Heart & Vascular Institute - Cleveland Clinic
Transcript of Heart & Vascular Institute - Cleveland Clinic
11
Outcomes | 2007
Heart & Vascular Institute
Chairman’s Letter
Outcomes 20072
Patients First
Heart & Vascular Institute
Quality counts when referring patients to hospitals and physicians, so Cleveland Clinic has created a series of Outcomes
books similar to this one for many of its institutes. Designed for a healthcare provider audience, the Outcomes books
contain a summary of our surgical and medical trends and approaches, data on patient volume and outcomes, and a
review of new technologies and innovations.
Although we are unable to report all outcomes for all treatments provided at Cleveland Clinic — omission of outcomes
for a particular treatment does not mean we necessarily do not offer that treatment — our goal is to increase outcomes
reporting each year. When outcomes for a specific treatment are unavailable, we often report process measures that have
documented relationships with improved outcomes. When process measures are unavailable, we report volume measures;
a volume/outcome relationship has been demonstrated for many treatments, particularly those involving
surgical technique.
Cleveland Clinic also supports transparent public reporting of healthcare quality data and participates in the following
public reporting initiatives:
• Joint Commission Performance Measurement Initiative (www.qualitycheck.org)
• Centers for Medicare and Medicaid (CMS) Hospital Compare (www.hospitalcompare.hhs.gov)
• Leapfrog Group (www.leapfroggroup.org)
• Ohio Department of Health Service Reporting (www.odh.state.oh.us)
Our commitment to providing accurate, timely information about patient care is designed to help patients and referring
physicians make informed healthcare decisions. We hope you find these data valuable. To view all our Outcomes books,
visit Cleveland Clinic’s Quality and Patient Safety website at www.clevelandclinic.org/quality/outcomes.
Outcomes 2007
Outcomes 20072
Dear Colleague:
I am proud to present the 2007 Cleveland Clinic Outcomes books. These books provide information on results, volumes and innovations related to Cleveland Clinic care. The books are designed to help you and your patients make informed decisions about treatments and referrals.
Over the past year, our ability to measure outcomes was enhanced by the reorganization of our clinical services into patient-centered institutes. Each institute combines all the specialties and support services associated with a specific disease or organ system under a single leadership at a single site. Institutes promote collaboration, encourage innovation and improve patient experience. They make it easier to benchmark and collect outcomes, as well as implement data-driven changes.
Measuring and reporting outcomes reinforce our commitment to enhancing care and achieving excellence for our patients and referring physicians. With the institutes model in place, we anticipate greater transparency and more comprehensive outcomes reporting.
Thank you for your interest in Cleveland Clinic’s Outcomes books. I hope you will continue to find them useful.
Sincerely,
Delos M. Cosgrove, MD CEO and President
Model of new Heart & Vascular Institute, opening October 2008
what’s insideChairman’s Letter 04
Introducing the Future of Healthcare: New Heart & Vascular Institute 05
Institute Overview 06
Quality and Outcomes Measures
Surgical Overview 08
Ischemic Heart Disease 10
Cardiac Rhythm Disorders 14
Valve Disease 18
Aortic Disease 25
Adult Congenital Heart Disease 34
Hypertrophic Obstructive Cardiomyopathy 36
Heart Failure and Transplant 38
Lung Transplant 40
Peripheral Vascular Disease 42
Venous Disease 43
Cerebrovascular Disease 44
Thoracic Surgery 45
Preventive Cardiology 48
Anesthesiology 50
Surgical Quality Improvement 52
Innovations 54
New Knowledge 64
Heart & Vascular Institute Staff Directory 70
Patient Experience 76
Cleveland Clinic Overview 79
Online Services 79
eCleveland Clinic
Dr Connect
My Consult
Referral Contact Information and Locations 80
Chairman’s Letter
4
Chairman’s Letter
Thank you for your interest in the Cleveland Clinic Heart & Vascular Institute 2007 Outcomes. This represents the 10th year we have shared our clinical outcomes with physicians around the country.
As an institution, Cleveland Clinic has moved toward organizing its clinical areas around organ and disease systems, rather than individual specialties. By fully integrating multiple specialties along disease lines, institutes, such as the Heart & Vascular Institute, have created a synergy among medical professionals with similar clinical, research and educational interests, centering on patient care.
In the Heart & Vascular Institute, the classic departmental structure has been preserved and encompasses the departments of Cardiovascular Medicine, Thoracic and Cardiovascular Surgery and Vascular Surgery. In addition to the medical departments, the Heart & Vascular Institute includes its counterparts in the diagnostic laboratories, inpatient nursing units, operating rooms and research sections. Combined, this includes more than 130 physicians, 2,000 employees (of whom 1,000 are nurses), 369 inpatient beds (including 91 ICU beds) and 16 operating rooms. The Institute structure will help further the innovation and research that is revolutionizing the prevention, diagnosis and treatment of heart disease.
The number of effective therapies for cardiovascular and thoracic diseases continues to increase. Patients will benefit greatly. However, the increased number of therapeutic strategies makes the choices among them more complex. We believe that the Heart & Vascular Institute structure will help us to make the best choices and to carry out these therapies effectively.
Bruce W. Lytle, MDChairman, Heart & Vascular Institute
5Heart & Vascular Institute 5
Introducing the Future of Healthcare
Innovative new buildings improve patient access, experience
In October 2008, Cleveland Clinic is introducing the future of healthcare with the opening of the Sydell and Arnold Miller Family Pavilion and the Glickman Tower.
These buildings, which represent the largest construction and philanthropy project in Cleveland Clinic history, embody the pioneering spirit and commitment to quality that define Cleveland Clinic. These structures are a tangible expression of institutes, our new model of care that organizes patient services by organ and disease.
At 1 million square feet, the Miller Family Pavilion is the country’s largest single-use facility for heart and vascular care. The 12-story Glickman Tower, new home to the Glickman Urological & Kidney Institute, is the tallest building on Cleveland Clinic’s main campus. Both will help us improve patient experience by increasing our capacity and by consolidating services, so patients can stay in one location for their care.
1 Million Square-feet area dedicated to the new Miller Family Pavilion, the country’s largest single-use facility for heart and vascular care, opening in October 2008
278 Private patient rooms
16 State-of-the-art operating rooms
20 Cardiac catheterization suites including electrophysiology labs and hybrid operating rooms
– Cardiac radiology and nuclear medicine facilities
– Recovery unit for same-day procedures
– Robotic surgery suite
• 278 private patient rooms
• 21-bed dialysis suite (nearly double the size as before)
• Conference room equipped with teleconferencing, satellite video and digital imaging capabilities to broadcast lectures and live surgeries around the world
• Rooftop helipad to receive critically ill/injured patients
With a combined total of nearly 200 exam rooms and more than 90 procedure rooms, patients will have faster access to Cleveland Clinic cardiac and urological services.
In 2007, Cleveland Clinic was ranked No. 1 in the nation for heart care and heart surgery (13 years in a row) by U.S. News & World Report. Cleveland Clinic also is ranked second in the nation for urology (eight years in a row), and fifth for kidney disease.
For details, including a virtual tour, please visit eet he uildings.com.m t b
• State-of-the-art technology center with:
– 16 operating rooms
– 20 catheterization suites including electrophysiology labs and hybrid operating rooms
– 4 specialized ICUs: coronary ICU, heart failure ICU and two surgical ICUs, with a combined total of more than 90 ICU beds
Highlights:
Outcomes 20076
Institute Overview
6
The Heart & Vascular Institute at Cleveland Clinic
is composed of more than 130 physicians within
cardiovascular medicine, cardiothoracic surgery
and vascular surgery. In October 2008, the Heart
& Vascular Institute will reside in the newly
constructed Sydell and Arnold Miller Family Pavilion
at Cleveland Clinic. This remarkable facility will
be the home of more than 2,000 employees in
nearly one million square feet dedicated to treating
cardiovascular disease.
Cleveland Clinic is recognized as the national leader
in the clinical care of patients with cardiovascular
disease. Cleveland Clinic heart and vascular
specialists continue to provide leading-edge
innovations in patient care therapies and clinical
research.
This institute overview provides a snapshot of the
variety and volume of clinical therapies currently
provided.
Heart & Vascular Institute Overview 2007 Total Patient Visits 294,022
Total New Patients 8,322
Admissions (Acute and Post-acute Patients) 16,351
Total Beds 369
Coronary Intensive Care Beds 16
Heart Failure Intensive Care Beds 8
Thoracic and Cardiovascular Surgery Intensive Care Beds 67
Cardiology/Vascular Step-Down Beds 278
Severity Indices Cardiology 2.15
Cardiac Surgery 6.86
Thoracic Surgery 4.49
Vascular Surgery 2.96
Non-Surgical Procedures Cardiac Procedures Interventional Cardiac Procedures 2,262
Myocardial Biopsies 1,268
Percutaneous Aortic Valvuloplasty Procedures 64
Percutaneous Mitral Valvuloplasty Procedures 20
Percutaneous Atrial Septal Defect (ASD) Closures 38
Percutaneous Patent Foramen Ovale (PFO) Closures 47
Vascular Procedures Interventional Carotid Procedures 144
Interventional Vascular Procedures 4,060
Electrophysiology Procedures Total Electrophysiology Ablations 1,489
Pulmonary Vein Isolation Catheter Ablation Procedures for Atrial Fibrillation 1,015
Total Device Implants 1,138
Permanent Pacemaker Implants (Including 22 biventricular pacemaker implants and 4 loop recorder implants) 470
Implantable Cardiac Defibrillator (ICD) Insertions (Including 232 biventricular ICD implants) 672
Lead Extractions 249
Cardioversions 962
Heart & Vascular Institute 7
50 statesIn 2007, patients traveled from every
state to Cleveland Clinic for their
cardiovascular care.
