bypass grafts and stents. In 2011, 36,775 vascular lab studies were performed.

2011 Volume

Bypass 229

Thrombectomy 74

Lower Extremity Interventional Procedure Volume

2011

Angioplasty 451

Atherectomy 74

Stenting 260

Thrombolysis 91

2011 30-Day Mortality (%)

Bypass 0%

Noninvasive Vascular Lab Ultrasound Study Distribution (N = 36,775)

2011

58

Fibromuscular Dysplasia

Fibromuscular dysplasia (FMD) is a vascular condition in which there is abnormal cell growth in the walls of medium- and large-sized arteries. This can cause the arteries to become narrowed (stenosis), and can also lead to aneurysm and dissection. Cleveland Clinic’s FMD program is dedicated to caring for and educating patients with FMD. We conduct research to better understand the condition and treatment options. In 2011, a total of 209 patients seen in the program had a primary diagnosis of FMD, and 177 patients had a secondary diagnosis of FMD.

Lower Extremity Wound Clinic Volume 2007 – 2011

In 2011, a total of 1,381 patients were treated in the Lower Extremity Wound Clinic.

Fibromuscular Dysplasia – Patient Volume 2007 – 2011

400400

300300

200200

100100

002007 2008 2009 2010 2011

Volume

2,0002,000

1,5001,500

1,0001,000

500500

002007 2008 2009 2010 2011

Volume

0%

Thrombosis Center

Cleveland Clinic’s Thrombosis Center was established in 2009. It includes a multidisciplinary group of specialists in vascular medicine, vascular surgery, adult and pediatric care, hematology, interventional radiology, cardiology, cardiac surgery, and laboratory medicine. The group works together to provide the best possible treatment to patients with deep vein thrombosis, pulmonary embolism and hypercoagulable states. In 2011, a total of 1,914 patients with a primary thrombosis diagnosis were seen at Cleveland Clinic’s main campus.


60

Venous Disease

The vascular medicine physicians and vascular surgeons at Cleveland Clinic use a variety of methods to treat patients with venous disease.

Varicose Veins

The most common venous disorder is varicose veins. Treating patients with this condition includes conservative therapy with support stockings, skin care and a regular walking program. However, some patients require careful assessment if this therapy is unsuccessful.

Our comprehensive examination helps determine the exact venous abnormalities, which allows for the best plan of care. This assessment includes duplex ultrasound in the Noninvasive Vascular Laboratory. Treatment depends on the underlying pathology and can include sclerotherapy, endovenous ablation with radiofrequency or laser energy sources, stab excision of variscosities and ligation of saphenous veins.

In 2011, 96% of venous duplex examinations for DVT were interpreted and posted to the electronic medical record in final form within 24 hours of the study date.

Endovenous Ablation Procedure

Endovenous ablation is the preferred treatment for patients with valvular incompetence of the greater saphenous vein. It involves ablation of the diseased vein through the application of radiofrequency or laser energy. The procedure is minimally invasive and causes less pain and bruising than vein stripping. This leads to improved outcomes.

Deep Vein Thrombosis (DVT)

Patients with deep vein thrombosis (DVT) are usually treated with long-term anticoagulation medication. If patients cannot take Coumadin®, we use newer drugs to prevent clot formation. In cases of recurrent episodes of DVT, our specialists assess for clotting abnormalities. A DVT can cause long-term complications. Studies show that early removal of clots, be it chemical or mechanical, decreases these long-term problems. Cleveland Clinic relies heavily on thrombolysis with or without mechanical thrombectomy to treat patients with DVT and improve outcomes.

652Number of endovenous ablations

performed in 2011

100%Immediate closure rate for

venous ablation proceduresTop to bottom: Catheter inserted in vein, treated vein and catheter withdrawn, closing vein.

Outcomes 2011

87%The success rate for resolution of DVT among patients with DVT who had a vascular procedure.

Image 1 and image 2 show the external iliac vein. In image 2, compression is being applied. The vein is dilated and does not compress, showing that it is thrombosed.

61

Cerebrovascular Disease

Cleveland Clinic has

nationally accredited

vascular laboratories in

multiple locations to help

care for patients with

cerebrovascular disease.

We perform noninvasive

diagnostic imaging of the

cerebrovascular system.

Our standardized reporting

system efficiently provides

current and accurate

information to aid the

treatment of patients

with conditions such

as carotid dissections,

atherosclerotic disease

of the brachiocephalic

vessels, fibromuscular

dysplasia and aneurysms.

More than half of all temporary and permanent strokes are caused by carotid artery stenosis. The risk of carotid disease is higher in patients who have hypertension, coronary artery disease and peripheral artery disease. Early diagnosis with vascular ultrasound and disease management with medication, including antiplatelet and antihypertensive agents, can reduce this risk. Cleveland Clinic uses the latest technology and methods to care for patients with cerebrovascular disease. We have specialized ultrasound laboratories and offer advanced medical therapy, open carotid surgery and minimally invasive carotid artery stenting (CAS) procedures.


*All procedures performed at Cleveland Clinic’s main campus

2011

Cerebrovascular Disease Treatment Mortality

Cleveland Clinic uses state-of-the-art imaging with 3-D CAT scan angiography and biplanar flouroscopic imaging to diagnose and treat patients with a wide range of cerebrovascular disease. These include carotid dissections, aneurysms and atherosclerotic disease. We participate in all national clinical trials to evaluate medical, surgical and percutaneous treatment of atherosclerotic and dysplastic diseases of the carotid and subclavian arteries. Our surgeons routinely perform cerebrovascular debranching to enhance the use of minimally invasive treatment of thoracic aortic aneurysms and dissections (Thoracic Endovascular Aortic Repair, or TEVAR).

55

44

22

33

11

000% 0%0%

CarotidStenting

Endarterectomy

Percent

ObservedExpected

The mortality rate for patients treated for cerebrovascular disease at Cleveland Clinic’s main campus was below the expected rate.

2007 – 2011


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

Carotid Stenting 477 0.4 2.3 0.4

Diagnostic Angiograms 728 0.3 0.7 0.1

Carotid Endarterectomy 699 1.7 2.1 0.7

62 Outcomes 2011

Thoracic Surgery

General Thoracic Surgery Volume and Mortality

In 2011, Cleveland Clinic thoracic surgeons performed 1,380 procedures. The mortality rate was 2 percent.

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 the latest screening techniques to the most advanced minimally invasive surgical procedures.

2007 2008 2009 2010

2,0002,000

1,5001,500

1,0001,000

500500

00

6.06.0

4.54.5

3.03.0

1.51.5

00

Surgical VolumeSurgical Volume Mortality (%)

2011

Outcomes 2011


Pulmonary procedures accounted for the majority of major thoracic surgical procedures at Cleveland Clinic in 2011. Our surgeons treat patients with a variety of conditions of varying complexity.

2011

Major Thoracic Surgery by Type (N = 1,380)

10% Mediastinum/Diaphragm (N = 138)10% Mediastinum/Diaphragm (N = 138)

39% Pulmonary (N = 536)39% Pulmonary (N = 536)

18% Esophagus (N = 248)18% Esophagus (N = 248)

15% Pleura (N = 207)15% Pleura (N = 207)

8% Lung Transplant (N = 108)8% Lung Transplant (N = 108)10% Other (N = 143)10% Other (N = 143)

100%100%

Pulmonary Resection Volume and Mortality

44

33

22

11

002007 2008 2009 2010

Volume400400

300300

200200

100100

00

Mortality (%)

2011

Cleveland Clinic performed 282 pulmonary resections in 2011 and maintained a low rate of mortality.

64 Outcomes 2011

Thoracic Surgery (continued)

Distribution of Pulmonary Resections by Type (N = 282)2011

Pulmonary Resection Postoperative Length of Stay (N = 282)

Abbreviation: VATS, video-assisted thoracoscopic surgery

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

2011

In 2011, the most common procedure was video-assisted wedge. Our surgeons perform a variety of less invasive, video-assisted procedures, which account for half of our pulmonary resections. They are also performing an increasing number of anatomic lung resections using minimally invasive techniques.

29% Open Lobectomy (N = 83)29% Open Lobectomy (N = 83)

6% Open Wedge (N = 18) 6% Open Wedge (N = 18)

19% Video-Assisted Lobectomy (N = 53)19% Video-Assisted Lobectomy (N = 53)

31% Video-Assisted Wedge (N = 86)31% Video-Assisted Wedge (N = 86)

2% Segmentectomy (N = 5) 2% Segmentectomy (N = 5)

8% Pneumonectomy (N = 23) 8% Pneumonectomy (N = 23)

5% Other (N = 14) 5% Other (N = 14)

100%100%

55OpenVATSOpenVATS

33

00

Days

WedgeResection

Segmentectomy Lobectomy Pneumonectomy

22

11

44

64

65

*University HealthSystem Consortium (UHC) Comparative Database, 2011 discharges.


Stage-Specific Anatomic Resection: Stage I VATS vs. Open

Major Pulmonary Resections Operative Mortality

100100

8080

002009 2010 2011

VATSOpen

6060

4040

2020

Volume

2.0

1.5

1.0

0.5

02007 2011 UHC

Expected2008 2009 2010

Percent

Risk-Adjusted Standardized Incidence Eligible Procedures Unadjusted Rate Rate (95% CI) Ratio (95% CI)

238 3.4% 4.0% (12.4%, 6.1%) 0.874 (0.44, 1.12)

Postoperative Length of Stay > 14 days for Lobectomy, July 2008 – June 2011

Min0.59

25th0.91

Cleveland Clinic

Median1.01

75th1.14

Max2.00

= STS standardized incidence ratioSource: STS General Thoracic Surgery Database, July 2008 – June 2011.

2009 – 2011

2007 – 2011

66 Outcomes 2011

Esophageal Surgery Volume 2007 – 2011

Lobectomy Length of Stay 2011 2011

Major esophageal surgery includes resections for cancer and reoperative surgery for motility and reflux disorders. In 2011, we performed 247 esophageal operations with a low mortality of 2 percent.

When possible, lobectomy is performed using a minimally invasive technique and video assistance to allow patients to leave the hospital sooner and return to work earlier.

Thoracic Surgery (continued)

6

0Open Lobectomy

(N = 83)

Median (Days)

Video-AssistedLobectomy(N = 53)

4

2

2007 201020092008

Volume400400

300300

200200

100100

002011

Esophagectomy Mortality Three Years After Surgery 2011

4

Percent

3

2

03 yr 3 yr

STS Expected

1

Observed

Source: STS General Thoracic Surgery Database, July 2008 – June 2011.


Our surgeons manage high volumes of both benign and malignant esophageal conditions.

Risk-Adjusted Standardized Incidence Eligible Procedures Unadjusted Rate Rate (95% CI) Ratio (95% CI)

137 25.5% 23.6% (17.5%, 30.5%) 0.88 (0.65, 1.13)

Distribution of Esophageal Surgeries by Indication (N = 247)

Combined Morbidity/Mortality for Esophagectomy, July 2008 – June 2011

2011

32% Cancer (N = 80)32% Cancer (N = 80)

31% Reflux (N = 76)31% Reflux (N = 76)

9% Achalasia (N = 22)9% Achalasia (N = 22)

28% Other (N = 69)28% Other (N = 69)

100%100%

Min0.47

25th0.92

Cleveland Clinic

Median1.00

75th1.23

Max2.00

= STS standardized incidence ratio Source: STS General Thoracic Surgery Database - July 2008 – June 2011.

Preventive Cardiology and Rehabilitation

2011 Volume

Prevention Outpatient Visits 7,239

Phase I Rehab 8,976

Phase II Rehab 4,215

Phase III Rehab 3,524

LDL Levels Among Statin-Tolerant Adults

Patients taking statins for both primary and secondary prevention experienced reductions in low-density lipoprotein (LDL) cholesterol levels. Patients were seen at baseline and had at least two follow-up visits within one year. The time between visits varied from patient to patient.

Primary Prevention, Statin-Tolerant Adults (N = 715)

2006 – 2011

160

120

80

200

2006 2007 2008 2009 2010 201181 mg/dL 2nd Follow-up

111.5 mg/dL Baseline

LDL Value

130

90

50

170

62 mg/dL 2nd Follow-up

82 mg/dL Baseline

LDL Value

2006 2007 2008 2009 2010 2011

Secondary Prevention, Statin-Tolerant Adults (N = 301)

2006 – 2011

68 Outcomes 2011

The Center for Preventive Cardiology and Rehabilitation at Cleveland Clinic provides patients with a comprehensive assessment to identify traditional and emerging nontraditional cardiovascular risk factors. We collaborate with referring physicians to create individualized treatment plans. Patients typically have a limited number of visits in the center and return to their primary care or referring physician for care.