77 countriesPatients from 77 different countries
came to Cleveland Clinic for their
cardiovascular care in 2007.
Diagnostic and Imaging Procedures Diagnostic Catheterization Procedures 9,078
Diagnostic Vascular Procedures 3,992
Electrophysiology Diagnostic Studies 1,555
Stress Tests 12,135
Echocardiograms (Echos) 52,572
Electrocardiograms (ECGs) 118,344
Noninvasive Vascular Lab Procedures 40,111
Surgical Procedures Open Heart Surgeries 3,438
Robotically-Assisted Cardiac Surgeries 160
Thoracic and Cardiac Surgeries Coronary Artery Bypass Graft (CABG) Surgeries 1,418
Valve Surgeries (Primary and Reoperations) 2,194
General Thoracic Surgeries 1,493
Adult Lung Transplants 72
Adult Heart Transplants (Including 3 heart/lung transplants and 1 heart/kidney transplant) 64
Pediatric Heart Transplants 5
Congenital Heart Surgeries (including 68 adult congenital heart procedures) 186
Surgical Procedures for Atrial Fibrillation 395
Septal Myectomy Surgeries for Hypertrophic Cardiomyopathy 157
Vascular Surgeries General Vascular Surgeries (including bypasses, blood vessel repair, endarterectomy, wound care, amputations) 1,843
Venous Surgeries (including endovenous ablation, surgical ligation, vein resection, stripping) 756
Arteriovenous Access Surgeries 435
Aorta Surgeries Open Ascending and Arch Repair Surgeries 541
Open Descending and Thoracoabdominal Surgeries 56
Infrarenal Endovascular Abdominal Aortic Aneurysm Repairs 158
Endovascular Repairs of Juxtarenal and Thoracoabdominal Aneurysm 88
Endovascular Repairs of Descending Thoracic Aneurysms or Dissections 87
Outcomes 20078
Surgical Overview
1997 1999 2001 2003 2005 2007
6,0006,000
4,0004,000
VolumeVolume
2,0002,000
00
1997 1999 2001 2003 2005 2007
12,00012,000
10,00010,000
VolumeVolume
8,0008,000
6,0006,000
4,0004,000
2,0002,000
00
Thoracic and Cardiac Surgery VolumeThe Department of Thoracic and Cardiovascular Surgery performs a high volume and variety of procedures. In 2007, the department and its affiliates performed 10,853 cardiovascular and thoracic surgical procedures. Improved clinical outcomes are demonstrably linked to centers with high surgical volumes.
Vascular Surgery VolumeThe Department of Vascular Surgery has consistently performed over 5,000 surgical interventions since 2004 and has more than doubled its volume of procedures in the past 10 years.
Primary Operations and Reoperations
Distribution of Cardiac SurgeriesCleveland Clinic has one of the nation’s largest experiences performing a variety of cardiac operations. Isolated valve and combined valve operations accounted for 64 percent of the total cardiac surgical volume in 2007.
Isolated Valve Surgeries
Isolated CABG Surgeries
Isolated Great Vessel Surgeries 2%
Combined Valve Surgeries
4% Combined CABG Surgeries (valve excluded)2% Transplants
Other Cardiac Surgeries
24%
18%40%
10%
Of the 3,438 cardiac
surgeries performed at
Cleveland Clinic’s main
campus for acquired heart
disease, 27 percent
(N = 920) were reoperations,
which are generally more
complex and entail greater
risk than primary operations
(N = 2,518). Extensive
experience with reoperations
benefits patients and can
ensure better outcomes.
Heart & Vascular Institute 9
Cardiac Surgery Hospital MortalityHospital mortality for all cardiac surgeries in 2007 was 3.1 percent, despite the high patient acuity.
0
6
4
2
8
1997 1999 2001 2003 2005 2007
3.1% Mortality
6.9 Patient Acuity
0
60
40
20
100
80
1997 1999 2001 2003 2005 2007
Endovascular cases
Percent
Open cases
Mortality (%)
Age
Vascular Surgery Volume - Open and Endovascular RepairOur treatment approach over the past six years has transitioned from traditional, open surgical repair to endovascular intervention, revolutionizing the management of patients with vascular disease.
Vascular Surgery Hospital MortalityThe cumulative hospital mortality average for patients discharged by the Vascular Surgery Department from 2002 to 2007 was 3.28 percent, in comparison to the 5.4 percent adjusted national teaching hospital mortality average.
Outcomes 200710
Ischemic Heart Disease
External BenchmarkingCleveland Clinic’s inter-
ventional group believes it
is important, both for their
own quality review and
for the sake of potential
patients, to compare their
results with those of other
hospitals with comparable
volumes of interventional
procedures. The American
College of Cardiology-
National Cardiovascular
Data Registry (ACC-NCDR)
is a comprehensive national
cardiac data repository that
publishes such outcomes.
Cleveland Clinic Adjunctive CareReceiving timely and appropriate adjunctive care before and after PCI procedures is important to optimize outcomes, and has been recognized by the American College of Cardiology (ACC) as an important performance measure. Compared to the average high-volume interventional center, Cleveland Clinic physicians administer these medications more frequently.
Percutaneous ProceduresAs a regional and national referral center, Cleveland Clinic treats both simple and complex ischemic disease. Cleveland Clinic patients undergoing percutaneous coronary interventional (PCI) procedures more often have prior heart attack and prior bypass surgery, as well as depressed left ventricular function, than patients at other comparable hospitals.
Cleveland Clinic Angioplasty Baseline Patient Characteristics Cleveland Clinic (%) Other* (%)
Age (>75 years) 24.6 19.7
Prior heart attack 37.0 30.1
Heart failure 15.4 10.9
Diabetes 37.0 33.5
Renal insufficiency 5.4 3.5
Prior bypass surgery 34.1 20.5
Severe left ventricular dysfunction 9.2 5.1
Multi-vessel disease 53.2 45.4
More than one stenosis treated 76.0 56.6
Data based on one-year rolling average *Comparable ACC/NCDR Hospitals (>500 PCI Procedures/Year)
Adjunctive Care Cleveland Clinic (%) Other* (%)
Aspirin before procedure 98.1 93.6
Beta blockers before procedure 80.3 70.5
Statins before procedure 84.7 61.2
Door to balloon time** 85 minutes 148 minutes
Aspirin at discharge 99.6 96.6
ACE inhibitors at discharge 73.2 76.0
Beta blockers at discharge 85.3 78.9
Statins at discharge 96.0 82.5
Data based on one-year rolling average *Comparable ACC/NCDR Hospitals (>500 PCI Procedures/Year) ** Time from arrival in the Emergency Department to balloon inflation for PCI procedure for patients with ST-elevation acute myocardial infarction.
Heart & Vascular Institute 11
PCI ComplicationsAfter adjustment for complexity and severity of illness, the mortality of PCI procedures and the incidence of unplanned bypass surgery at Cleveland Clinic are lower than the national averages, reported by the American College of Cardiology National-Cardiovascular Data Registry (ACC-NCDR). The number of patients who required emergent CABG surgery following an unsuccessful PCI remained low at 0.7 percent in 2007.
*Comparable ACC/NCDR Hospitals (>500 PCI Procedures/Year)
4.00
3.00
0.00Mortality Emergent CABG Blood Transfusions Major Vascular
Complications
2.00
1.00
Percent
Other*
Cleveland Clinic
Complications of PCI Procedures Performed to Treat Other Cardiac Conditions (Non-Acute MI)
2004 (%) 2005 (%) 2006 (%) 2007 (%)
Cardiac death 0.3 0.6 0.5 0.7
Non-cardiac death 0.1 0.2 0.0 0.1
Q-wave MI 0.1 0.1 0.3 0.2
Non-Q-wave MI 3.3 3.5 3.7 3.4
Emergent CABG 0.2 0.2 0.0 0.2
Blood transfusions 2.6 2.2 2.2 2.0
Complications of PCI Procedures Performed to Treat Acute MI
2004 (%) 2005 (%) 2006 (%) 2007 (%)
Cardiac death 3.6 2.3 2.8 6.2
Non-cardiac death 0.0 1.5 1.0 0.3
Reinfarction 0.8 0.4 0.7 0.6
Emergent CABG 0.4 0.8 0.7 0.7
Blood transfusions 10.8 9.5 10.8 10.1
Outcomes 200712
Ischemic Heart Disease (continued)
1997 1999 2001 2003 2005 2007
44
33
22
11
00
3.04 Severity Score
1.9% Mortality
Mortality (%)Mortality (%) Severity Score
Diagnostic Cardiac Catheterization Complications
The composite rate of procedural complications for diagnostic cardiac catheterizations, including acute myocardial infarction (MI), emergent coronary artery bypass graft (CABG) surgery, stroke and death was 0.03 percent in 2007.