Primary Prevention, Statin-Intolerant Adults (N = 152)

2006 – 2011

160

120

80

200

2006 20082007 2010 20112009


148 mg/dL Baseline

LDL Value

130

90

110

70

150


129.5 mg/dL Baseline

LDL Value

2006 20082007 2010 20112009

LDL Levels Among Statin-Intolerant Adults

Patients referred to the prevention clinic who could not tolerate statins still experienced reductions in LDL levels. Patients had at least two follow-up visits within a year.

Secondary Prevention, Statin-Intolerant Adults (N = 96)

2006 – 2011


Preventive Cardiology and Rehabilitation (continued)

Blood Pressure Among Primary and Secondary Prevention Patients (N = 834)2011

The Weigh to a Healthy Heart

The Weigh to a Healthy Heart is a comprehensive 11-week weight loss program designed to help prevent cardiovascular disease. The program includes a team of dietitians, physicians, exercise physiologists and behavioral counselors. Patients receive an exercise prescription and participate in private nutrition sessions, group exercise classes, lipid and fasting sugar testing, and weekly group support sessions. They also get help creating a grocery list.

In 2011, patients who attended more than 75 percent of the classes lost an average of 7.1 pounds. Those who attended fewer than 75 percent of the classes lost an average of 4 pounds.

Median Weight Loss over 11 Weeks

2010 8.2 pounds

2011 5 pounds

Shared Medical Appointments include groups of six to

eight patients with similar

health concerns. The group

meets with a dietitian and

nurse practitioner during

one appointment. The visit

addresses multiple needs,

and patients receive

personalized dietary

counseling and group

interaction and support.

120

150

0Systolic Diastolic

90

60

30

Value (mg/dL)

7278

2nd Follow-upBaseline124 122

Patients who were seen in the prevention clinic for both primary and secondary prevention experienced reductions in blood pressure. All patients had at least two follow-up visits within a year.

70 Outcomes 2011

Exercise Prescriptions2005 – 2011

Cleveland Clinic’s exercise prescriptions are designed to help patients start an exercise program. The prescription is written after the patient’s fitness level is determined. It provides the information about the recommended frequency, intensity, type and length of exercise sessions.

2007 20092006 2008 20102005260 364207 297 308

2011333N = 100

Volume

0

400

300

200

100

Patients seen in the prevention clinic who had diabetes reduced HbA1c levels during the course of their treatment. All patients were seen at baseline and had at least two follow-up visits within a year.

0

2

4

6

8

10

Percent

2nd Follow-up

6.57.0

Baseline

HbA1c Levels Among Patients with Diabetes (N = 239)2011


Cardiac Rehabilitation

Outcomes measured in the Cardiac Rehabilitation Program include those related to functional capacity, quality of life, blood pressure and weight.

Improvement in Exercise Capacity by Exercise Stress Test (N = 278)

2011

The metabolic equivalent of task (MET) is the ratio of the working metabolic rate to the resting metabolic rate. Each 1-MET increase in functional capacity reduces the risk of mortality by 8 to 12 percent. The average predicted reduction in mortality for patients in the program based on improvement in functional capacity (METs) was approximately 15 percent.

Improvement in Quality of Life Assessment (N = 278)

2011

60

0

50

Program Entry Program Exit

40

10

30

20

Mental Summary Score

Physical Summary Score

SF-36 Score

10

0Entry METs

8.6

METs

Exit METs

Change = +1.7

8

2

6

4

6.9

Quality of life (QOL) is measured using the 36-item short-form health survey (SF-36®) Health Status Survey. This is a validated QOL measure to track overall wellness of patients in cardiac rehabilitation. Patients who completed the program experienced improved physical and emotional QOL.

Data represent all cardiac rehab patients with both entry and exit visits in 2011.

72 Outcomes 2011

Preventive Cardiology and Rehabilitation (continued)

Cardiac RehabilitationImprovement in Systolic Blood Pressure (SBP) (N = 278)

2011

Among patients who completed the Cardiac Rehabilitation Program, 86 percent achieved normal blood pressure (< 140/< 90 mm Hg). The average improvement was -10 mm Hg.

Cardiac Rehabilitation Improvement in Weight (N = 278)

2011

250

0Entry

208.2

Weight (lbs.)

Exit

200

50

150

100

212.6

150

0Entry

129

Systolic Blood Pressure (mm Hg)

Exit

120

30

90

60

139

Patients who completed the Cardiac Rehabilitation Program lost an average of 4.5 pounds.



73Sydell and Arnold Miller Family Heart & Vascular Institute 73

74 Outcomes 2011

Anesthesia

Time Spent on Ventilator After CABG Surgery

2010 – 2011

Cardiothoracic anesthesia (CTA) is an integral part of Cleveland Clinic’s open heart surgery program. In 2011, we continued to make improvements that have a positive effect on patient outcomes and the success of the program.

Cleveland Clinic continues to make improvements in the time patients remain on a ventilator after coronary artery bypass grafting (CABG) surgery. Shorter ventilator times are associated with improved quality of care and increased patient comfort and satisfaction.

2525

2020

1515

1010

55

00J

2010 2011

A S O N D J F M A M J J A S O N D

Percentage of Patients on Ventilator > 24 HoursExpected Percentage of Patients on Ventilator > 24 Hours Trend for Ventilator Time > 24 HoursPercent


Postoperative Blood Glucose Levels

Central Line-Associated Bloodstream Infection

2011 – 2012

We continue to work toward achieving 100 percent compliance with the Joint Commission’s measures for assessing postoperative blood glucose levels.

Postoperative 6 a.m. Glucose Readings

2011 – 2012

Our efforts continue to reduce the incidence of central line-associated bloodstream infection (CLABSI), which can contribute to increased length of stay with higher associated medical costs.

98

94

90

86

100

Q1 Q2

2011 2012

Q3 Q4 Q2Q1

Target FrequencyObserved Frequency

Percent

2.0

1.5

1.0

0.5

0

2.5

Q1 Q2

2011 2012

Q3 Q4 Q1

TargetObserved

Incidence of CLABSI per 1,000 patients

20Percent

16

12

030-Day Mortality 30-Day Morbidity

ExpectedCleveland Clinic

8

43.42 3.54

55

44

33

00Cardiac Events Pneumonia Surgical Site

InfectionsUrinary Tract

Infections

Cleveland ClinicExpected

22

11

Percent

N = 439 439 429 439

National Surgical Quality Improvement Program

The American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) objectively measures and reports risk-adjusted surgical outcomes based on a defined sampling and abstraction methodology. The outcome data below reflect Cleveland Clinic’s surgical cases between July 1, 2010, and June 30, 2011.

Vascular Surgery 30-Day Mortality and Morbidity (N = 439)

July 2010 – June 2011

Vascular Surgery Complications

July 2010 – June 2011

Vascular surgery mortality was lower than expected, and morbidity was higher than expected; the differences were not statistically significant.

Vascular surgery-associated cardiac events and pneumonia were higher than expected; the difference between observed and expected rates for pneumonia was statistically significant. Vascular surgery surgical site infections and urinary tract infections were lower than expected; the difference between observed and expected rates for urinary tract infections was statistically significant.

76 Outcomes 2011

Surgical Quality Improvement

Surgical Appropriateness of Care

2010 – 2011

Cleveland Clinic has set a target of UHC’s 90th percentile, and results are trending positively.

0

60

80

100

40

20

Percent

* Source: University HealthSystem Consortium (UHC) Clinical Database https://www.uhc.edu

84.892.3

96.0 Cleveland Clinic, 2010 (N = 1,501)Cleveland Clinic, 2011 (N = 1,501)UHC Top Decile, 2011*

Surgical Care Improvement Program (SCIP) – Appropriateness of Care

This composite metric, based on 10 hospital surgical quality process measures developed by the Centers for Medicare and Medicaid Services (CMS), shows the percentage of patients who received all the recommended care for which they were eligible.


Patient Experience

Cleveland Clinic is dedicated to delivering excellent clinical outcomes and the best possible experience for our patients and their families. Patient feedback is critical in driving priorities and assessing results. Based on this feedback, Cleveland Clinic’s Office of Patient Experience implements training programs to improve service and communication as well as educational initiatives to help patients understand what to expect when they are in our care.

Outpatient – Miller Family Heart & Vascular Institute

Source: Press Ganey, a national hospital survey vendor

100

80

0

60

40

20

Percent

Very Good Good Fair Poor Very Poor

2011 (N = 4,670)2010 (N = 3,068)

Overall Rating of Outpatient Care and Services 2010 – 2011

78 Outcomes 2011

Likelihood of Recommending Outpatient Care Provider 2010 – 2011


100

80

0

60

40

20

Percent


2011 (N = 4,670)2010 (N = 3,068)

100

80

0

60

40

20

Percent



2011 (N = 4,670)2010 (N = 3,068)

Rating of Outpatient Provider 2010 – 2011


HCAHPS Overall Assessment 2010 – 2011

Inpatient – Miller Family Heart & Vascular Institute

The Centers for Medicare and Medicaid Services (CMS) requires United States hospitals that treat Medicare patients to participate in the national Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a standardized tool that measures patients’ perspectives of hospital care. Results collected for public reporting are available at hospitalcompare.hhs.gov.

100

80

0

60

84%

40

20

Percent

Rate Hospital Would Recommend

% 9 or 10(0 – 10 scale)

% “definitely yes”


2011 (N = 4,079)2010 (N = 4,184)87% 90%87%

80 Outcomes 2011

Patient Experience (continued)

Outcomes 2011

HCAHPS Domains of Care 2010 – 2011

100

80

0

60

40

20

Percent

DischargeInformation Given

% yes

Doctor Communication

Nurse Communication

PainManagement

RoomClean

New MedicationsCommunication

Responsivenessto Needs

Quiet atNight


% always(Options: always, usually, sometimes, never)

2011 (N = 4,079)2010 (N = 4,184)

81Sydell and Arnold Miller Family Heart & Vascular InstituteSydell and Arnold Miller Family Heart & Vascular Institute 81

In 2011, the Global Cardiovascular Innovation Center (GCIC) awarded $3.3 million in commercialization funding to eight companies. In total, we have awarded more than $18 million to support 54 companies and projects. The GCIC portfolio companies continue to report significant growth. They have created more than 400 jobs and secured more than $300 million in outside funding. The 50,000-square foot GCIC incubator facility (pictured) is home to CCIC and GCIC as well as 24 young companies that are developing innovative healthcare products and services.

Outcomes 2011

Innovations

Cleveland Clinic Innovation Center

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

Outcomes 20118282

Ventana Device

Cleveland Clinic was the first in the United States to implant the Ventana™

Fenestrated Stent Graft System for endovascular repair of juxtarenal/pararenal

abdominal aortic aneurysm. The procedure was performed as part of a multicenter

trial led by Cleveland Clinic surgeons. This graft allows for a minimally invasive

approach to treating complex abdominal aortic aneurysms. During the procedure, a

device is inserted through the femoral artery. This allows preservation of blood flow

to the kidney arteries, which are located near the aneurysm.

Strain Imaging

Strain imaging is a technique used to identify the risk of heart

disease in patients who have previously had chemotherapy.

The incidence of radiation-induced heart disease has increased

in recent years. This sophisticated screening process uses

echocardiography to identify the timing and extent of myocardial

damage. Imaging specialists in Cleveland Clinic’s Cardio-Oncology

Center can focus on specific segments of the heart and identify

even subtle changes. The technology also enables physicians to

predict damage before it occurs. Initial research is promising,

demonstrating prediction of problems up to three months earlier

than monitoring ejection fraction alone.

Bull’s-eye display of global longitudinal strain measured in a patient with breast cancer prior to initiation of cardiotoxic chemotherapy. The average global longitudinal strain is -20.1 percent. Figure 1b shows follow-up study during the patient’s chemotherapy. The average global longitudinal strain is now -17 percent (15.4 percent drop as compared to baseline).

Our data show that a drop of more than 12 percent is a very early indicator that the patient will subsequently develop a drop in ejection fraction.


A Novel Technique for Hybrid Repair of Extensive Thoracic Aneurysm and Dissection

Cleveland Clinic surgeons have demonstrated successful

endovascular treatment of patients with chronic descending

aortic dissection. Historically, this type of treatment has

produced inconsistent remodeling of the aorta. However,

all 24 patients in this study, which involved first-stage

elephant trunk surgery with fenestration of the descending

aorta intimal flap, experienced technical success. Most had

moderate reductions in the size of the aorta, and there was

no retrograde false lumen flow.Reference: Roselli EE, Sepulveda E, Pujara AC, Idrees J, Nowicki E. Distal landing zone open fenestration facilitates endovascular elephant completion and false lumen thrombosis. Ann Thorac Surg. 2011 Dec;92(6):2078-2084.

84 Outcomes 2011

Innovations

Ultra-Small Implantable LVAD

Cleveland Clinic is developing a family of ultra-small implantable left ventricular assist devices (LVADs) for patients with

heart failure. The devices will provide the circulatory support needed to restore health. This will dramatically improve

patients’ quality of life with minimal impact on their daily activities. This platform technology is designed to provide

treatment throughout the patients’ continuum of care — from catheter-based temporary assistance to chronic implants.

The ultra-small size allows surgeons to use invasive procedures and those with lower risk. The modular platform is being

designed to provide individual therapy tailored to each patient’s needs. This

includes use for left-sided or biventricular treatment, which

reduces the need for multiple controllers and batteries. These

features ultimately improve patient experience and outcomes.

Transitioning Patients from Hospital to Home

Cleveland Clinic is committed to finding ways to ease the

transition from the hospital to home. Within the Miller Family

Heart & Vascular Institute, patients are given a phone number

they can call 24/7 to speak to a registered nurse. The nurses

can answer questions and concerns patients or caregivers have

once they return home. In addition, our Heart Care at Home

program uses a combination of technology monitoring and nurse

practitioner visits to assess patients and provide clinical support.

This leads to improvements in patient experiences and outcomes.

Research into extending care at home through the use of virtual

visits via tablet technology is ongoing.

85Sydell and Arnold Miller Family Heart & Vascular Institute 85

Hybrid Operating Room

Cleveland Clinic remains committed to providing our patients with the most innovative technology and procedures to

ensure the best possible outcomes and patient satisfaction. As part of this effort, the Miller Family Heart & Vascular

Institute is replacing two operating rooms (ORs) with new ORs equipped with the latest advances in imaging technology

and other equipment. The new rooms will allow us to increase our ability to perform endovascular and hybrid procedures.

They will also help us expand our use of transcatheter aortic valve applications. Cleveland Clinic is a leader in

transcatheter procedures, and securing a dedicated space for these operations will further our ability to extend the use of

this technology to other areas.

Advanced Technology in Coronary Guide Wires

Coronary guide wires are essential to percutaneous coronary intervention (PCI). The wires are threaded to areas of blocked vessels and help deliver therapeutic devices, such as percutaneous transluminal coronary angioplasty (PTCA) balloons and stents. In cases of chronic total occlusions, PCI is unsuccessful because the wires cannot penetrate the blockage. Cleveland Clinic has developed guide wires designed for use in even these complex and difficult cases. The technology, which incorporates novel materials and construction, is still in development but proves promising to expand the use of PCI to a greater patient population.

86 Outcomes 2011

Innovations

Making the “Good” Cholesterol Better

Researchers at Cleveland Clinic have created an oxidant-resistant apolipoprotein A-1 (apo A-1) that they hope to develop for the treatment of coronary artery disease. Apo A-1 is the major protein in HDL, the carrier of what is commonly known as “good” cholesterol because it can help remove cholesterol from the artery wall and reverse the growth of atherosclerotic plaques. However, apo A-1 can become dysfunctional when oxidized in the artery wall. While current therapies focus primarily on lowering LDL or “bad” cholesterol, this therapy involves the delivery of a novel modified apo A-1 that is resistant to becoming dysfunctional in order to reverse disease progression. Cleveland Clinic researchers are collaborating with a biopharmaceutical company in the preclinical development of this modified apo A-1 with the goal of developing a new therapy to treat at-risk patients.

0 5H2O2: apoAI Mole Ratio

10

rh-apoAI

rh-apoAI 4WF

15

[3H]Cholesterol Efflux (5 of total dpm)

2020

1515

1010

55

00

Cleveland Clinic researchers are working with an in vitro diagnostics company

to develop a diagnostic test for the gut flora metabolite trimethylamine

oxide (TMAO). In a study of more than 4,000 patients, it was demonstrated

that increased plasma levels of TMAO can indicate the risk of myocardial

infarction, stroke or death within three years. Measurement of TMAO levels

TMAO: A Predictor of Cardiovascular Risk

Self-Attaching Annuloplasty Ring and Delivery System

Researchers at Cleveland Clinic are developing a cardiac valve repair

system for treatment of valve regurgitation to restore valve function. This

allows surgeons to re-establish the normal shape and contour of the native

valve and simplifies the surgical process of repairing mitral valves. The

system includes a delivery device that allows the annuloplasty ring to

self-attach to the native annulus with a “single shot” instead of suturing

the ring in the valves. In addition, the self-attaching ring is designed in a

“saddle” shape to mimic the anatomy of the native valve.


Use of 3-D Imaging to Assess Severity of Aortic Stenosis

Successful transcatheter

treatment of patients with

aortic stenosis depends

on exact assessment of

the severity of the disease.

This is typically assessed

with 2-D echocardiography.

While this approach is well-

established in the context of

conventional surgical aortic

valve replacement (SAVR),

the emerging transcatheter

approaches (TAVR)

increasingly rely on 3-D

imaging for procedural planning. In order to precisely guide treatment decisions, Cleveland Clinic has incorporated the use

of 3-D imaging to determine the extent of disease and the anatomy of the aortic root. This includes detailed measurements

and characterization of the device landing zone.

ValveXchange Two-Part Heart Valve System

The ValveXchange two-part heart valve system was originally developed at Cleveland

Clinic. The valves are two-piece bioprosthetic tissue valve systems that deliver a

permanently implanted base along with a replaceable leaflet set. The device allows

for the exchange of leaflets, over time, without invasive surgery. This allows a broader

and younger range of patients to have tissue valve replacement without the need for

lifelong anticoagulation therapy. This therapy is required for patients who receive longer-

lasting mechanical valves. Cleveland Clinic participated in the first successful in-man

implantation surgeries in 2011. ValveXchange, Inc. is furthering the development of this

technology.

88 Outcomes 2011

Innovations

Pivotal-Branch Device

Physicians at Cleveland Clinic continue to lead the way in the development of

fenestrated and branched endograft technology to treat aortic aneurysms. To date,

our surgeons have performed more than 800 procedures using this technology. This

experience has facilitated the development of the pivotal-branch endograft device (Cook

Medical, Bloomington, IN), which will allow for an off-the-shelf graft to treat patients

with aneurysms in a shorter period of time and in case of emergencies.

Improvements in Valvular Assessment in Patients with Aortic Regurgitation

The use of echocardiography is the current standard to

assess the severity of aortic regurgitation (AR). However,

this method can lead to differences in interpretation

of the results because there is no hierarchy of the key

parameters used to grade the severity. The Cardiovascular

Imaging Section has worked to improve the method of

assessment by using a left ventricular volume-based

consensus strategy. The use of this strategy has improved

our ability to accurately assess AR and, thus, tailor the

treatment plan for patients with this condition.

Better Consistency in Estimation of Ejection Fraction

Visual assessment of ejection fraction (EF) is a cornerstone of left ventricular (LV) function quantification. Previous studies

have shown up to 14 percent variability in interobserver estimations. We have developed a self-directed learning program to

address this. In our program, EF misclassification (defined as ± 5% of MRI) was reduced from 51 percent to 43.6 percent

(P = 0.01). This also resulted in a decrease in the absolute difference between cardiac magnetic resonance and echo EF

(median [IQR] from 7[3 – 10.3] to 5[3.0 – 9.0], P = 0.02). This simple, mostly self-directed intervention decreased the

misclassification rate and improved the accuracy of EF measurements.

.8.8

.6.6

.4.4

00Overall Mild AR Moderate AR Severe AR

Agreement

Pre-KappaPost-Kappa

.2.2

Multirater Free-Range Kappa


90

AlJaroudi W, Chen J, Jaber WA, Lloyd SG, Cerqueira MD, Marwick T. Nonechocardiographic imaging in evaluation for cardiac resynchronization therapy. Circ Cardiovasc Imaging. 2011 May 1;4(3):334-343.

Argalious MY, Dalton JE, Mascha EJ, Cywinski JB, Clair DG. Association of red blood cell transfusion and postoperative outcomes after endovascular aortic repair. Semin Cardiothorac Vasc Anesth. 2011 Mar;15(1-2):49-55.

Arthurs ZM, Lyden SP, Rajani RR, Eagleton MJ, Clair DG. Long-term outcomes of Palmaz stent placement for intraoperative type IA endoleak during endovascular aneurysm repair. Ann Vasc Surg. 2011 Jan;25(1):120-126.

Arthurs ZM, Titus J, Bannazadeh M, Eagleton MJ, Srivastava S, Sarac TP, Clair DG. A comparison of endovascular revascularization with traditional therapy for the treatment of acute mesenteric ischemia. J Vasc Surg. 2011 Mar;53(3):698-705.

Becker RC, Mahaffey KW, Yang H, Marian AJ, Furman MI, Lincoff AM, Hazen SL, Petersen JL, Reist CJ, Kleiman NS. Heparin-associated anti-Xa activity and platelet-derived prothrombotic and proinflammatory biomarkers in moderate to high-risk patients with acute coronary syndrome. J Thromb Thrombolysis. 2011 Feb;31(2):146-153.

Berger JS, Bhatt DL, Steg PG, Steinhubl SR, Montalescot G, Shao M, Hacke W, Fox KA, Berger PB, Topol EJ, Lincoff AM. Bleeding, mortality, and antiplatelet therapy: Results from the Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA) trial. Am Heart J. 2011 Jul;162(1):98-105.

Bingham SE, Hachamovitch R. Incremental prognostic significance of combined cardiac magnetic resonance imaging, adenosine stress perfusion, delayed enhancement, and left ventricular function over preimaging information for the prediction of adverse events. Circulation. 2011 Apr 12;123(14):1509-1518.

Heart & Vascular Institute Selected Publications

This is a representative sample of publications authored by the Miller Family Heart & Vascular Institute in 2011.

Outcomes 2011

Selected Publications

The Miller Family Heart & Vascular Institute staff authored

716 publications in 2011. For a complete list, go to

www.clevelandclinic.org/outcomes.

716 Publications

C5ResearchCleveland Clinic Coordinating Center for Clinical Research

(C5Research) 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 80 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.

91

Bub GL, Greenberg RK, Mastracci TM, Eagleton MJ, Panuccio G, Hernandez AV, Cerqueira MD. Perioperative cardiac events in endovascular repair of complex aortic aneurysms and association with preoperative studies. J Vasc Surg. 2011 Jan;53(1):21-27.e1-2.

Cam A, Goel SS, Agarwal S, Menon V, Svensson LG, Tuzcu EM, Kapadia SR. Prognostic implications of pulmonary hypertension in patients with severe aortic stenosis. J Thorac Cardiovasc Surg. 2011 Oct;142(4):800-808.

Clair D. Neuroprotection during carotid artery stenting. Italian Journal of Vascular and Endovascular Surgery. 2011 Jun;18(2):109-116.

Clair DG, Hopkins LN, Mehta M, Kasirajan K, Schermerhorn M, Schonholz C, Kwolek CJ, Eskandari MK, Powell RJ, Ansel GM. Neuroprotection during carotid artery stenting using the GORE flow reversal system: 30-day outcomes in the EMPiRE Clinical Study. Catheter Cardiovasc Interv. 2011 Feb 15;77(3):420-429.

De S, Borowski AG, Wang H, Nye L, Xin B, Thomas JD, Tang WHW. Subclinical echocardiographic abnormalities in phenotype-negative carriers of myosin-binding protein C3 gene mutation for hypertrophic cardiomyopathy. Am Heart J. 2011 Aug;162(2): 262-267.

Desai MY, Ommen SR, McKenna WJ, Lever HM, Elliott PM. Imaging phenotype versus genotype in hypertrophic cardiomyopathy. Circ Cardiovasc Imaging. 2011 Mar 1;4(2):156-168.

Di Bartolo BA, Nicholls SJ, Bao S, Rye KA, Heather AK, Barter PJ, Bursill C. The apolipoprotein A-I mimetic peptide ETC-642 exhibits anti-inflammatory properties that are comparable to high density lipoproteins. Atherosclerosis. 2011 Aug;217(2):395-400.

Dijkstra ML, Eagleton MJ, Greenberg RK, Mastracci T, Hernandez A. Intraoperative C-arm cone-beam computed tomography in fenestrated/branched aortic endografting. J Vasc Surg. 2011 Mar;53(3):583-590.

Ellis SG, Shishehbor MH, Kapadia SR, Lincoff AM, Nair R, Whitlow PL, Bajzer CT, Cho LL, Tuzcu EM, Raymond R, Vargo

P, Cunningham R, Dushman-Ellis SJ. Enhanced prediction of mortality after percutaneous coronary intervention by consideration of general and neurological indicators. JACC Cardiovasc Interv. 2011 Apr;4(4):442-448.