Surgical Treatment for Ischemic Heart Disease
Primary Isolated CABG SurgeriesPrimary isolated CABG surgery refers to a patient’s first CABG when performed without any other procedure. In 2007, Cleveland Clinic surgeons performed 506 primary isolated CABG procedures, and mortality was 1.9 percent.
Severity score is assigned before surgery based on the presence of patient conditions known to lead to complications and high mortality risk after surgery. Cleveland Clinic performs a large volume of primary isolated CABG operations on high-risk patients with greater mean severity scores, yet mortality remains low.
2003 2004 2005 2006
0%
2007
0.050.05
0.040.04
PercentPercent
0.030.03
0.020.02
0.010.01
00
Heart & Vascular Institute 13
Isolated CABG Surgery Volume and MortalityIsolated CABG surgeries include primary operations and reoperations. Nearly 20 percent of Cleveland Clinic isolated CABG surgeries were reoperations in 2007. Reoperations are associated with higher morbidity and mortality. Cleveland Clinic’s expertise in cardiac surgeries leads to a higher percentage of referrals for CABG reoperations.
Primary Isolated CABG MortalityIncreased age is a known risk factor for cardiovascular disease and contributes to the complexity of CABG surgical cases. In 2007, Cleveland Clinic achieved very low mortality rates in patients under age 70.
83%
17%
Primary Operations(N = 506)
Reoperations(N = 103)
Isolated CABG ÍSurgeries
2007 Volume Hospital Mortality
609 2.6%
85% Single ITA
4% Single ITA + Radial
2% Bilateral ITA + Radial
9% Bilateral ITA
Arterial GraftsArterial grafts are known for their excellent long-term patency and are the conduits of choice for coronary revascularization.
2007 Primary Isolated CABG Mortality (N = 50 )6
Age Mortality (%)
< 50 years 0.0
50-59 years 0.0
60-69 years 1.1
70-79 years 4.0
≥ 80 years 7.7
Outcomes 200714
Pulmonary Vein Antrum Isolation Procedures (PVAI)PVAI is an effective treatment option for patients with symptomatic atrial fibrillation that has not been effectively treated with antiarrhythmic medications.
2007 PVAI Procedure Volume (N = 1,015) and Outcomes
Success Rate* 80%
Complications
Stroke 0.6%
Severe Pulmonary Vein Stenosis 1.0%
Other Complications 2.0%
*PVAI success rate is defined as a restored sinus rhythm without dependency on medications to control the heart rhythm for at least six months post-procedure. Success rates for repeat ablations range from 90 percent to 95 percent.
During PVAI, high-frequency energy is applied through catheters to the region of the pulmonary veins. This energy produces a circular scar that blocks abnormal impulses firing from the pulmonary veins, thereby “disconnecting” the pathway of the abnormal rhythm and preventing atrial fibrillation.
Higher Ablation Success with New CatheterA Cleveland Clinic study
demonstrated that using an
open-irrigation-tip ablation
catheter resulted in greater
success for treating atrial
flutter, shorter procedure
times, as well as reduced
X-ray exposure and radio-
frequency delivery. The
study compared treatment
with the open-irrigation-tip
catheter to that of the 8-mm
tip catheter.
Source: Bai R, Fahmy TS, Patel D, et al. Radiofrequency ablation of atypical atrial flutter after cardiac surgery or atrial fibrillation ablation: a randomized comparison of open-irrigation-tip and 8-mm-tip catheters. Heart Rhythm. 2007;4:1489-1496.
Cardiac Rhythm Disorders
Pulmonary VeinsPulmonVeins
Comprehensive Atrial Fibrillation TreatmentCleveland Clinic is expert at catheter-based treatments to effectively cure atrial fibrillation. The Center for Atrial Fibrillation, comprising electrophysiologists, cardiologists, cardiac surgeons, imaging specialists and specially trained nurses and researchers, offers comprehensive, state-of-the-art technologies to tailor treatment for each patient.
Heart & Vascular Institute 15
Atrial Fibrillation Surgical Procedure Volume (N = 395)Surgical techniques for atrial fibrillation (AF) include a minimally invasive “keyhole” approach and the classic Maze procedure in patients who require stand-alone ablation. The choice of operation depends upon the patient’s condition; the left atrial appendage is routinely removed. In 2007, Cleveland Clinic cardiovascular surgeons performed 395 procedures to treat atrial fibrillation. The majority of surgical ablation procedures were performed during other cardiac procedures, as shown in the chart below.
Left Atrial Appendage LigationCleveland Clinic physicians and researchers
have developed a ligation device for clipping
and isolating the left atrial appendage, a
potential source of blood clots that may
cause stroke in atrial fibrillation patients.
Clinical trials of this device are currently
under way in Europe, with more than 25
patients successfully treated.
AF + Valve Surgery + CABG
AF + Other Cardiac Surgery
AF + CABG Surgery
Isolated AF Procedures 2%AF + Valve Surgery
In patients having ablation with other heart surgery, lines of conduction block are created on the heart using radiofrequency, cryothermy or microwave energy sources, instead of incisions, to restore normal sinus rhythm.
Distribution of Atrial Fibrillation Surgical Techniques
Three-dimensional CT view of the ligation device.
60%
27%
6%
6%
35%
15%
49%Radiofrequency
Cut-and-Sew Incision MethodMicrowave Ablation <0.5%
Cryoablation
Outcomes 200716
Cardiac Rhythm Disorders (continued)Device ImplantsThe Electrophysiology Lab utilizes the latest device technology, including pacemakers, implantable cardiac defibrillators (ICDs), biventricular pacemakers and biventricular ICDs.
Device Lead ExtractionsSometimes, patients develop uncommon conditions that require the removal of device leads, such as an untreatable infection, a blockage of the blood vessel through which the lead passes, or an electrical malfunction of the lead wire or insulation.
To minimize trauma and cardiac tissue damage, Cleveland Clinic electrophysiologists have participated in the development and use all of the available tools for lead extraction, including electrosurgical energy, mechanical sheaths and excimer laser energy. With these tools and techniques, almost all leads can be safely removed without the need for surgery.
The data below show that with the appropriate experience, training and tools, the lead extraction procedure can be performed with an excellent success rate.
2007 Volume and Outcomes Year # Extraction # Leads % Clinical % Major Procedures Extracted Success* Complications
2007 249 445 99.8 0.4
2006 357 636 99.2 0.0
2005 326 610 99.7 0.3
2004 273 473 100.0 0.0
2003 291 496 99.0 0.7
Average 299 532 99.5 0.28
*Our success rate is defined as removal of all of the required leads without causing bleeding from the veins or heart.
Cleveland Clinic electro-
physiologists perform the
largest volume of lead
extraction procedures in
the world.
Cleveland Clinic patients
undergoing the highly
specialized lead extraction
procedure come from all over
the United States.
Largest Lead Extraction Volume
Infection Rate
Primary Device Implants Infection Rate (%)
408* 0.25
*Excluding device replacements
2007 Volume
Biventricular Pacemakers and ICDs 254
Pacemakers 444
ICDs 440
Total Device Implants 1,138
Heart & Vascular Institute 17
5,252 Total of remote ICD follow-up transmissions performed at Cleveland Clinic in 2007. The ability to remotely evaluate device patient populations broadens access to care.
10,000
8,000
6,000
4,000
2,000
020072003 2004 2005 2006
Total Evaluations
ICD
Pacemaker
8,170 Holter scans performed in
2007
34,696 Arrhythmia transmissions
received in 2007
7,330 Transtelephonic device
transmissions received in 2007
Device Clinic EvaluationsAll device evaluations are linked to each patient’s electronic medical record. Data are accessible to referring physicians via secure access when necessary.
2007 Volume
Pacemaker Evaluations 8,277
ICD Evaluations 6,275
Total Device Evaluations 14,552
Outcomes 200718
Valve Disease
2,5002,500
2,0002,000
1,5001,500
1,0001,000
500500
00
1010
88
66
44
22
001997 1999 2001 2003 2005 2007
VolumeVolume Primary Operative Mortality (%)
Primary Valve Operations and ReoperationsNearly one-third (N = 610) of valve surgeries performed at Cleveland Clinic in 2007 were reoperations. Cleveland Clinic has expertise in performing complicated valve reoperations.
Valve Surgery Volume and MortalityCleveland Clinic continues to perform the largest number of valve operations in the United States. In 2007, Cleveland Clinic surgeons performed 2,194 total valve operations, including 1,584 primary operations and 610 reoperations.
Distribution of Valve SurgeriesIn 2007, 56 percent of patients undergoing primary valve operations also had other concomitant procedures.
Combined Mitral Valve
All Other
Combined Aortic ValveIsolated Mitral Valve
Isolated Aortic Valve
33%
13%
15%
16%23%
27%Isolated Primary Valve Surgeries 10%Isolated Valve Reoperations
45%
Combined Primary Valve Surgeries
18%
Combined Valve Reoperations
64%Valve surgeries
represented 64
percent of our total
cardiac surgical
volume in 2007.
Heart & Vascular Institute 19
Isolated Aortic Valve Replacement MortalityMortality for primary isolated aortic valve replacement at Cleveland Clinic in 2007 was 1.2 percent, significantly lower than The Society of Thoracic Surgeons’ (STS) benchmark of 2.5 percent.