Gillinov AM, Argenziano M, Blackstone EH, Iribarne A, Derose JJ, Jr., Ailawadi G, Russo MJ, Ascheim DD, Parides MK, Rodriguez E, Bouchard D, Taddei-Peters WC, Geller NL, Acker MA, Gelijns AC. Designing comparative effectiveness trials of surgical ablation for atrial fibrillation: Experience of the Cardiothoracic Surgical Trials Network. J Thorac Cardiovasc Surg. 2011 Aug;142(2):257-264.

Goel SS, Tuzcu EM, Agarwal S, Aksoy O, Krishnaswamy A, Griffin BP, Svensson LG, Kapadia SR. Comparison of ascending aortic size in patients with severe bicuspid aortic valve stenosis treated with versus without a statin drug. Am J Cardiol. 2011 Nov 15;108(10):1458-1462.

Gorodeski EZ, Ishwaran H, Kogalur UB, Blackstone EH, Hsich E, Zhang ZM, Vitolins MZ, Manson JE, Curb JD, Martin LW, Prineas RJ, Lauer MS. Use of hundreds of electrocardiographic biomarkers for prediction of mortality in postmenopausal women: the Women’s Health Initiative. Circ Cardiovasc Qual Outcomes. 2011 Sep 1; 4(5):521-532.

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 initiatives, 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,

fellows and faculty.


92

Grattan AG, Digiannantonio A, Mihaljevic T, Gillinov AM, Gornik HL. Duplex ultrasound mapping protocol for placement of cardiopulmonary bypass cannulae for robotic mitral valve surgery. Journal for Vascular Ultrasound. 2011 Sep;35(3):143-147.

Hachamovitch R, Rozanski A, Shaw LJ, Stone GW, Thomson LEJ, Friedman JD, Hayes SW, Cohen I, Germano G, Berman DS. Impact of ischaemia and scar on the therapeutic benefit derived from myocardial revascularization vs. medical therapy among patients undergoing stress-rest myocardial perfusion scintigraphy. Eur Heart J. 2011 Apr;32(8):1012-1024.

Hare JL, Hordern MD, Leano R, Stanton T, Prins JB, Marwick TH. Application of an exercise intervention on the evolution of diastolic dysfunction in patients with diabetes mellitus: efficacy and effectiveness. Circ Heart Fail. 2011 Jul 1;4(4):441-449.

Haulon S, Greenberg RK. Part Two: Treatment of type IV thoracoabdominal aneurysms — Fenestrated stent-graft repair is now the best option. Eur J Vasc Endovasc Surg. 2011 Jul;42(1):4-8.

Hertzer NR. The CREST results: Another piece to an unfinished puzzle. Ann Vasc Surg. 2011 Feb;25(2):152-158.

Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jr., Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2011 Dec 6;58(24):e123-e210.

Holland DJ, Kumbhani DJ, Ahmed SH, Marwick TH. Effects of treatment on exercise tolerance, cardiac function, and mortality in heart failure with preserved ejection fraction. A meta-analysis. J Am Coll Cardiol. 2011 Apr 19;57(16):1676-1686.

Horai T, Fukamachi K, Fumoto H, Takaseya T, Shiose A, Arakawa Y, Rao S, Dessoffy R, Mihaljevic T. Direct endoscopy-guided mitral valve repair in the beating heart: An acute animal study. Innovations (Phila). 2011;6(2):122-125.

Hussein AA, Saliba WI, Martin DO, Bhargava M, Sherman M, Magnelli-Reyes C, Chamsi-Pasha M, John S, Williams-Adrews M, Baranowski B, Dresing T, Callahan T, Kanj M, Tchou P, Lindsay BD, Natale A, Wazni O. Natural history and long-term outcomes of ablated atrial fibrillation. Circ Arrhythm Electrophysiol. 2011 Jun 1;4(3):271-278.

Hussein AA, Saliba WI, Martin DO, Shadman M, Kanj M, Bhargava M, Dresing T, Chung M, Callahan T, Baranowski B, Tchou P, Lindsay BD, Natale A, Wazni OM. Plasma B-type natriuretic peptide levels and recurrent arrhythmia after successful ablation of lone atrial fibrillation. Circulation. 2011 May 17;123(19):2077-2082.

Hussein AA, Uno K, Wolski K, Kapadia S, Schoenhagen P, Tuzcu EM, Nissen SE, Nicholls SJ. Peripheral arterial disease and progression of coronary atherosclerosis. J Am Coll Cardiol. 2011 Mar 8;57(10):1220-1225.

Jacob M, Smedira N, Blackstone E, Williams S, Cho L. Effect of timing of chronic preoperative aspirin discontinuation on morbidity and mortality in coronary artery bypass surgery. Circulation. 2011 Feb 15;123(6):577-583.

Jolly MA, Brennan DM, Cho L. Impact of exercise on heart rate recovery. Circulation. 2011 Oct 4;124(14):1520-1526.

Kang WC, Greenberg RK, Mastracci TM, Eagleton MJ, Hernandez AV, Pujara AC, Roselli EE. Endovascular repair of complicated chronic distal aortic dissections: Intermediate outcomes and complications. J Thorac Cardiovasc Surg. 2011 Nov;142(5): 1074-1083.

Kim ESH, Carrigan TP, Menon V. International participation in cardiovascular randomized controlled trials sponsored by the national heart, lung, and blood institute. J Am Coll Cardiol. 2011 Aug 9;58(7):671-676.

Outcomes 2011


93

Kodali SK, O’Neill WW, Moses JW, Williams M, Smith CR, Tuzcu M, Svensson LG, Kapadia S, Hanzel G, Kirtane AJ, Leon MB. Early and late (one year) outcomes following transcatheter aortic valve implantation in patients with severe aortic stenosis (from the United States REVIVAL trial). Am J Cardiol. 2011 Apr 1;107(7):1058-1064.

Krasuski RA, Cater GM, Devendra GP, Wolski K, Shishehbor MH, Nissen SE, Oberti C, Ellis SG. Downstream coronary effects of drug-eluting stents. Am Heart J. 2011 Oct;162(4):764-771.e1.

Krasuski RA, Magyar D, Hart S, Kalahasti V, Lorber R, Hobbs R, Pettersson G, Blackstone E. Long-term outcome and impact of surgery on adults with coronary arteries originating from the opposite coronary cusp. Circulation. 2011 Jan 18;123(2): 154-162.

Krishnaswamy A, Gillinov AM, Griffin BP. Ischemic mitral regurgitation: pathophysiology, diagnosis, and treatment. Coron Artery Dis. 2011 Aug;22(5):359-370.

Kumbhani DJ, Bavry AA, Harvey JE, de Souza R, Scarpioni R, Bhatt DL, Kapadia SR. Clinical outcomes after percutaneous revascularization versus medical management in patients with significant renal artery stenosis: A meta-analysis of randomized controlled trials. Am Heart J. 2011 Mar;161(3):622-630.

Lakin RO, Bena JF, Sarac TP, Shah S, Krajewski LP, Srivastava SD, Clair DG, Kashyap VS. The contemporary management of splenic artery aneurysms. J Vasc Surg. 2011 Apr;53(4):958-964.

Lazar LD, Pletcher MJ, Coxson PG, Bibbins-Domingo K, Goldman L. Cost-effectiveness of statin therapy for primary prevention in a low-cost statin era. Circulation. 2011 Jul 12;124(2):146-153.

Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American

College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation. 2011 Dec 6;124(23):e574-e651.

Lima B, Nowicki ER, Miller CM, Hashimoto K, Smedira NG, Gonzalez-Stawinski GV. Outcomes of simultaneous liver transplantation and elective cardiac surgical procedures. Ann Thorac Surg. 2011 Nov;92(5):1580-1584.

Lindsay BD, Asirvatham SJ, Curtis AB, Gura MT, Hayes DL, Jalife J, Klein GJ, Knight BP, Lampert R, Natale A, Packer DL, Page RL, Scheinman MM, Shanker AJ, Wang PJ, Weiss JP, Wilkoff BL, Busky CD. Guidance for the Heart Rhythm Society pertaining to interactions with industry: Endorsed by the Heart Rhythm Society on April 26, 2011. Heart Rhythm. 2011 Jul;8(7):e19-e23.

Mangi AA, Mason DP, Nowicki ER, Batizy LH, Murthy SC, Pidwell DJ, Avery RK, McCurry KR, Pettersson GB, Blackstone EH. Predictors of acute rejection after lung transplantation. Ann Thorac Surg. 2011 Jun;91(6):1754-1762.

Mastracci TM, Eagleton MJ. Endovascular repair of type II and type III thoracoabdominal aneurysms. Perspect Vasc Surg Endovasc Ther. 2011 Sep;23(3):178-185.

Mehran R, Pocock S, Nikolsky E, Dangas GD, Clayton T, Claessen BE, Caixeta A, Feit F, Manoukian SV, White H, Bertrand M, Ohman EM, Parise H, Lansky AJ, Lincoff AM, Stone GW. Impact of bleeding on mortality after percutaneous coronary intervention: Results from a patient-level pooled analysis of the REPLACE-2 (Randomized Evaluation of PCI Linking Angiomax to Reduced Clinical Events), ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy), and HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) trials. JACC Cardiovasc Interv. 2011 Jun;4(6):654-664.


94

Mehran R, Rao SV, Bhatt DL, Gibson CM, Caixeta A, Eikelboom J, Kaul S, Wiviott SD, Menon V, Nikolsky E, Serebruany V, Valgimigli M, Vranckx P, Taggart D, Sabik JF, Cutlip DE, Krucoff MW, Ohman EM, Steg PG, White H. Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the bleeding academic research consortium. Circulation. 2011 Jun 14;123(23):2736-2747.

Mihaljevic T, Jarrett CM, Gillinov AM, Williams SJ, DeVilliers PA, Stewart WJ, Svensson LG, Sabik JF, III, Blackstone EH. Robotic repair of posterior mitral valve prolapse versus conventional approaches: Potential realized. J Thorac Cardiovasc Surg. 2011 Jan;141(1):72-80.e4.

Moon MC, Greenberg RK, Morales JP, Martin Z, Lu Q, Dowdall JF, Hernandez AV. Computed tomography-based anatomic characterization of proximal aortic dissection with consideration for endovascular candidacy. J Vasc Surg. 2011 Apr;53(4):942-949.

Murthy SC, Nowicki ER, Mason DP, Budev MM, Nunez AI, Thuita L, Chapman JT, McCurry KR, Pettersson GB, Blackstone EH. Pretransplant gastroesophageal reflux compromises early outcomes after lung transplantation. J Thorac Cardiovasc Surg. 2011 Jul;142(1):47-52.

Nicholls SJ, Ballantyne CM, Barter PJ, Chapman MJ, Erbel RM, Libby P, Raichlen JS, Uno K, Borgman M, Wolski K, Nissen SE. Effect of two intensive statin regimens on progression of coronary disease. N Engl J Med. 2011 Dec 1;365(22):2078-2087.

Nicholls SJ, Brewer HB, Kastelein JJP, Krueger KA, Wang MD, Shao M, Hu B, McErlean E, Nissen SE. Effects of the CETP inhibitor evacetrapib administered as monotherapy or in combination with statins on HDL and LDL cholesterol: a randomized controlled trial. JAMA. 2011 Nov 16;306(19):2099-2109.

Nicholls SJ, Gordon A, Johansson J, Wolski K, Ballantyne CM, Kastelein JJ, Taylor A, Borgman M, Nissen SE. Efficacy and safety of a novel oral inducer of apolipoprotein A-I synthesis in statin-treated patients with stable coronary artery disease: a randomized controlled trial. J Am Coll Cardiol. 2011 Mar 1;57(9):1111-1119.

Nicholls SJ, Tang WHW, Brennan D, Brennan ML, Mann S, Nissen SE, Hazen SL. Risk prediction with serial myeloperoxidase monitoring in patients with acute chest pain. Clin Chem. 2011 Dec;57(12):1762-1770.

Nicholls SJ, Tuzcu EM, Wolski K, Bayturan O, Lavoie A, Uno K, Kupfer S, Perez A, Nesto R, Nissen SE. Lowering the triglyceride/high-density lipoprotein cholesterol ratio is associated with the beneficial impact of pioglitazone on progression of coronary atherosclerosis in diabetic patients: Insights from the PERISCOPE (pioglitazone effect on regression of intravascular sonographic coronary obstruction prospective evaluation) study. J Am Coll Cardiol. 2011 Jan 11;57(2):153-159.

O’Brien B, Schoenhagen P, Kapadia SR, Svensson LG, Rodriguez L, Griffin BP, Tuzcu EM, Desai MY. Integration of 3D imaging data in the assessment of aortic stenosis: impact on classification of disease severity. Circ Cardiovasc Imaging. 2011 Sep 1;4(5):566-573.