*Based on data from January to June 2007
** Based on four hospital deaths in 325 cases from January to December 2007
0
1
3
4
2
2006
1.2% Cleveland Clinic**
2.5% STS benchmark*
2002 2003 20052004
Mortality (%)
2007
Aortic Valve ReplacementsBioprostheses (biological tissue valves) are the prostheses of choice for both aortic and mitral valve replacement procedures. These valves are durable and allow most patients to avoid lifetime use of anticoagulants after surgery.
0
1,200
1,000
800
600
400
200
1,400
1997
Volume
1999 2001 2003 2005 2007
Mechanical
Bioprostheses
Allografts
1,5001,500
1,0001,000
AV SparingAV RepairsAV Replacements
AV SparingAV RepairsAV Replacements
500500
001997
Volume
1998 1999 2000 2001 2002 20042003 2006 20072005
Aortic Valve Surgery VolumeCleveland Clinic performs the largest volume of aortic valve-sparing procedures in the nation. In 2007, 88 percent (N = 1,169) of aortic valve surgeries performed at Cleveland Clinic were aortic valve replacements, and 12 percent (N = 165) were aortic valve repairs, including 79 aortic valve-sparing operations.
Systole
Diastole
3D Live three-dimensional
echocardiography of the
aortic valve is available
for diagnostic and
intraoperative imaging,
allowing us to perform
intricate aortic valve
surgical procedures.
Outcomes 200720
Valve Disease (continued)Mitral Valve Surgery Volume
In 2007, 1,057 mitral valve surgeries were performed at Cleveland Clinic; 70 percent were valve repairs, and 30 percent were valve replacements. Additionally, 67 percent of isolated mitral valve procedures were performed with a minimally invasive technique.
Isolated Mitral Valve Repair Mortality In 2007, Cleveland Clinic performed 261 primary isolated mitral valve repairs with 0 percent mortality, significantly lower than The Society of Thoracic Surgeons’ (STS) benchmark of 1.5 percent.
1997 1999 2001 2003 2005 2007
33
Mortality (%)Mortality (%)
22
11
00
1.5% STS benchmark*
0% Cleveland Clinic**
*Based on data from January to June 2007 **Based on data from January to December 2007
ACC/AHA Guidelines for Surgery and Mitral Valve Regurgitation Guidelines published by the the American College of Cardiology (ACC) and the American Heart Association (AHA) recommend surgery for certain asymptomatic patients with mitral valve regurgitation, and encourage patients to find large centers specializing in valve repair procedures.
Mitral valve (MV) repair is recommended over MV replacement in the majority of patients with severe chronic mitral regurgitation who require surgery, and patients should be referred to surgical centers experienced in MV repair.
MV repair is reasonable in experienced surgical centers for asymptomatic patients with chronic severe mitral valve regurgitation (MR) with preserved left ventricular function (ejection fraction greater than 0.60 and end-systolic dimension less than 40 mm) in whom the likelihood of successful repair without residual MR is greater than
90 percent.
Source: Bonow RO, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease). J Am Coll Cardiol, August 1, 2006. 48(3):e1-148.
1,0001,000
800800
600600
001997
Volume
1998 1999 2000 2001 2002 20042003 2006 20072005
400400
200200
Mitral Valve Regurgitation
Heart & Vascular Institute 21
Triangular Resection Mitral Valve Repair
Ruptured chords at free edge of posterior leaflet. Region to be resected is indicated.
Abnormal segment has been removed. Leaflet edges are sewn together.
Annuloplasty completes the repair.
Minimally Invasive Valve Treatments
Cleveland Clinic Heart & Vascular Institute is a worldwide leader in the development and clinical treatment of minimally invasive valve surgery. These techniques encompass a variety of methods including the use of very small incisions, robotic heart surgery and percutaneous procedures. Minimally invasive techniques are known to have a patient benefit in reduction of trauma and shorten recovery times.
Isolated Valve Surgery Volume and Mortality
More than 50 percent of isolated valve surgeries were performed using a minimally invasive approach in 2007.
00
500500
300300
400400
200200
100100
0.00.0
1.01.0
0.60.6
0.80.8
0.40.4
VolumeVolume Mortality (%)
2003 2004 2005 2006 2007
0.2
Procedure 2007 Volume Hospital Mortality (%)
Minimally invasive aortic valve procedures 157 0.6
Minimally invasive mitral valve procedures 220 0.0
Infective endocarditis is a life-threatening condition requiring prompt treatment. Surgery for endocarditis requires extensive experience and familiarity with different reconstructive methods, including the use of homografts (human cadaver valves). Cleveland Clinic heart surgeons have vast experience treating infective endocarditis, with excellent outcomes.
Infective Endocarditis Surgical Treatment Volume and Mortality
120120
100100
8080
6060
4040
001997 1999 2001 2003 2005 2007
2020
Volume
2424
2020
1616
1212
88
44
00
ReoperationMortality (%)
Primary
Outcomes 200722
Valve Disease (continued)
Access ports
30% Shorter
Length of Stay
Surgical instruments attached to robotic arms are inserted through a small incision on the right side of the chest, without the need for the division of the breast bone. Sensors attached to the robotic “wrist” provide the surgeon with precise motion control.
00
300300
2006
Volume
VolumeMortality (%)
Percent
2007 2008Projected
100100
200200
00
7575
2525
5050
Isolated Mitral Valve Repair Robotic Procedures
Robotically-Assisted Valve Surgeries
Robotically-assisted mitral valve repair represents a novel, minimally invasive approach for treating mitral valve regurgitation (leaky mitral valve). Cleveland Clinic began performing robotically-assisted mitral valve repairs in 2006. The volume of these procedures greatly increased in 2007, with 0 percent hospital mortality.
Percutaneous Valve Treatments
Cleveland Clinic is the national leader in the development and application of percutaneous valve approaches and has been the leading center in percutaneous valve approaches over the last decade.
Percutaneous Aortic ValvuloplastiesCritically ill patients and other patients who are not candidates for traditional valve replacement surgery due to comorbid conditions may be candidates for percutaneous aortic valvuloplasty. Many patients with severe,
Robotic surgery for isolated
mitral valve repair was
associated with a
30 percent shorter length
of stay than traditional non-
robotic techniques in 2007.
The average length of stay
for robotic isolated mitral
valve repair in 2007 was
5.0 days, compared to 8.5
days for non-robotic isolated
mitral valve repair. This less
invasive technique provides
excellent patient satisfaction
and quick return to normal
activities.
Hospital mortality for both
groups was 0 percent in
2007.
*Three patients in 2007
2007 Volume Hospital Mortality (%)
64 4.6*
00
8080
2006
Volume
2007
6060
4040
2020
The volume of percutaneous aortic valvuloplasty procedures increased by 49 percent in 2007.
symptomatic aortic valve stenosis who underwent this procedure were successfully bridged to surgical aortic valve replacement.
Heart & Vascular Institute 23
Additional percutaneous approaches for the treatment of mitral, tricuspid and aortic valve disease are being developed and investigated at Cleveland Clinic. Please see the “Innovations” section on page 54 for more information.
Percutaneous Mitral Valvuloplasties Percutaneous Mitral Valve Repair Procedures
3030
2020
1010
00
3030
2020
1010
002002 2003 2004 2005 2006 2007
Volume Mortality (%)
Percutaneous mitral valvuloplasty (valvotomy), performed in the cardiac catheterization laboratory, is a less invasive treatment approach for mitral valve stenosis and is often the first choice of treatment in most patients. Cleveland Clinic mortality for this procedure has been 0 percent since 2002, with a 10-year cumulative stroke incidence of 0.5 percent and a 0.5 percent rate of emergency surgery.
Percutaneous mitral valve repair is being investigated as an alternative treatment option for select patients with mitral valve regurgitation. During this procedure, a small metal clip is delivered and positioned via the catheter. Please see page 63 for more information.
In 2007, Cleveland Clinic performed 29 percutaneous aortic valve replacements in clinical trials using the transfemoral approach.
Percutaneous aortic valve replacement is being investigated as an alternative treatment option for select patients with severe aortic valve stenosis who are high-risk surgical candidates.
A compressed tissue heart valve is placed on a balloon-mounted catheter that is positioned directly in the diseased aortic valve. When the balloon is inflated, the position of the implant is secured.
The balloon is positioned across the narrowed mitral valve. The valve opening is dilated by inflating the balloon, increasing diameters under close monitoring.
Ultrasound and fluoroscopy are used to guide the placement of the clip, which holds the mitral valve leaflets together. Placement of the clip is adjusted until optimal improvement in hemodynamics is observed; then the clip is released and the catheter withdrawn.
Percutaneous Aortic Valve Replacements
Outcomes 200724
Valve DiseaseNavy Hopeful Gets “Textbook” Robotic Repair
Robert Laconis was stunned. The Navy turned
him down. He’d applied for a commission in
the Reserves, but the doctors told him he had
a heart murmur. A cardiologist later diagnosed
it as a severely leaking mitral valve caused by
mitral valve prolapse. Robert hoped for a future
in the Navy. Now he was looking at the near-
certainty of heart failure. He needed surgery to
replace or repair that valve. But where could he
go? Who would do the best job? Internet savvy,
Robert and his wife Lexie scoured the web for
information on doctors and hospitals. After
weighing the alternatives, they determined that
Cleveland Clinic Heart & Vascular Institute had
the most experience and the best outcomes. Best
of all, it offered robotically assisted minimally
invasive valve repair for certain cases, and Robert
qualified.