O’Connor CM, Starling RC, Hernandez AF, Armstrong PW, Dickstein K, Hasselblad V, Heizer GM, Komajda M, Massie BM, McMurray JJV, Nieminen MS, Reist CJ, Rouleau JL, Swedberg K, Adams KF, Jr., Anker SD, Atar D, Battler A, Botero R, Bohidar NR, Butler J, Clausell N, Corbalan R, Costanzo MR, Dahlstrom U, Deckelbaum LI, Diaz R, Dunlap ME, Ezekowitz JA, Feldman D, Felker GM, Fonarow GC, Gennevois D, Gottlieb SS, Hill JA, Hollander JE, Howlett JG, Hudson MP, Kociol RD, Krum H, Laucevicius A, Levy WC, Mendez GF, Metra M, Mittal S, Oh BH, Pereira NL, Ponikowski P, Wilson WH, Tanomsup S, Teerlink JR, Triposkiadis F, Troughton RW, Voors AA, Whellan DJ, Zannad F, Califf RM. Effect of nesiritide in patients with acute decompensated heart failure. N Engl J Med. 2011 Jul 7;365(1):32-43.

Oderich GS, Greenberg RK. Endovascular iliac branch devices for iliac aneurysms. Perspect Vasc Surg Endovasc Ther. 2011 Sep;23(3):166-172.

Pettersson GB, Subramanian S, Flynn M, Nowicki ER, Batizy LH, Svensson LG, Blackstone EH. Reoperations after the Ross procedure in adults: towards autograft-sparing/Ross reversal. J Heart Valve Dis. 2011 Jul;20(4):425-432.

Outcomes 2011


95

Prasad Z, Martin ZL, Mastracci TM. The evaluation of aortic dissections with intravascular ultrasonography. Vascular Disease Management. 2011 Apr;8(4):E93-E97.

Priest VL, Scuffham PA, Hachamovitch R, Marwick TH. Cost-effectiveness of coronary computed tomography and cardiac stress imaging in the emergency department: a decision analytic model comparing diagnostic strategies for chest pain in patients at low risk of acute coronary syndromes. JACC Cardiovasc Imaging. 2011 May;4(5):549-556.

Qureshi MA, Martin Z, Greenberg RK. Endovascular management of patients with Takayasu arteritis: Stents versus stent grafts. Semin Vasc Surg. 2011 Mar;24(1):44-52.

Rader F, Costantini O, Jarrett C, Gorodeski EZ, Lauer MS, Blackstone EH. Quantitative electrocardiography for predicting postoperative atrial fibrillation after cardiac surgery. J Electrocardiol. 2011 Nov-Dec;44(6):761-767.

Raja S, Rice TW, Goldblum JR, Rybicki LA, Murthy SC, Mason DP, Blackstone EH. Esophageal submucosa: The watershed for esophageal cancer. J Thorac Cardiovasc Surg. 2011 Dec;142(6):1403-1411.

Rajani RR, Arthurs ZM, Srivastava SD, Lyden SP, Clair DG, Eagleton MJ. Repairing immediate proximal endoleaks during abdominal aortic aneurysm repair. J Vasc Surg. 2011 May;53(5):1174-1177.

Reynolds MR, Magnuson EA, Lei Y, Leon MB, Smith CR, Svensson LG, Webb JG, Babaliaros VC, Bowers BS, Fearon WF, Herrmann HC, Kapadia S, Kodali SK, Makkar RR, Pichard AD, Cohen DJ. Health-related quality of life after transcatheter aortic valve replacement in inoperable patients with severe aortic stenosis. Circulation. 2011 Nov 1;124(18):1964-1972.

Rice TW, Murthy SC, Mason DP, Rybicki LA, Yerian LM, Dumot JA, Rodriguez CP, Blackstone EH. Esophagectomy for clinical high-grade dysplasia. Eur J Cardiothorac Surg. 2011 Jul;40(1): 113-119.

Rice TW, Shay SS. A primer of high-resolution esophageal manometry. Semin Thorac Cardiovasc Surg. 2011;23(3):181-190.

Roselli EE, Sepulveda E, Pujara AC, Idrees J, Nowicki E. Distal landing zone open fenestration facilitates endovascular elephant trunk completion and false lumen thrombosis. Ann Thorac Surg. 2011 Dec;92(6):2078-2084.

Sabik JF, III. Understanding saphenous vein graft patency. Circulation. 2011 Jul 19;124(3):273-275.

Sarac TP, Bannazadeh M, Rowan AF, Bena J, Srivastava S, Eagleton M, Lyden S, Clair DG, Kashyap V. Comparative predictors of mortality for endovascular and open repair of ruptured infrarenal abdominal aortic aneurysms. Ann Vasc Surg. 2011 May;25(4):461-468.

Schanzer A, Greenberg RK, Hevelone N, Robinson WP, Eslami MH, Goldberg RJ, Messina L. Predictors of abdominal aortic aneurysm sac enlargement after endovascular repair. Circulation. 2011 Jun 21;123(24):2848-2855.

Schoenhagen P, Bolen MA, Halliburton SS. Iterative CT reconstruction of aortic intramural hematoma. Circ J. 2011 Jun 24;75(7):1774-1776.

Schoenhagen P, Hachamovitch R, Achenbach S. Coronary CT angiography and comparative effectiveness research: Prognostic value of atherosclerotic disease burden in appropriately indicated clinical examinations. JACC Cardiovasc Imaging. 2011 May;4(5):492-495.

Schoenhagen P, Kapadia SR, Halliburton SS, Svensson LG, Tuzcu EM. Computed tomography evaluation for transcatheter aortic valve implantation (TAVI): Imaging of the aortic root and iliac arteries. J Cardiovasc Comput Tomogr. 2011 Sep;5(5):293-300.

Sengupta PP, Marwick TH, Narula J. Adding dimensions to unimodal cardiac images. JACC Cardiovasc Imaging. 2011 Jul;4(7):816-818.


96

Shiose A, Takaseya T, Fumoto H, Horai T, Kim HI, Fukamachi K, Mihaljevic T. Cardioscopy-guided surgery: Intracardiac mitral and tricuspid valve repair under direct visualization in the beating heart. J Thorac Cardiovasc Surg. 2011 Jul;142(1):199-202.

Shiota M, Gillinov AM, Takasaki K, Fukuda S, Shiota T. Recurrent mitral regurgitation late after annuloplasty for ischemic mitral regurgitation. Echocardiography. 2011 Feb;28(2):161-166.

Shyu S, Dew MA, Pilewski JM, DeVito Dabbs AJ, Zaldonis DB, Studer SM, Crespo MM, Toyoda Y, Bermudez CA, McCurry KR. Five-year outcomes with alemtuzumab induction after lung transplantation. J Heart Lung Transplant. 2011 Jul;30(7): 743-754.

Smith CR, Leon MB, Mack MJ, Miller DC, Moses JW, Svensson LG, Tuzcu EM, Webb JG, Fontana GP, Makkar RR, Williams M, Dewey T, Kapadia S, Babaliaros V, Thourani VH, Corso P, Pichard AD, Bavaria JE, Herrmann HC, Akin JJ, Anderson WN, Wang D, Pocock SJ. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med. 2011 Jun 9;364(23):2187-2198.

Starling RC, Naka Y, Boyle AJ, Gonzalez-Stawinski G, John R, Jorde U, Russell SD, Conte JV, Aaronson KD, McGee EC, Jr., Cotts WG, Denofrio D, Pham DT, Farrar DJ, Pagani FD. Results of the post-U.S. Food and Drug Administration-approval study with a continuous flow left ventricular assist device as a bridge to heart transplantation: A prospective study using the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support). J Am Coll Cardiol. 2011 May 10;57(19):1890-1898.

Stone GW, Ellis SG, Colombo A, Grube E, Popma JJ, Uchida T, Bleuit JS, Dawkins KD, Russell ME. Long-term safety and efficacy of paclitaxel-eluting stents final 5-year analysis from the TAXUS Clinical Trial Program. JACC Cardiovasc Interv. 2011 May;4(5):530-542.

Svensson LG, Batizy LH, Blackstone EH, Gillinov AM, Moon MC, D’Agostino RS, Nadolny EM, Stewart WJ, Griffin BP, Hammer DF, Grimm R, Lytle BW. Results of matching valve and root repair to aortic valve and root pathology. J Thorac Cardiovasc Surg. 2011 Dec;142(6):1491-1498.

Svensson LG, Kim KH, Blackstone EH, Rajeswaran J, Gillinov AM, Mihaljevic T, Griffin BP, Grimm R, Stewart WJ, Hammer DF, Lytle BW. Bicuspid aortic valve surgery with proactive ascending aorta repair. J Thorac Cardiovasc Surg. 2011 Sep;142(3):622-629.

Tang WHW, Francis GS. Cardiac resynchronization therapy in patients with class I-II heart failure and a wide QRS: a cautionary note. Circulation. 2011 Jan 18;123(2):203-208.

Tang WHW, Shrestha K, Shao Z, Borowski AG, Troughton RW, Thomas JD, Klein AL. Usefulness of plasma galectin-3 levels in systolic heart failure to predict renal insufficiency and survival. Am J Cardiol. 2011 Aug 1;108(3):385-390.

Tang WHW, Wu Y, Mann S, Pepoy M, Shrestha K, Borowski AG, Hazen SL. Diminished antioxidant activity of high-density lipoprotein-associated proteins in systolic heart failure. Circ Heart Fail. 2011 Jan 1;4(1):59-64.

Tarakji KG, Sabik JF, III, Bhudia SK, Batizy LH, Blackstone EH. Temporal onset, risk factors, and outcomes associated with stroke after coronary artery bypass grafting. JAMA. 2011 Jan 26;305(4):381-390.

Titus JM, Moise MA, Bena J, Lyden SP, Clair DG. Iliofemoral stenting for venous occlusive disease. J Vasc Surg. 2011 Mar;53(3):706-712.

To ACY, Gabriel RS, Park M, Lowe BS, Curtin RJ, Sigurdsson G, Sherman M, Wazni OM, Saliba WI, Bhargava M, Lindsay BD, Klein AL. Role of transesophageal echocardiography compared to computed tomography in evaluation of pulmonary vein ablation for atrial fibrillation (ROTEA Study). J Am Soc Echocardiogr. 2011 Sep;24(9):1046-1055.

To ACY, Popovic ZB, Thomas JD, Schoenhagen P. Multimodality imaging of an asymptomatic female with anomalous origin of right coronary artery from the pulmonary artery. J Am Coll Cardiol. 2011 Jan 18;57(3):e5.

Outcomes 2011


97

Traverse JH, Henry TD, Ellis SG, Pepine CJ, Willerson JT, Zhao DXM, Forder JR, Byrne BJ, Hatzopoulos AK, Penn MS, Perin EC, Baran KW, Chambers J, Lambert C, Raveendran G, Simon DI, Vaughan DE, Simpson LM, Gee AP, Taylor DA, Cogle CR, Thomas JD, Silva GV, Jorgenson BC, Olson RE, Bowman S, Francescon J, Geither C, Handberg E, Smith DX, Baraniuk S, Piller LB, Loghin C, Aguilar D, Richman S, Zierold C, Bettencourt J, Sayre SL, Vojvodic RW, Skarlatos SI, Gordon DJ, Ebert RF, Kwak M, Moye LA, Simari RD. Effect of intracoronary delivery of autologous bone marrow mononuclear cells 2 to 3 weeks following acute myocardial infarction on left ventricular function: the LateTIME randomized trial. JAMA. 2011 Nov 16;306(19):2110-2119.

Tuzcu EM, Ozkan A, Kapadia SR. Prosthesis-patient mismatch in the transcatheter aortic valve replacement era. J Am Coll Cardiol. 2011 Oct 25;58(18):1919-1922.

Verheugt FWA, Steinhubl SR, Hamon M, Darius H, Steg PG, Valgimigli M, Marso SP, Rao SV, Gershlick AH, Lincoff AM, Mehran R, Stone GW. Incidence, prognostic impact, and influence of antithrombotic therapy on access and nonaccess site bleeding in percutaneous coronary intervention. JACC Cardiovasc Interv. 2011 Feb;4(2):191-197.

Vivacqua A, Koch CG, Yousuf AM, Nowicki ER, Houghtaling PL, Blackstone EH, Sabik JF, III. Morbidity of bleeding after cardiac surgery: is it blood transfusion, reoperation for bleeding, or both? Ann Thorac Surg. 2011 Jun;91(6):1780-1790.

Wang Z, Klipfell E, Bennett BJ, Koeth R, Levison BS, Dugar B, Feldstein AE, Britt EB, Fu X, Chung YM, Wu Y, Schauer P, Smith JD, Allayee H, Tang WHW, DiDonato JA, Lusis AJ, Hazen SL. Gut flora metabolism of phosphatidylcholine promotes cardiovascular disease. Nature. 2011 Apr 7;472(7341):57-63.

Wilkoff BL, Bello D, Taborsky M, Vymazal J, Kanal E, Heuer H, Hecking K, Johnson WB, Young W, Ramza B, Akhtar N, Kuepper B, Hunold P, Luechinger R, Puererfellner H, Duru F, Gotte MJW, Sutton R, Sommer T. Magnetic resonance imaging in patients with a pacemaker system designed for the magnetic resonance environment. Heart Rhythm. 2011 Jan;8(1):65-73.

Zhong L, Su Y, Gobeawan L, Sola S, Tan RS, Navia JL, Ghista DN, Chua T, Guccione J, Kassab GS. Impact of surgical ventricular restoration on ventricular shape, wall stress, and function in heart failure patients. Am J Physiol Heart Circ Physiol. 2011 May;300(5):H1653-H1660.

Zurick AO, Bolen MA, Kwon DH, Tan CD, Popovic ZB, Rajeswaran J, Rodriguez ER, Flamm SD, Klein AL. Pericardial delayed hyperenhancement with CMR imaging in patients with constrictive pericarditis undergoing surgical pericardiectomy: A case series with histopathological correlation. JACC Cardiovasc Imaging. 2011 Nov;4(11):1180-1191.

Emergency Services Institute

Bhardwaj A, Truong QA, Peacock WF, Yeo KT, Storrow A, Thomas S, Curtis KM, Foote RS, Lee HK, Miller KF, Januzzi JL, Jr. A multicenter comparison of established and emerging cardiac biomarkers for the diagnostic evaluation of chest pain in the emergency department. Am Heart J. 2011 Aug;162(2):276-282.

Collins S, Peacock WF, Lindenfeld J. Acute heart failure guidelines: moving in the right direction? Ann Emerg Med. 2011 Jan;57(1):29-30.

Tubaro M, Danchin N, Goldstein P, Filippatos G, Hasin Y, Heras M, Jansky P, Norekval TM, Swahn E, Thygesen K, Vrints C, Zahger D, Arntz HR, Bellou A, De La Coussaye JE, De Luca L, Huber K, Lambert Y, Lettino M, Lindahl B, McLean S, Nibbe L, Peacock WF, Price S, Quinn T, Spaulding C, Tatu-Chitoiu G, Van De Werf F. Pre-hospital treatment of STEMI patients. A scientific statement of the Working Group Acute Cardiac Care of the European Society of Cardiology. Acute Card Care. 2011 Jun;13(2):56-67.

Valle R, Aspromonte N, Milani L, Peacock FW, Maisel AS, Santini M, Ronco C. Optimizing fluid management in patients with acute decompensated heart failure (ADHF): the emerging role of combined measurement of body hydration status and brain natriuretic peptide (BNP) levels. Heart Fail Rev. 2011 Nov;16(6):519-529.


∆Chair Holders

Outcomes 20119898

Staff Directory

Institute LeadershipBruce W. Lytle, MD∆, Chairman, Sydell and Arnold 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

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 SurgeryJoseph F. Sabik III, MD∆, Chairman

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

Cardiovascular Surgery

A. Marc Gillinov, MD∆

Douglas R. Johnston, MD

Bruce W. Lytle, MD∆

Kenneth R. McCurry, MD

Stephanie Mick, MD

Tomislav Mihaljevic, MD∆

Nader Moazami, MD

José L. Navia, MD

Gösta B. Pettersson, MD, PhD∆

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

Siva Raja, MD, PhD

Daniel Raymond, MD

Pediatric and Adult Congenital Heart Surgery

Gösta B. Pettersson, MD, PhD∆, Section Head

Robert D. Stewart, MD, Surgical Director of Congenital Heart Transplantation

Vascular SurgeryDaniel Clair, MD∆, Chairman

Linda Graham, MD, Vice-Chair

Timur Sarac, MD, Vice-Chair

Matthew Eagleton, MD

Roy K. Greenberg, MD

Jeanwan Kang, MD

Rebecca Kelso, MD

Levester Kirksey, MD

Sean Lyden, MD

∆Chair Holders


Tara Mastracci, MD

Patrick O’Hara, MD

Michael Park, MD

Christopher Smolock, MD

Sunita Srivastava, MD

Robert and Suzanne Tomsich Department of Cardiovascular MedicineSteven E. Nissen, MD, Chairman

A. Michael Lincoff, MD, Vice-Chairman

Randall C. Starling, MD, Vice-Chairman

E. Murat Tuzcu, MD, Vice-Chairman

Cardiac Electrophysiology and Pacing

Bruce D. Lindsay, MD, Section Head

Bryan Baranowski, MD

Mandeep Bhargava, MD

P. Peter Borek, MD

Thomas Callahan IV, MD

Daniel Cantillon, 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

Robert D. Mosteller, MD

Mark Niebauer, MD

Walid I. Saliba, MD

Richard Sterba, MD

Christine Tanaka-Esposito, 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

Thomas Marwick, MD, PhD∆, Section Head

Wael Al Jaroudi, MD

Manuel Cerqueira, MD*

Milind Desai, MD

Scott Flamm, MD*

Brian P. Griffin, MD∆

Richard A. Grimm, DO

Rory Hachamovitch, MD

Wael Jaber, MD

Vidyasagar Kalahasti, MD

Allan L. Klein, MD

Deborah Kwon, MD*

Harry M. Lever, MD

Chiara Liguori, MD

Venugopal Menon, MD

Juan Carlos Plana, MD

∆Chair Holders

Outcomes 2011100100

Staff Directory

Zoran Popovic, MD

L. Leonardo Rodriguez, MD

Ellen Mayer Sabik, MD

Paul Schoenhagen, MD*

William James Stewart, MD

Balaji Tamarappoo, MD

Maran Thamilarasan, MD

James Thomas, MD

*Joint appointment with Radiology

Clinical Cardiology

Ben Barzilai, MD, Section Head

Ajay Bhargava, MD

Caroline Casserly, MD

Michael Faulx, MD

Adam Grasso, MD, PhD

Donald F. Hammer, MD

Joel B. Holland, MD

Julie Huang, MD

Fuad Y. Jubran, MD∆

Umesh Khot, MD

Richard Krasuski, MD

David Majdalany, 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, Section Head

Corinne Bott-Silverman, MD

Eiran Gorodeski, MD

Mazen A. Hanna, MD

Robert E. Hobbs, MD

Eileen Hsich, MD

Karen B. James, MD

Christine Moravec, PhD

Maria Mountis, DO

Guilherme Oliveira, 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

Joseph G. Cacchione, MD

Leslie Cho, MD*

Khosrow Dorosti, MD

Michael Faulx, MD

Perry L. Fleisher, MD

∆Chair Holders


Irving Franco, MD*

Frederick A. Heupler Jr., MD

Robert E. Hobbs, MD

Samir Kapadia, MD*†

Richard Krasuski, MD*†

A. Michael Lincoff, MD*

Ravi N. Nair, MD*

Russell E. Raymond, DO*

Gustavo Rincon, MD

Mehdi Shishehbor, DO

Conrad C. Simpfendorfer, MD*

John Stephens, MD

E. Murat Tuzcu, MD*†

Patrick L. Whitlow, MD*

*Coronary interventionalists

†Interventionalists who also perform percutaneous structural heart procedures

Preventive Cardiology and Rehabilitation

Leslie Cho, MD, Section Head

Stanley L. Hazen, MD, PhD, Section Head

Michael B. Rocco, MD, Medical Director, Cardiac Rehabilitation

Gordon Blackburn, PhD, Program Director, Cardiac Rehabilitation

David J. Frid, MD Department of Cardiovascular Medicine

Betul Hatipoglu, MD Department of Endocrinology

Julie Huang, MD Department of Cardiovascular Medicine

Leopoldo Pozuelo, MD Program Director, Cardiovascular Behavioral Health Clinic

Paul Schoenhagen, MD Department of Diagnostic Radiology

Pediatric Preventive and Metabolic Clinic

Naim Alkhouri, MD Department of Pediatric Gastroenterology

Richard Lorber, MD Department of Pediatric Cardiology

Douglas Rogers, MD Section Head, Pediatric Endocrinology

Vascular Medicine

John R. Bartholomew, MD, Section Head

Christopher Bajzer, MD*

Robert Bauman, MD

Natalie Ecans, MD

Carmen Fonseca, MD

Leslie Gilbert, MD

Marcelo Gomes, MD

Heather L. Gornik, MD

Douglas Joseph, DO

Samir Kapadia, MD*

Soo Hyun (Esther) Kim, MD

Natalia Fendrikova Mahlay, MD

Michael Maier, DPM

William Ruschhaupt, MD

Mehdi Shishehbor, DO

Patrick L. Whitlow, MD*

*Vascular interventionalists who perform interventional and endovascular procedures

Wael A. Jaber, MD


Venugopal Menon, MD

Mehdi H. Shishehbor, DO

Pediatric and Adult Congenital Heart Surgery Research

Marshall Jacobs, MD, Director Clinical Research

Cardiothoracic AnesthesiologyMichael S. O’Connor, DO, Chairman

Colleen Koch, MD, Vice-Chair

Michael Licina, MD, Vice-Chair

John Apostolakis, MD, Quality Review Officer

Ahmad Adi, MD

Andrej Alfirevic, MD

C. Allen Bashour, MD

M. Gregory Bourdakos, MD

Sergio Bustamante, 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

Sarawathi Karri, MD

Erik Kraenzler, MD

Tory McGrath, MD

Anand Mehta, MD∆Chair Holders

Outcomes 2011102102

Staff Directory

Women’s Cardiovascular Center

Leslie Cho, MD, Director

Julie Huang, MD


Ellen Mayer Sabik, MD

ResearchClinical Investigations

Eugene H. Blackstone, MD∆, Director

Vascular Surgery Research

Roy K. Greenberg, MD, Director of Endovascular Research

Cardiovascular Research and C5Research (Cleveland Clinic Coordinating Center for Clinical Research)