Traveling from Florida to Cleveland, Robert and
Lexie met the surgeon who would be performing
the robotic procedure, A. Marc Gillinov, MD.
They liked his friendly manner and record of
expertise. “What can you say about the surgeon
who performs the most mitral valve repairs in
the world?” Lexie said later. “Robert couldn’t be
in better hands.” On Friday, April 4, Robert had
what Dr. Gillinov later called a “textbook” robotic
repair procedure. It was done through small
incisions on the side of his chest. On Sunday,
April 6, Robert was walking the halls of the
step-down unit. By Tuesday, April 8th, he was
out of the hospital, back in his hotel, and making
plans to visit the Rock and Roll Hall of Fame and
Museum before heading back to Florida. “We
have only great things to say about Dr. Gillinov
and Cleveland Clinic,” says Lexie. “Everyone
was so helpful every step of the way. We were
confident we were getting the best care possible.”
Heart & Vascular Institute 25
1,2001,200
1,0001,000
800800
00
Volume
2001 20021999 2000 20042003 2006 20072005
600600
400400
200200
Ascending/Arch repairAscending/Arch repair
Descending/ThoracoabdominalrepairDescending/ThoracoabdominalrepairThoracoabdominalendovascular repairThoracoabdominalendovascular repairAbdominal open repairAbdominal open repair
Abdominal endovascular repairAbdominal endovascular repair
Diseases affecting the entire aorta, from the aortic valve to the blood supply of the pelvic vasculature, are managed at Cleveland Clinic with a comprehensive, multidisciplinary approach. In addition to conventional surgical therapies, we offer minimally invasive and endovascular approaches for almost every type of aortic disease.
of men aged 65 years and
older will develop an aortic
aneurysm.
5 percent
Aortic Disease
Ascending Aorta
Thoracic Aortic Aneurysm
Iliac ArteryAbdominal Aortic Aneurysm
Stratified ResultsIn this section, we have stratified our results according to treatment indications, extent of aortic involvement and treatment modalities.
Aortic Surgery Volume and Distribution
Outcomes 200726
Aortic Disease (continued)Ascending Aorta and Arch Disease Surgery VolumeConventional therapy for aneurysms and dissections of the ascending aorta include graft replacement of the diseased vessels (Figure 1). Minimally invasive approaches pioneered at Cleveland Clinic include the use of stent-grafts (Figure 2) and occlusion devices. Therapeutic options are tailored to both the anatomy and physiology of each patient.
Ascending Aorta and Arch Repairs
Over the past five years the volume of ascending aorta and aortic arch repair surgeries performed at Cleveland Clinic increased by 49 percent.
600600
400400
200200
001997 1999 2001 2003 2005 2007
Volume
Elective Ascending Arch Surgery Stroke and Mortality
In 2007, mortality and stroke remained low for elective ascending aorta and arch repairs.
Emergent Ascending Arch Surgery Mortality
The mortality for urgent and emergent ascending aorta and arch repair surgeries decreased by 4.2 percent in 2007 and remains low.
00
250250
150150
200200
100100
5050
00
2525
1515
2020
1010
PatientsPatients Mortality (%)
1997 1999 2001 2003 2005 2007
5
00
500500
300300
400400
200200
100100
00
1010
66
88
44
PatientsPatientsStroke (%)Mortality (%)
1997 1999 2001 2003 2005 2007
2
Aortic dissection results in complex blood flow patterns caused by a split or tear in the aortic wall. The wall of the aorta typically splits. Arteries that supply the kidneys, intestines or lower extremities may derive blood flow from the proper lumen (true lumen) or the split lumen (false lumen).
In the images above, note the false lumen has less contrast and appears more red, while the yellowish true lumen narrows as a result of compression, potentially restricting blood flow to the critical abdominal organs.
Figure 1
Figure 2
Heart & Vascular Institute 27
Descending Thoracic Aortic DiseaseAortic dissections or ruptured aneurysms commonly occur in the descending thoracic aorta and require rapid evaluation and treatment. Physicians carefully assess each patient to determine the optimal therapy based on anatomy and disease presentation.
The development of endovascular grafts has revolutionized the management of patients with descending thoracic aortic disease (DTA). Cleveland Clinic’s team of aortic physicians has pioneered techniques for both surgical and endovascular repair.
DTA Open Repair Distribution
In 2006 and 2007, Cleveland Clinic thoracic surgeons performed 80 open repair procedures for descending thoracic aneurysms, including 61 elective procedures and 19 emergent procedures.
76%
24%
Elective (N = 61)
Emergent (N = 19)
DTA Hospital Mortality
Mortality for both emergent and elective open thoracic aortic repairs in 2006 and 2007 was 5 percent.
1010
88
66
44
00Emergent Elective
22
Percent
Aneurysmal disease of the descending thoracic aorta and aortic arch are frequently coexistent. Figure 1 depicts a three-dimensional reconstruction of a CT scan following arch repair with an elephant trunk graft left in place. The descending thoracic portion of the repair can then be done with a stent-graft, thus creating a hybrid repair. The stent-graft is placed into the elephant trunk graft, which extends from the arch repair, and relines the diseased aorta within the chest and abdomen if necessary (Figure 2).
Figure 1 Figure 2
Outcomes 200728
Aortic Disease (continued)
67%
33%
Elective (N = 98)
Emergent (N = 48)
Endovascular Repair Volume and MortalityCleveland Clinic has pioneered less invasive therapies for almost every type of aortic disease. Complex aneurysms and aortic dissections that involve the ascending aorta, arch branches, the entire thoracoabdominal aorta and the iliac arteries can be treated with a minimally invasive surgical or percutaneous approach.
2020
1616
1212
88
00Emergent Elective
44
Mortality (%)
The mortality for emergent endovascular thoracic procedures in 2006 and 2007 was 15 percent.
The mortality for elective endovascular thoracic procedures was low at 5 percent.
The most common indication for emergent repair was thoracic aneurysm rupture or dissection (40 percent), followed by 23 percent of patients who presented with ischemia resulting from acute complicated aortic dissection. Other urgent treatment indications included rapid aortic growth in patients with connective tissue diseases (such as Marfan syndrome and Ehlers-Danlos syndrome), traumatic aortic injuries and aorto-bronchial fistulas.
the 13th leading cause of death
Aortic Aneurysms
These two CT scan reconstructions show results following endovascular aortic dissection (Figure 1) and arch rupture (Figure 2) treatments. Following an aortic dissection, the blood to the lower body may be insufficient to sustain life. The placement of an endograft to close off the false lumen of blood flow can re-establish adequate blood flow to the abdomen and legs. Ruptured aneurysms typically are fatal, however, if evaluated in a timely manner, endovascular grafts can be placed to seal the leak. This can be done even when the leaking aorta involves critical branches, such as those to the brain (Figure 2).
Figure 1 Figure 2
Heart & Vascular Institute 29
Distribution of TAA Surgeries 2007
Thoracoabdominal Aortic Surgeries Diseases of the thoracoabdominal aorta (TAA) are the most difficult to treat due to their complexity, as well as the risk of major complications and mortality. Data published in a 2006 Medicare audit for the state of California support these claims; almost 20 percent of the patients treated for elective thoracoabdominal aneurysms died within 30 days of the procedure, and 31 percent died within 12 months after the procedure.
Reference: Rigberg DA, et al. Thirty-day mortality statistics underestimate the risk of repair of thoracoabdominal aortic aneurysms: A statewide experience. J Vasc Surg. 2006 Feb;43(2):217-222.
Thoracoabdominal aneurysm stent-graft
8080
6060
4040
2020
00Type I Type II
EndovascularOpen
Type III Type IV
Percent
Type I aneurysms involve most or all of the
descending thoracic aorta to the level of the
renal arteries. Type II aneurysms involve most
or all of the descending thoracic aorta, with
abdominal extension to below the renal arteries.
Type III aneurysms involve the lower portion of
the descending thoracic aorta, extending to the
abdominal aorta below the level of the renal
arteries. Type IV aneurysms involve the upper
half or all of the abdominal aorta.
Crawford Classification for Aortic Aneurysms
Outcomes 200730
Aortic Disease (continued)Thoracoabdominal Aortic Aneurysm (TAAA) Surgery Volume and DistributionFor the first time in history, the treatment of thoracoabdominal aneurysms at Cleveland Clinic was more commonly performed with an endovascular approach rather than an open surgical approach in 2007. A total of 260 procedures were performed to treat thoracoabdominal aneurysms in 2006 and 2007, including 122 open surgeries and 138 endovascular branch vessel grafts.
TAAA Surgery Mortality
4040
3030
2020
1010
00
Elective TAAA Urgent
OpenEndovascular
Percent
Open
47%
53%
Open
Branch Vessel Endovascular Grafts
For 122 open thoracoabdominal procedures performed in 2006 and 2007, mortality was 15.6 percent.
Vascular surgeons performed 138 branch vessel procedures for thoracoabdominal disease in 2006 and 2007, with a 7 percent mortality.
TAAA before endovascular repair TAAA after endovascular repair
The paraplegia rate for patients with
thoracoabdominal aneurysms who were treated
with an endovascular procedure was
2.7 percent, well below the national average.