A. Michael Lincoff, MD∆, Director

Stephen J. Nicholls, MD, PhD, Cardiovascular Director

Associate Directors of C5Research

Heather L. Gornik, MD


Wael A. Jaber, MD

David O. Martin, MD

Stephen J. Nicholls, MD, PhD

W.H. Wilson Tang, MD

Patrick L. Whitlow, MD

C5Research Core Laboratory Directors


Stanley L. Hazen, MD, PhD

Michael S. O’Connor, DO

Grzegorz Pitas, MD

Dominique Prud’Homme, MD

Shiva Sale, MD

Robert M. Savage, MD

Joyce Shin, MD

Norman J. Starr, MD

Carlos Trombetta, MD

Lee Wallace, MD

Jean-Pierre Yared, MD

Cardiovascular Intensive Care Units Anesthesiology

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

A. Maher Adi, MD

David Anthony, MD

C. Allen Bashour, MD

Gregory Bourdakos, MD

Gohar Dar, MD

José Diaz-Gomez, MD

Andra Duncan, MD

Marius Gota, MD

Steven Insler, DO

Eric Kaiser, MD

Donn Marciniak, MD

Michael S. O’Connor, DO

Robert Savage, MD

Vascular Surgery Anesthesiology

Theodore Marks, MD, Section Head

Maged Argalious, MD

Harendra Arora, MD

Jacek Cywinski, MD

Tracy Dovich, MD

Brian Fitzsimons, MD

Alexandru Gottlieb, MD

Robert Helfand, MD

Samuel Irefin, MD

Jia Lin, MD

Brian Parker, MD

Mangalakaraipudur Ramachandran, MD

Regional Medical Practice

Avon (Richard E. Jacobs) Health Center

James Bekeny, MD, Vascular Surgery

Lon W. Castle, MD, Cardiovascular Medicine

Albert Chan, MD, Cardiovascular Medicine

Basem Droubi, MD, Vascular Surgery

Thomas B. Edel, MD, Cardiovascular Medicine

Lawrence Jacobs, MD, Cardiovascular Medicine

Jeanwan Kang, MD, Vascular Surgery

Soo Hyun (Esther) Kim, MD, Vascular Medicine

Chiara Liguori, MD, Cardiovascular Medicine

Robert D. Mosteller, MD, Cardiovascular Medicine

Ashoka Nautiyal, MD, Cardiovascular Medicine

Robert Reynolds, MD, Cardiovascular Medicine

Ramandeep Sidhu, MD, Vascular Surgery

Christopher Smolock, MD, Vascular Surgery

Christine Tanaka-Esposito, MD, Cardiovascular Medicine


Beachwood Family Health and Surgery Center

Joseph Cacchione, MD, Cardiovascular Medicine

Leslie Gilbert, MD, Vascular Medicine

Joel B. Holland, MD, Cardiovascular Medicine

Carlos Hubbard, MD, Cardiovascular Medicine

Douglas Joseph, DO, Vascular Medicine

David Naar, MD, Vascular Surgery

Michael B. Rocco, MD, Cardiovascular Medicine

Sunita Srivastava, MD, Vascular Surgery

Brunswick Family Health Center

Joel Godard, MD, Cardiovascular Medicine

Chagrin Falls Family Health Center

Jason Confino, MD, Cardiovascular Medicine


Joseph Martin, MD, Cardiovascular Medicine

Anthony Rizzo, MD, Vascular Surgery

Elyria Chestnut Commons Family Health Center


Cleveland Clinic Florida – Cardiovascular Medicine

Craig Asher, MD

Howard S. Bush, MD

Carmel Celestin, MD

Bernardo Fernandez, MD

Kenneth R. Fromkin, MD

Marcelo Eduardo Helguera, MD

Gian M. Novaro, MD

Sergio Pinski, MD

Michael Shen, MD

Independence Family Health Center

Caroline Casserly, MD, MBA, Cardiovascular Medicine


Lawrence Jacobs, MD, Cardiovascular Medicine

Rebecca Kelso, MD, Vascular Surgery

Michael Maier, DPM, Vascular Medicine

Michael B. Rollins, MD, Cardiovascular Medicine

Lorain Family Health and Surgery Center


Richard Sterba, MD, Pediatric Cardiology

Strongsville Family Health and Surgery Center

John R. Bartholomew, MD, Vascular Medicine


Natalia Fendrikova Mahlay, MD, Vascular Medicine

Tara Mastracci, MD, Vascular Surgery

Michael Park, MD, Vascular Surgery

Terrence G. Tulisiak, MD, Cardiovascular Medicine

Twinsburg Family Health Center

George Anton, MD, Vascular Surgery

Jason Confino, MD, Cardiovascular Medicine

Joseph Martin, MD, Cardiovascular Medicine

Mark Pace, DO, Cardiovascular Medicine

Outcomes 2011104104

Staff Directory

Willoughby Hills Family Health Center

Mohamed A. Atassi, MD, Cardiovascular Medicine


Kamal Riad, MD, Cardiovascular Medicine

Lincoln Roland, MD, Vascular Surgery

Wooster Family Health Center

Kenneth E. Shafer, MD, Cardiovascular Medicine

Richard Sterba, MD, Pediatric Cardiology

Cleveland Clinic HospitalsEuclid Hospital

J. Michael Koch, MD, Cardiovascular Medicine

John Patzakis, DO, Vascular Surgery

Kamal Riad, MD, Cardiovascular Medicine

Fairview Hospital


Inderjit S. Gill, MD, Thoracic and Cardiovascular Surgery

Jeanwan Kang, MD, Vascular Surgery

Joseph A. Lahorra, MD, Thoracic and Cardiovascular Surgery


Christopher Smolock, MD, Vascular Surgery

R. Thomas Temes, MD, Thoracic and Cardiovascular Surgery

Hillcrest Hospital

George Anton, MD, Vascular Surgery

Mark J. Botham, MD, Thoracic and Cardiovascular Surgery

Carmen Fonseca, MD, Hillcrest Vein Center

Avrum Jacobs, MD, Cardiovascular Medicine

David Naar, MD, Vascular Surgery

Anthony Rizzo, MD, Vascular Surgery

Lincoln Roland, MD, Vascular Surgery

Thomas G. Santoscoy, MD, Thoracic and Cardiovascular Surgery

Jonathan Scharfstein, MD, Cardiovascular Medicine

Vladimir Vekstein, MD, Cardiovascular Medicine

Donna J. Waite, MD, Thoracic and Cardiovascular Surgery

Martin Wiseman, MD, Cardiovascular Medicine

Lakewood Hospital

James Bekeny, MD, Vascular Surgery


Douglas Joseph, DO, Cardiovascular Medicine


Marymount Hospital

Javier Alvarez-Tostado, MD, Vascular Surgery

John Patzakis, DO, Vascular Surgery

Sotero Peralta, MD, Vascular Surgery

James Poliquin, MD, Vascular Surgery


Medina Hospital

Michael Amalfitano, DO, Cardiovascular Medicine

Kathleen Boyle, MD, Vascular Surgery

South Pointe Hospital


Monica Khot, MD, Cardiovascular Medicine

Thomas G. Santoscoy, MD, Thoracic and Cardiovascular Surgery



Affiliate ProgramsThoracic and Cardiovascular SurgeryCape Fear Valley Health System

Ali Husain, MD

Robert Maughan, MD

Central DuPage Hospital

Timothy James, MD

Neil Thomas, MD

The Chester County Hospital

Brian Priest, MD

Cleveland Clinic Florida

Nicolas Broaai, MD

Edward Savage, MD

EMH Regional Medical Center

Altagracia M. Chavez, MD

Michael S. Mikhail, MD

Lake Health

Rami Akhrass, MD

Mark Botham, MD

Thomas G. Santoscoy, MD

Donna J. Waite, MD

McLeod Health Regional Medical Center

Fred Holland II, MD

Gregory Jones, MD

Medina General Hospital

Kathleen Boyle, MD

Natalia Fendrikova Mahlay, MD

MetroHealth Medical Center

Rami Akhrass, MD

Inderjit S. Gill, MD

Joseph A. Lahorra, MD

R. Thomas Temes, MD

Pikeville Medical Center

Thomas A. Donohue, MD

Dennis Havens, MD

Rochester General Hospital

David Cheeran, MD

Ronald Kirshner, MD

Some physicians may practice in multiple locations.

For a complete list including staff photos, please visit

clevelandclinic.org/staff

Outcomes 2011106106

Staff Directory


Contact Information

Miller Family Heart & Vascular InstituteGeneral Information and Appointments

800.659.7822

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 877.8HEART1 (877.843.2781)

Cardiovascular Medicine Appointments/Referrals

216.444.6697 or 800.223.2273, ext. 46697

Vascular Medicine Appointments/Referrals

216.444.4420 or 800.223.2273, ext. 44420

Vascular Surgery Appointments/Referrals

216.444.4508 or 800.223.2273, ext. 44508

Miller Family Heart & Vascular Institute Resource Center

Nurses are available Monday through Friday, 8:30 a.m. to 4:00 p.m., Eastern time, to answer patient questions and concerns about heart and blood vessel disease or to schedule a second opinion.

216.445.9288 or toll-free 866.289.6911 or email [email protected]

On the Web at clevelandclinic.org/heart

Additional Contact InformationGeneral Information

216.444.2200

Hospital Transfers

24/7 hospital transfers or physician consults 800.553.5056

Referring Physician Center and Hotline

Cleveland Clinic’s Referring Physician Center has established a 24/7 hotline — 855.REFER.123 (855.733.3712) — to streamline access to our array of medical services. Contact the Referring Physician Hotline for information on our clinical specialties and services, to schedule and confirm patient appointments, for assistance in resolving service-related issues, and to connect with Cleveland Clinic specialists.

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

For address corrections or changes, please call

800.890.2467

Outcomes 2011108108

Institute Locations

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.

Cleveland Clinic Main Campus

9500 Euclid Ave. Cleveland, OH 44195 216.444.2200 or 800.223.2273

Cleveland Clinic Florida

2950 Cleveland Clinic Blvd. Weston, FL 33331954.659.5320 clevelandclinic.org/florida Cardiovascular medicine, vascular medicine, cardiothoracic surgery, thoracic surgery

Ashtabula County Medical Center

2420 Lake Road Ashtabula, OH 44004440.994.7622 acmchealth.orgInvasive cardiology

Beachwood Family Health and Surgery Center

26900 Cedar Road Beachwood, OH 44122216.839.3000 or toll-free 866.318.2491 Cardiovascular medicine, vascular surgery

Brunswick Family Health Center

3574 Center Road Brunswick, OH 44212330.225.8886Cardiovascular medicine

Elyria Family Health and Surgery Center

303 Chestnut Commons Drive Elyria, OH 44035440.366.9444 or 440.204.7900Vascular surgery

Euclid Hospital

18901 Lakeshore Blvd. Euclid, OH 44119216.531.9000 euclidhospital.orgCardiovascular medicine

Fairview Hospital

Fairview Physicians’ Center 18101 Lorain Ave. Cleveland, OH 44111216.476.7310 fairviewhospital.orgCardiothoracic surgery, vascular surgery

Hillcrest Hospital

Hillcrest Hospital Atrium 6780 Mayfield Road, Suite 400 Mayfield Heights, OH 44124440.449.9300 hillcresthospital.orgCardiothoracic surgery, vascular surgery

Independence Family Health Center

Crown Centre II 5001 Rockside Road Independence, OH 44131216.986.4000Cardiovascular medicine,vascular surgery

Lorain Family Health and Surgery Center

5700 Cooper Foster Park Road Lorain, OH 44053440.204.7400 or 800.272.2676 Pediatric cardiovascular medicine, vascular surgery

Marymount Hospital

12300 McCracken Road Garfield Heights, OH 44125216.587.4280 marymount.orgVascular surgery, thoracic surgery

South Pointe Hospital

20000 Harvard Road Warrensville Heights, OH 44122216.491.6000 southpointehospital.orgCardiovascular medicine, thoracic surgery

Strongsville Family Health and Surgery Center

16761 SouthPark Center Strongsville, OH 44136440.878.2500 or 800.239.1098 Cardiovascular medicine, vascular medicine, vascular surgery

Twinsburg Medical Office

8701 Darrow RoadTwinsburg, OH 44087330.888.4000 Cardiovascular medicine,vascular surgery

Westlake Family Health Center

30033 Clemens Road Westlake, OH 44145440.899.5555 or 800.599.7771 Cardiovascular medicine, thoracic and cardiovascular surgery

Willoughby Hills Family Health Center

2570 SOM Center Road Willoughby Hills, OH 44094440.943.2500 or 800.807.2888 Cardiovascular medicine, vascular medicine

Wooster Family Health and Surgery Center

1740 Cleveland Road Wooster, OH 44691330.287.4500 or 800.451.9870 Adult and pediatric cardiovascular medicine


Additional Locations

Cape Fear Valley Health System

Cardiothoracic Surgery Department 1638 Owen Drive Fayetteville, NC 28304 910.609.4000 capefearvalley.comCardiothoracic surgery

Central DuPage Hospital

25 N. Winfield Road Winfield, IL 60190 630.933.4234 cdh.orgCardiothoracic surgery

The Chester County Hospital

Cardiothoracic Surgery Department 701 E. Marshall St., 2nd Floor West Chester, PA 19380610.738.2690 cchosp.com Cardiothoracic surgery EMH Regional Medical CenterGates Medical Building, Suite 101 630 E. River St. Elyria, OH 44035440.284.1504 emh-healthcare.orgCardiothoracic surgery

Lake Health

West Medical Center36100 Euclid Ave, Suite 280 Willoughby, OH 44094440.918.4640 lakehealth.orgCardiothoracic surgery

McLeod Health Heart & Vascular Institute

Cardiothoracic Surgery Department 555 E. Cheves St. Florence, SC 29506843.777.2000 mcleodhealth.orgCardiothoracic surgery

MetroHealth Medical Center

Cardiothoracic Surgery Department 2500 MetroHealth Drive Cleveland, OH 44109216.778.4304 metrohealth.orgCardiothoracic surgery

Pikeville Medical Center

911 Bypass Road Pikeville, KY 41501606.218.4530 pikevillehospital.orgCardiothoracic surgery

Rochester General Hospital

Cardiothoracic Surgery Department 1445 Portland Ave. Rochester, NY 14621585.544.6550 rochestergeneralhospital.org

Outcomes 2011110110

Institute Locations


Improving Quality, Safety and the Patient Experience

Overview

Cleveland Clinic uses a scorecard approach to measure quality, safety and patient experience. In addition, real-time dashboard data are leveraged to drive performance improvement. Although not an exact match to publicly reported data, more timely internal data provide transparency for leaders at all levels of the organization to support improved care in their clinical locations. The following are examples of Cleveland Clinic’s 2011 focus areas and main campus results.

Appropriateness of Care 2011

Cleveland Clinic’s observed/expected (O/E) mortality ratio outperformed the University HealthSystem Consortium (UHC) academic medical center 50th percentile throughout 2011.

Cleveland Clinic’s goal is for all patients to receive all the recommended care for which they are eligible. An aggregated “all or nothing” measurement approach to monitoring multiple publicly reported process-of-care measures for heart failure, acute myocardial infarction, pneumonia and surgical patients is trending positively.