Cleveland Clinic has the world’s largest volume of
patients with thoracoabdominal aneurysms who
are treated with a stent-graft.
Detailed view of a device that provides a new means of incorporating the vessel that supplies the intestines with blood into a thoracoabdominal aneurysm stent-graft repair.
Heart & Vascular Institute 31
Open AAA Repair Mortality
4040
3030
2020
1010
00Elective Urgent
Percent
64%
36% Open (N = 171)
Endovascular (N = 299)
88%
12% Urgent (N = 20)
Elective (N = 151)
Abdominal Aortic Aneurysms (AAA)Abdominal aortic aneurysm surgeries are commonly performed at Cleveland Clinic. Aside from the ascending aorta, the abdominal aorta is the most frequent site for aneurysm formation. Both endovascular and open surgery techniques are employed to treat patients with AAA. As evidenced by our results, the mortality for elective abdominal aortic aneurysm repair with open surgery or endovascular surgery is approaching 0 percent.
AAA Procedure Volume and Distribution
In 2006 and 2007, 470 AAA repair surgeries were performed, including 171 open repairs and 299 endovascular (endo and fenestrated grafts) repairs.
Open AAA Repair Distribution
Of 171 open AAA procedures, 151 were performed electively, while 20 were performed urgently.
In 2006 and 2007, mortality for elective AAA open repair was 2 percent.
Mortality for the 20 urgent and ruptured AAAs was 35 percent.
Open Abdominal Aortic Aneurysm Repair
Outcomes 200732
Aortic Disease (continued)
0%The mortality for patients
with juxtrarenal aneurysms
treated with fenestrated
graft procedures (N = 41)
was 0 percent in 2006
and 2007.
Endovascular Repair Volume and Distribution
In 2006 and 2007, 299 elective endovascular AAA procedures were performed, including 41 patients with juxtrarenal aneurysms who were treated with a fenestrated gra andft 13 patients who required emergent surgery.
96%
4%
Elective
Urgent
Endovascular AAA Mortality
2020
1616
1212
88
00Elective Emergent
44
Percent
In 2006 and 2007, mortality for elective repair of an AAA was 2 percent (six patients out of 245). Mortality for patients with juxtrarenal aneurysms treated with fenestrated grafts was 0 percent.
Even in the setting of acute aortic emergencies, mortality was low (15 percent).
Endovascular repair of AAA with stent-grafts
Heart & Vascular Institute 33
Ruptured Aortic AneurysmWhen 74-year-old Jack Shannon learned that he was being transferred from his local hospital to Cleveland Clinic via helicopter for a ruptured aortic aneurysm, he knew his condition was life-threatening. But, he was also relieved.
“Well, if they’re sending me to Cleveland Clinic, I’ll make it because I’m going to the best hospital around,” Mr. Shannon recounted.
Mr. Shannon previously underwent coronary bypass surgery in 2002, but this time the surgeons in Cincinnati were concerned that he would not survive a conventional approach to this high-risk situation.
Cardiothoracic surgeon Eric Roselli, MD, agreed with their assessment and planned a hybrid repair for Mr. Shannon’s aneurysm while the transfer was coordinated. Hybrid repairs combine open surgical and transcatheter techniques to provide a less invasive, safer treatment alternative for high-risk patients.
In anticipation of Mr. Shannon’s arrival, all members of the multi-disciplinary team of cardiovascular specialists at Cleveland Clinic made preparations. He was taken directly to the hybrid operating room already equipped by the OR nurses and radiology technologists, and the CT anesthesia team proceeded with the extra care needed for an impending rupture. Transesophageal echocardiography was performed while the operation promptly began.
Dr. Roselli and his team performed a successful repair of the leaking 4-inch aortic arch aneurysm by first sewing a prosthetic graft on to his upstream aorta and bypassing the arteries supplying the right and left sides of his brain (Figure 1). A stentgraft was then delivered over a guidewire through a separate limb of this bypass graft using X-ray guidance to completely exclude the leaking aneurysmal portion of his aortic arch and descending thoracic aorta (Figure 2). Finally, because the leaking aneurysm had compromised one of his previous coronary artery bypass grafts, Dr. Roselli performed an off-pump coronary bypass graft to a diseased artery on his heart.
Mr. Shannon was transferred out of the intensive care unit on the third postoperative day and continued to recover on the step-down floor under the watchful care of cardiologist Harry Lever, MD, along with Dr. Roselli’s team. He was discharged to home on postoperative day nine.
Today, Mr. Shannon has returned to enjoying time with his family and is grateful for not only the technical expertise at Cleveland Clinic, but also their dedication, empathy and kindness.
“I’m alive – not only alive, but the kind of care that I had at Cleveland Clinic is just remarkable. It’s the kind of thing that doesn’t just happen.”
Figure 1
Aortic arch aneurysm
Figure 2
Outcomes 200734
Oval-shaped secundum
atrial septal defect (ASD)
is clearly demonstrated by
transesophageal 3-D echo.
2007 Volume
Total Adult Congenital Heart Disease Patient Visits 824
New Referral Visits for Adult Congenital Heart Disease 244
Adult Congenital Heart Disease ClinicAdults with complex congenital heart defects require expert, lifelong care. Cleveland Clinic’s technical expertise, collaboration between pediatric and adult cardiologists and cardiovascular surgeons, as well as state-of-the-art technologies provide the optimal treatment options for these patients, including:
• Adults with relatively benign defects who have not been diagnosed and treated in childhood. These are primarily patients with atrial septal defects, but also include patients with other defects such as atrioventricular (AV) canal defects, ventricular septal defects (VSD), tetralogy of Fallot, coarctation of the aorta, coronary anomalies and others.
• Adults who return with problems after having had surgical repairs in childhood. This patient population is growing steadily due to the development of more successful management strategies for even the most complex defects in childhood. Many of these patients are destined to return as adults with related and new problems that pose very difficult and special diagnostic and treatment challenges. The perioperative and postoperative management of these patients also presents special challenges.
Diagnoses of New Referrals to the Adult Congenital Heart Disease Clinic
AV Canal Defect 4.7%Ventricular Septal Defect 4.7%
Coarctation of Aorta
Transposition of the Great Vessels
Tetralogy of Fallot
Ebstein Anomaly 3.0%
Pulmonic Stenosis 4.7%
Shone Complex 2.4%
1.8% Coronary Anomalies
Other
Other Congenital Conditions TreatedSeveral other congenital anomalies and syndromes generally have not been classified as congenital heart disease. These include patients born with bicuspid aortic valves who present with leaky or stenotic valves as younger adults and patients with Marfan syndrome presenting with an aortic or mitral valve problem. Cleveland Clinic performed reconstructive and valve-preserving surgeries in many of these patients in 2007. Subaortic membranes and stenosis and coronary arteriovenous fistulas are other examples of such conditions posing surgical and percutaneous challenges.
Anomalous right coronary
artery arising from the left
coronary cusp and passing
between the great vessels.
Atrial Septal Defect
Adult Congenital Heart Disease
32.5%
23.1%10.1%
6.5%
6.5%
Heart & Vascular Institute 35
Interventional Procedures for Congenital Heart Disease2007 Volume and Outcomes
Congenital/Pulmonary Hypertension Cases 236
Vasodilator Challenges 47
Complex Congenital Cases 135
Complex Congenital Interventions 76
Success Rate* 99%
30-Day Mortality 1%
The Amplatzer® Septal
Occluder (top) and the
CardioSEAL® Septal
Occluder (bottom) are two
transcatheter closure devices
used at Cleveland Clinic
for nonsurgical treatment
of atrial septal defects
and patent foramen ovale,
respectively.
Percutaneous Closure Devices
Percutaneous Closure Procedures2007 Volume and Outcomes
Percutaneous ASD Closures 38
Percutaneous PFO Closures 47
Success Rate* 100%
30-day Mortality 1%
Patients Requiring Repeat Procedure 0
Adult Congenital Heart Surgery Distribution
Atrial Septal Defect Repair, Patch
Right Ventricular to Pulmonary Artery Conduit/Pulmonary Valve Replacement
Sinus Venosus/Atrial Septal Defect Repair
Coarctation Repair
Partial Anomalous Pulmonary Venous Connection Repair
Other Adult Congenital Heart Procedures*
*Other adult congenital heart procedures performed at Cleveland Clinic in 2007 included vascular ring, unroofed coronary sinus, Epstein anomaly valve replace-ment, anomalous right coronary artery from opposite sinus/modified unroofing, mitral valve repair for residual mitral valve cleft after previous AV canal repair and one heart transplant for failed Fontan circulation.
*After previous AV canal repair, one patient developed acute respiratory distress syndrome, mitral regurgitation and left ventricular outflow obstruction.
Top photo used with permission from AGA Medical Corporation. Bottom photo used with permission from NMT Medical, Inc.
*Based on one complication, including need for surgery, stroke and myocardial infarction.
*Based on zero complications, including need for surgery, stroke and myocardial infarction.
2007 Volume and Mortality
Adult Congenital Surgeries 68
Mortality* 1.5%
22%
22%
19%
12%
9%
16%
Outcomes 200736
Hypertrophic Obstructive Cardiomyopathy
Sudden Cardiac DeathHypertrophic cardiomyopathy is the most
common cause of sudden cardiac death in
people younger than 30 years of age.
Hypertrophic obstructive cardiomyopathy (HOCM) is thickening of the lower chambers of the heart, especially of the septal muscle, which separates the right and left chambers of the heart. This condition may impede blood flow from the heart to the aorta.
2007 Patient Volume
Total HOCM Outpatient Visits 609
New HOCM Patients 219
Septal Myectomy VolumeCleveland Clinic has one of the largest surgical practices for treating HOCM. In 2007, Cleveland Clinic surgeons performed 157 septal myectomy surgeries.
1997 1999 2001 2003 2005 2007
200200
150150
VolumeVolume
100100
5050
00
During a septal myectomy, the surgeon removes septal muscle to widen the path for blood to leave the heart.
2007 Surgical Volume and Outcomes
Isolated Myectomy and Concomitant Myectomy Procedures 157
Hospital Mortality 0%
1 in 500Hypertrophic cardiomyopathy affects
approximately 1 in 500 people in the U.S.
1,523Since 1967, 1,523 septal myectomies have
been performed at Cleveland Clinic.
O t 2007
2005 2007
Heart & Vascular Institute 37
Outflow Tract Obstruction Without Septal Hypertrophy
Outflow tract obstruction without septal hypertrophy has been recently recognized as an important cause of outflow tract obstruction, especially in young patients. Advanced imaging with MRI and stress echocardiography can identify this anomaly and most cases can be treated with valve repair.
Hypertrophy
REGISTRY: Hypertrophic CardiomyopathyThe Hypertrophic Cardiomyopathy (HCM) Registry is a case identification registry used to identify patients with HCM or patients who have a
strong history of HCM. The registry comprises a large number of Cleveland Clinic patients and contains data related to the diagnosis, evaluation
and management of HCM patients, including variables related to demographics, patient/family history, clinical information, cardiac procedures,
cardiac surgeries and follow-up information. Through this information, research projects are initiated, statistics are generated, education is
facilitated and manuscripts are written.
Septal Myectomy and Concomitant Procedure DistributionHOCM is an uncommon but serious problem, especially when associated with mitral valve dysfunction. In 2007, 41 percent of septal myectomies were performed in conjunction with a valve procedure, including 13 percent performed to treat mitral valve disease. Of these, 60 percent were mitral valve repair procedures.
Isolated Septal Myectomy
Septal Myectomy + Valve + CABG
Septal Myectomy + Other
Septal Myectomy + CABG
Septal Myectomy + Valve34%
11%17%
8%
30%
Papillary muscles directed toward septum
Sutures in papillary muscles Papillary muscles “reoriented” toward mitral valves
Outcomes 200738
Waiting List Mortality In 2007, Cleveland Clinic’s
waiting list mortality was
consistently lower than the
national median wait list
mortality.
Source: SRTR. Center and OPO-Specific Reports, January 2008. Ohio, Heart Centers, Cleveland Clinic. Table 4. www.ustransplant.org/csr/current/csrDefault.aspx
1,349 Number of adult heart
transplants performed at
Cleveland Clinic since
inception of the Cardiac
Transplant Program in 1984.
Heart Failure and Transplant
100
Survival (%)
90
80
70
50
1 Year** 3 Years
Expected*Observed
60
Heart Transplant Patient Survival The January 2008 report of the Scientific Registry of Transplant Recipients (SRTR) demonstrates Cleveland Clinic achieved better-than-expected patient survival at 12 and 36 months post transplant.
Heart Transplant VolumeCleveland Clinic’s Cardiac Transplant Program remains the leading center in both Ohio and the Midwest, and is the fourth largest transplant program in the U.S. In 2007, 64 adult heart transplants were performed at Cleveland Clinic, including three heart-lung transplants and one heart-kidney transplant. Five pediatric heart transplants were performed.
Source: SRTR. Center and OPO-Specific Reports, January 2008. Ohio, Heart Centers, Cleveland Clinic. Table 11. www.ustransplant.org/csr/current/csrDefault.aspx *Expected based on risk adjustment **One year survival is statistically higher
10
Median Months
8
6
4
0
Cleveland Clinic Region
2
United States
Median (50th percentile) months to transplant for patients registered on wait list. Our waiting times are consistently lower than the national average.
Source: SRTR. Center and OPO-Specific Reports, January 2008. Ohio, Heart Centers, Cleveland Clinic. Table 6. www.ustransplant.org/csr/current/csrDefault.aspx
Reduced Waiting Time for Heart Transplant
Heart & Vascular Institute 39
Mechanical Circulatory Device SupportCleveland Clinic has significant depth and breadth of experience with mechanical circulatory device support, including the utilization of pumps for acute support as a bridge to transplant and as permanent support for patients who are not candidates for organ replacement.
In 2007, mechanical circulatory support devices were implanted into 23 patients. Access to and expertise with four mechanical support devices allows us to utilize the optimal device in each patient.
Heartmate II LVASCleveland Clinic uses
the Heartmate II LVAS in
clinical trials for destination
therapy and recently began
using the device as a
bridge to transplant. This
next-generation pump is
small, light-weight, quiet
and easier to implant, with
shorter surgical times than
previous models. The device
has been shown to restore
hemodynamic function and
improve patient outcomes
and quality of life.
Image used with permission from Thoratec Corp.
Left Ventricular RemodelingThe treatment data below represent patients who have undergone mitral valve repair with CorCap and the control group represents patients who have undergone mitral valve repair surgery alone. There is a consistent and sustained reduction in heart size in the patients who underwent mitral valve repair, with additional benefits seen in patients who were also treated with the cardiac support device.
This study demonstrates the potential of existing and evolving therapies to promote “reverse remodeling” and improved heart function.
Note: The CorCap device is available in Europe and in clinical trials in the United States.
-100
-20
-40
-60
-80
0
0
LV End Diastolic Volume
6 12 18 24 30 36
Treatment
Est. Treatment Dif. = -16.0P = 0.032
Follow-up Month
Control
Treatment: 72 64 64 45 49 26 Control: 72 63 60 36 44 21
Get with the Guidelines - Heart Failure ProgramIn 2007, Cleveland Clinic was recognized with the Silver Performance Achievement Award by the American Heart Association for achieving the aggressive goal of treating heart failure patients for 12 consecutive months in compliance with core heart failure treatment measures outlined by the AHA. The “Get with the Guidelines - Heart Failure Program” is the AHA’s quality improvement initiative that aims to decrease re-hospitalizations and reduce mortality in heart failure patients.
Source: Starling RC, et al. Sustained benefits of the CorCap Cardiac Support Device on left ventricular remodeling: three year follow-up results from the Acorn clinical trial. Ann Thorac Surg. 2007 Oct;84(4):1236-1242. Figure adapted with permission.
Outcomes 200740
Lung Transplant
In 2007, Cleveland Clinic performed three heart-lung transplants, one liver-lung transplant, 53 double-lung transplants and 15 single-lung transplants.
Distribution of Lung Transplant Procedures
100100
8080
Liver-LungHeart-LungDouble LungSingle Lung
Liver-LungHeart-LungDouble LungSingle Lung
6060
00
Volume
2002 20042003 2006 20072005
4040
2020
Primary Disease of Lung Transplant Recipients*
*Patients who received a lung transplant from 7/1/06 to 6/30/07, N = 67.
Source: Scientific Registry of Transplant Recipients. Center and OPO-Specific Reports, January 2008. Ohio, Lung Centers, Cleveland Clinic. Table 7. www.ustransplant.org/csr/current/csrDefault.aspx
72Adult lung transplants
performed in 2007.
Cleveland Clinic’s Lung Transplant Program is the leading program in Ohio and among the top programs nationally. The program has gained a reputation for accepting and transplanting challenging and complex cases. Patients have been referred nationally and internationally for lung and heart-lung transplantation evaluations.
Cystic FibrosisIdiopathic Pulmonary Fibrosis
38.8%
40.3%
16.4%
Emphysema/COPD
Other 2% Unknown 1.5%
Heart & Vascular Institute 41
Waiting List Mortality*
Lung Transplant Survival
Reduced Waiting Time for Lung TransplantMedian (50th percentile) months to transplant for patients registered on wait list between 07/01/2001 and 12/31/2006.
Cleveland Clinic’s waiting list mortality has been consistently lower than the national median wait list mortality.
Percent
50
90
100
70
60
80
360 12
Months
Observed Survival
Expected Survival*
24
2020
1515
1010
55
00Cleveland Clinic Region United States
Median Months
1010
88
66
44
22
006 12 18
Cleveland Clinic (N=61)United States (N=1,562)
Percent
Median Months
Source: SRTR. Center and OPO-Specific Reports, January 2008. Ohio, Lung Centers, Cleveland Clinic. Table 4. www.ustransplant.org/csr/current/csrDefault.aspx
Cleveland Clinic lung transplant survival compares favorably to the expected national experience.
*Expected based on risk adjustment Source: SRTR. Center and OPO-Specific Reports, January 2008. Ohio, Lung Centers, Cleveland Clinic. Table 11. www.ustransplant.org/csr/current/csrDefault.aspx
Source: SRTR. Center and OPO-Specific Reports, January 2008. Ohio, Lung Centers, Cleveland Clinic. Table 6. www.ustransplant.org/csr/current/csrDefault.aspx
*Patients placed on wait list between 1/1/2005 and 12/31/2005
Outcomes 200742
Peripheral Vascular Disease
29,857Total volume of ultrasound
procedures performed in the
Non-Invasive Vascular Lab
in 2007
Lower Extremity Interventional ProceduresOur vascular surgeons and cardiologists are skilled in performing procedures on the peripheral arteries, including angioplasty, atherectomy, stenting, thrombectomy and thrombolysis.