Mortality 2011

98

96

100

86Q1 Q2

2010 2011

Q3 Q4 Q1 Q2 Q3 Q4

94

92

90

88

Percent of Patients

Cleveland Clinic performanceCleveland Clinic target

*Source: Performance Accelerator Suite Program maintainedby the University HealthSystem Consortium (UHC)https://www.uhc.edu/

0.8

1.0

0.6

0.0Q1 Q2

2010 2011

Q3 Q4 Q1 Q2 Q3 Q4

0.4

0.2

O/E Ratio

Cleveland Clinic*UHC academic medicalcenter 50th percentile*

Outcomes 2011112112


Patient Safety Indicators (PSIs) 2011

Cleveland Clinic established a 2011 target ICU surveillance rate of 1.33 central line-associated bloodstream infections (CLABSIs) per 1,000 central line days with the goal of reducing our rate by an additional 50 percent over the 2010 results. This 2011 target was met by the end of the year.

Cleveland Clinic focused on reducing the incidence of 10 Agency for Healthcare Research and Quality PSIs. Cleveland Clinic achieved a reduction of more than 60 percent in the total number of these PSIs in 2011 through a combination of clinical and documentation improvement activities.

Central Line-Associated Bloodstream Infections — ICUs 2010 – 2011

3

4

2

0Q1 Q2

2010 2011

Q3 Q4 Q1 Q2 Q3 Q4

1

Rate per 1,000 Line Days

Cleveland Clinic performanceCleveland Clinic target

* PSI 3 Stage III/IV Pressure Ulcers, PSI 6 Iatrogenic Pneumothorax, PSI 7 CLABSI, PSI 8 Post-Op Hip Fracture, PSI 9 Post-Op Hemorrhage/Hematoma, PSI 11 Post-Op Respiratory Failure, PSI 12 Post-Op PE or DVT, PSI 13 Post-Op Sepsis, PSI 14 Post-Op Wound Dehiscence, PSI 15 Accidental Puncture/Laceration

150

200

100

0Jan Mar May July Sep Nov

50

Number of PSIs*


Hospital-Acquired Pressure Ulcers — ICUs 2010 – 2011

Patient Falls — Stepdown Units 2010 – 2011

Hospital-acquired pressure ulcers in Cleveland Clinic ICU patients were below the national average in 2010 and 2011.

Falls in Cleveland Clinic stepdown unit patients were below the national average for most of 2010 and 2011. In 2011, Cleveland Clinic supplemented proactive falls reduction strategies with after-event huddles to evaluate causality and develop prevention strategies.

*The National Database of Nursing Quality Indicators® (NDNQI®) is owned by the American Nurses Association. The database collects and evaluates unit-specific nurse-sensitive data from hospitals domestically and globally with over 1,800 hospitals participating. The comparison data represented here are based on a third of all hospitals in the U.S. participating. © 2012 American Nurses Association, All Rights Reserved. https://www.nursingquality.org/

12

14

8

10

0Q1 Q2

2010 2011

Q3 Q4 Q1 Q2 Q3 Q4

6

4

2

Pressure Ulcer Prevalence (%)

Cleveland Clinic ICUsBenchmark: NDNQI* ICUs

3.0

4.0

2.0

3.5

2.5

0Q1 Q2

2010 2011

Q3 Q4 Q1 Q2 Q3 Q4

1.5

1.0

0.5

Fall Rate per 1,000 Patient Days

Cleveland Clinic Stepdown UnitsBenchmark: NDNQI* Stepdown Units

Outcomes 2011114114

Medical Emergency Team Event Volume* 2009 – 2011

Critical Response Outcomes

Percent of Medical Emergency Team Events Resulting in ICU Transfer 2009 – 2011

Medical Emergency Teams (METs) bring critical care experience to patients across the hospital and provide early intervention that can prevent unplanned transfers to ICUs. As adult MET activations increased from 2009 through 2011, post-event adult ICU transfers decreased.

3,000

2,500

0

2,000

1,500

1,000

500

Events

2009 2010 2011

*Excluding events originating in ORs and ICUs

40

30

0

20

10

Percent

2009 2010 2011


Overview

Cleveland Clinic is a nonprofit multispecialty academic medical center that integrates clinical and hospital care with research and education. Across the health system, 2,800 Cleveland Clinic physicians and scientists practice in 120 medical specialties and subspecialties, annually recording more than 4.6 million physician visits and nearly 188,000 surgeries. Patients come for treatment from every state and from more than 125 countries annually. Cleveland Clinic’s main campus, with 50 buildings on 180 acres in Cleveland, Ohio, includes a 1,400-bed hospital, outpatient clinic, specialty institutes, and supporting labs and facilities. The hospital currently has the highest CMS case-mix index in America. Cleveland Clinic also operates 18 family health centers, eight community hospitals, one affiliate hospital, a rehabilitation hospital for children, Cleveland Clinic Florida, Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas, Cleveland Clinic Canada, and Sheikh Khalifa Medical City. Cleveland Clinic Abu Dhabi (United Arab Emirates), a multispecialty care hospital and clinic, is scheduled to open in 2013. With 41,000 employees, Cleveland Clinic is the second largest employer in Ohio and is responsible for an estimated $9 billion of economic activity every year.

The Cleveland Clinic Model

Cleveland Clinic was founded in 1921 by four physicians who had served in World War I and hoped to replicate the organizational efficiency of military medicine. The organization has grown through the years by adhering to the model set forth by the founders. All Cleveland Clinic staff physicians receive a straight salary with no bonuses or other financial incentives. The hospital and physicians share a financial interest in controlling costs, and profits are reinvested in research and education. 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 leader and focuses the energies of multiple professionals on the patient. Institutes are improving the patient experience at Cleveland Clinic.


About Cleveland Clinic

Cleveland Clinic Lerner Research Institute At the Lerner Research Institute, hundreds of principal investigators, project scientists, research associates and postdoctoral fellows are involved in laboratory-based, translational and clinical research. Total research expenditures from external and internal sources exceeded $240 million in 2010. Research programs include cardiovascular, cancer, neuralgic, musculoskeletal, allergic and immunologic, eye, metabolic, and infectious diseases.

Cleveland Clinic Lerner College of Medicine Celebrating its 10th anniversary in 2012, the Lerner College of Medicine of Case Western Reserve University is known for its small class size, unique curriculum and full-tuition scholarships for all students. The program graduated 31 students as physician investigators in 2011.

Graduate Medical Education In 2011, nearly 1,800 residents and fellows trained at Cleveland Clinic and Cleveland Clinic Florida, the most ever hosted by Cleveland Clinic and part of a continuing upward trend.

U.S.News & World Report Ranking 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.

Outcomes 2011116116

About Cleveland Clinic

© The Cleveland Clinic Foundation 2012

This project would not have been possible without the commitment and expertise of a team led by Dr. Umesh Khot, Pam Goepfarth, Sandra Hays-Flynn and Vi Huynh.

9500 Euclid Avenue, Cleveland, OH 44195 ClevelandClinic.org

prescriptions and review test results and medications from their personal computers. MyChart provides a link to Microsoft HealthVault, a free online service that helps patients securely gather and store health information. It connects to Cleveland Clinic’s social media and Internet site, currently the most visited hospital website in America. For more information, visit clevelandclinic.org/mychart.

Critical Care Transport Worldwide Cleveland Clinic’s critical care transport team and fleet of mobile ICU vehicles, helicopters and fixed-wing aircraft serve critically ill and highly complex patients across the globe.

To arrange a transfer for STEMI (ST elevated myocardial infarction), acute stroke, ICH (intracerebral hemorrhage), SAH (subarachnoid hemorrhage) or aortic syndrome, call toll-free 877.379.CODE (2633).

For all other critical care transfers, call 216.444.8302 or 800.553.5056.

CME Opportunities: Live and Online Cleveland Clinic’s Center for Continuing Education operates one of the largest and most successful CME programs in the country. The Center’s website (ccfcme.com) is an educational resource for healthcare providers and the public. Available 24/7, it houses programs that cover topics in 30 areas – if not from A to Z, at least from Allergy to Wellness – with a worldwide reach. Among other resources, the website contains a virtual textbook of medicine (Disease Management Project) and myCME, a system for physicians to manage their CME portfolios. Live courses, however, remain the backbone of the Center’s CME operation. Most live courses are held in Cleveland, but outreach plans are under way. In 2011, the Center offered 15 simultaneous courses at Arab Health, a major world healthcare forum.

Referring Physician Center and Hotline

Cleveland Clinic’s Referring Physician Center has established a 24/7 hotline – 855.REFER.123 (855.733.3712) – to streamline access to our array of medical services. Contact the Referring Physician Hotline for information on our clinical specialties and services, to schedule and confirm patient appointments, for assistance in resolving service-related issues, and to connect with Cleveland Clinic specialists.

Remote Consults

Online medical second opinions from Cleveland Clinic’s MyConsult are particularly valuable for patients who wish to avoid the time and expense of travel. Cleveland Clinic offers online medical second opinions for more than 1,000 life-threatening and life-altering diagnoses. For more information, visit clevelandclinic.org/myconsult, email [email protected] or call 800.223.2273, ext. 43223.

Request Medical Records 216.444.2640 or 800.223.2273, ext. 42640

Track Your Patient’s Care Online DrConnect offers referring physicians secure access to their patients’ treatment progress while at Cleveland Clinic. To establish a DrConnect account, visit clevelandclinic.org/drconnect or email [email protected].

Medical Records Online Cleveland Clinic continues to expand and improve electronic medical records (EMRs) to provide faster, more efficient and accurate care by sharing patient data through a highly secure network. Patients using MyChart can renew


Cleveland Clinic Resources

Treating the Whole Patient

The Miller Family Heart & Vascular Institute works together with the Office of Patient Experience, Spiritual Care Department, Healing Services and the Arts & Medicine Institute to provide a full range of complimentary services to our patients and their families.

Services include light massage therapy, Reiki and Healing TouchTM therapies, art and music therapy, and a guided imagery program to help patients relax and prepare for surgery or other procedures.

Our chapel and Muslim prayer room are available to everyone throughout their time at Cleveland Clinic.

Art programs include art therapy, guided tours and the Cleveland Museum of Art Distance Learning Program — an interactive experience that allows participants to take a virtual tour through some of the world’s best galleries via high-definition video conferencing.

Each day, there are scheduled activities on the rooftop plaza. The space provides a spectacular view of the city. Guests can enjoy yoga, chair massages, labyrinth walk meditation, Reiki, live cooking demonstrations, concerts and tea.

In addition, the Miller Family Pavilion hosts many musical and other performances and events throughout the year.

Patient and Family Health & Education Center800.223.2273 ext. 43771 [email protected]

The Patient and Family Health & Education Center has provided resources to patients and visitors since October 2008. The center serves as a library of health and education materials. In addition, patients and guests have access to complimentary computers with Internet access, audio and video education programs, and health education classes and screenings. In 2011, the center had 13,632 visitors.

Miller Family Heart & Vascular Institute Resource Nurses866.289.6911 [email protected]

A team of dedicated, experienced nurses staff the Resource Center. They answer thoracic- and cardiovascular-related questions by phone, email and online chat. This service is open to everyone and is especially helpful to those who do not have immediate access to a Cleveland Clinic cardiologist or surgeon. In 2011, there were 17,522 total contacts. This includes 6,308 nurse webchats; 5,178 phone, mail or in-person contacts; and 4,025 emails.

The nurses also staff a 24/7 toll-free inbound call line for all patients discharged from the institute who have questions or concerns after they leave the hospital. In 2011, they answered 2,237 calls. Our effort to improve the patient experience also includes a follow-up phone call from a registered nurse to every patient. Patients are asked about symptoms, complications or concerns they may have once they are home.

Staying in Touch

The Miller Family Heart & Vascular Institute has a variety of ways for patients and others to contact us and learn more about topics related to heart and vascular health. Our Twitter account (twitter.com/ClevClinicHeart) has more than 10,000 followers and was recently named one of Good Housekeeping’s 14 Most Trusted Health Sites. In 2011, we hosted 38 live webchats with institute experts who answered questions about specific thoracic and cardiovascular topics. Transcripts are posted at clevelandclinic.org/heart/webchat. Our website, clevelandclinic.org/heart, had more than 6.4 million visits in 2011. We also host a YouTube channel, youtube.com/ClevelandClinic, that had more than 2.3 million views in 2011, and a blog, thebeatingedge.org, that started in 2011 and has had more than 35,000 visits.

Outcomes 2011118118

Institute Resources

Documents

2011 Outcomes...Hospital Mortality – Isolated Procedures (N = 1,426) 2011 Hospital Mortality – Combined Procedures (N = 347) 2011 10 88 00 CABGA ortic Valve Replacement Mitral