2007 Interventional Procedure Volume
Angioplasty 945
Atherectomy 87
Lower Extremity Stenting 570
Thrombolysis 218Lower extremity procedures: Superficial femoral artery disease is the most common site of blockage in peripheral artery disease. Multiple modalities exist to treat blockages causing intermittent claudication.
Renal mesenteric procedures: Patients with atherosclerotic arterial disease to the kidney and mesentery receive targeted treatment from our multidisciplinary team, which includes vascular surgeons, interventional and vascular medicine specialists, as well as nephrologists and gastroenterologists.
Lower Extremity (LE) Surgery Volume and MortalityOur vascular surgeons specialize in performing peripheral artery bypass surgery and strive to use autologous vein grafts.
Non-Invasive Vascular Lab Ultrasound Study Distribution
3% Arterial Mapping (Mammary Artery)
5% Evaluation of Mass7% Renal/Messenteric Duplex
2% Arterial Duplex
Carotid Duplex
<1% Carotid Intimal-Medial Thickness
Venous Duplex
<1% Valvular IncompetencyPhysiologic Testing
4% Vein Mapping
18%
13%
47%
2007 Mortality (%)
LE Bypass 1.0
2007 Volume
Lower Extremity Bypass 194
Thrombectomy 8
Heart & Vascular Institute 43
Venous Disease
Disposable catheter inserted into vein
Vein treated Catheter withdrawn, closing vein
Four weeks post-endovenous ablation
Before endovenous ablation
Endovenous Ablation ProcedureEndovenous ablation is the treatment choice at Cleveland Clinic for valvular incompetency of the great saphenous vein. This minimally invasive procedure improves outcomes with less scarring, bruising or swelling compared to vein stripping. During the procedure, radiofrequency or laser energy is applied to ablate, or scar, the diseased vein.
Number of endovenous ablation procedures performed at Cleveland Clinic in 2007182
Venous Diseases Treated at Cleveland ClinicCleveland Clinic vascular medicine physicians and vascular surgeons offer a full range of therapies for venous diseases.
Varicose vein treatments include conservative treatments such as properly-fitting support stockings, skin care and a regular walking program. When further treatment is needed, medical and surgical options include sclerotherapy, endovenous ablation with radiofrequency or laser energy sources, stab excision and ligation of saphenous veins and varicose vein branches.
Venous stasis ulcer treatments include endoluminal therapy for proximal venous occlusion and endoscopic therapy for perforator incompetence.
Venous occlusive diseases, such as deep vein thrombosis and venous scarring due to venous catheters or device leads, are treated with venous procedures such as mechanical thrombectomy, thrombolysis, venous angioplasty and stenting.
Saphenous Varicose Veins
PhlebotestThe Cleveland Clinic Non-
Invasive Vascular Laboratory
is only the second institution
in the United States to use the
Phlebotest system. Phlebotest
is a comprehensive venous
physiologic examination using
air plethysmography and an
automated positioning chair.
Multiple aspects of vein
function are assessed, and
the system can be used to
diagnose lower extremity
venous obstruction, valvular
incompetency and calf muscle
pump dysfunction. The simple
diagnostic exam usually lasts
only 10 minutes.
Outcomes 200744
Cerebrovascular Disease
CTA of the internal carotid artery showing a stenosis of the vessel.
Carotid Stenting and Endarterectomy TrialsCleveland Clinic Heart &
Vascular Institute is one of a
few institutions participating
in prospective randomized
trials to evaluate both carotid
stenting and carotid endar-
terectomy in symptomatic
and asymptomatic patients.
300300
200200
100100
00CarotidStenting
CarotidEndarterectomy
Cerebral VascularReconstruction
200520062007
Volume
Cerebrovascular disease is a potentially devastating process that may result in temporary or permanent stroke. People with carotid artery stenosis have an increased risk for heart attack and peripheral arterial disease (PAD). Treatment options include medical therapy, surgical treatment with carotid endarterectomy or minimally invasive carotid stenting.
These volumes represent all procedures performed at Cleveland Clinic’s main campus and its affiliates.
Innovative Devices to Treat Cerebrovascular Disease
Flow Reversal System
A novel system of carotid protection during stenting is currently being investigated for its ability to reverse blood flow during stent placement. This device may reduce the risk of debris reaching the brain, thereby preventing stroke.
Carotid Filter and Stenting Devices
Cleveland Clinic is investigating carotid stenting procedures that utilize different types of embolic protection devices. These devices, or filters, are placed to catch any particles that may dislodge during stent placement to treat patients at risk of stroke.
Embolic protection deviceStent
Image used with permission of W.L. Gore and Associates.
2007 Procedural Complications* (N) MI (%) Stroke (%) Mortality (%)
Carotid Stenting 109 0 4.6 0
Diagnostic Angiograms 220 0 0.9 0
Carotid Endarterectomy 163 2.5 2.4 0.6*All procedures performed at Cleveland Clinic’s main campus
Images courtesy of Abbott Vascular. ©2008 Abbott Laboratories. All rights reserved.
Heart & Vascular Institute 45
Thoracic Surgery
General Thoracic SurgeryIn 2007, Cleveland Clinic thoracic surgeons performed 1,520 procedures and continued to maintain a low mortality of 0.4 percent. A high volume of operative procedures translates into depth of clinical expertise.
Distribution of Thoracic Surgeries
1997 1999 2001 2003 2005 2007
1,6001,600
1,2001,200
800800
400400
00
3.003.00
2.252.25
1.501.50
0.750.75
00
Surgical VolumeSurgical Volume Mortality (%)
Cleveland Clinic thoracic surgeons specialize in the diagnosis and surgical treatment of diseases of the lung and esophagus, including lung and esophageal cancer, lung failure, swallowing disorders and airway disease. Our staff offers a broad range of services, from cutting-edge screening techniques to the latest advances in minimally invasive surgical procedures.
Esophagogastric
18%
11%
5%
24%16%
22%
5%
Mediastinum–Neck
Lung Transplant
AirwayPleura and Pericardium
Other
Pulmonary
Outcomes 200746
Median Postoperative Length of Stay (Days)
00 332211 44 55 66
Wedge Resection
Segmentectomy
Lobectomy
Pneumonectomy
Thoracic Surgery (continued)
Distribution of Pulmonary Resection (N = 311)
Pulmonary Resection MortalityCleveland Clinic continues to perform a large number of pulmonary resections, having done 311 in 2007.
44
33
22
11
001997 1999 2001 2003 2005 2007
Median age
8080
6060
4040
2020
00
Mortality (%)
Pulmonary Resection Length of Stay (LOS)Cleveland Clinic’s multidisciplinary care model results in shorter length of stay for patients.
51%
40%
6%
Lobectomy
Pneumonectomy
3% Segmentectomy
Wedge
Heart & Vascular Institute 47
Distribution of Esophageal Surgery by Indication (N = 274)
Esophageal Surgery Length of Stay (LOS)
00
44
33
1997
Percent
22
11
1999 2001 2003 20072005
Median Postoperative Length of Stay (Days)
00 4422 66 88 1010
Fundoplication
Esophagectomy
Esophagectomy remains one of the most challenging of general thoracic operations. Cleveland Clinic’s experience with this procedure leads to shorter LOS for patients.
SuperficialEsophageal Cancer
ESOPHAGECTOMY FOR SUPERFICIAL CANCER
Patients with superficial esophageal cancer generally underwent resection without a chest incision (transhiatal esophagectomy).
Esophageal Surgery Operative Mortality
Major esophageal surgery includes resections for cancer and reoperative surgery for motility and reflux disorders. In 2007, 274 esophageal operations were performed with a low mortality of 0.37 percent.
43%
29%
22%
5%
Cancer
1% Esophageal PerforationOtherReflux
Achalasia
Outcomes 200748
Preventive Cardiology
9,0009,000
7,0007,000
5,0005,000
3,0003,000
1,0001,000Prevention Phase I Rehab Phase II Rehab Phase III Rehab
Volume
20052004
20072006
250
0HDL
200
LDL Triglycerides Total Cholesterol
150
50
100
Value (mg/dL)
49.71 50.95
141.6
100.3
225.2
152
236.9
182.2After 2nd Follow-up Visit
Baseline Visit
2007 Volume
Prevention Outpatient Visits 6,293
Phase I Rehab 8,248
Phase II Rehab 4,601
Phase III Rehab 3,539
Outcome MeasuresPreventive Cardiology
and Rehabilitation tracks
outcomes on numerous
cardiovascular risk factors,
including lipid levels, blood
pressure, body mass index,
Framingham risk score,
diabetes, smoking, high
sensitivity c-reactive protein
and emerging nontraditional
cardiac risk factors.
The Cardiac Rehabilitation
Program reports outcomes
related to quality of life,
functional capacity, blood
pressure and compliance.
Preventive Cardiology Adult PatientsTypically, the patients first seen in the Preventive Cardiology program are already taking lipid-lowering drugs and have mixed dyslipidemia or a history of statin intolerance. Despite this, our patients achieved significant improvements in fasting lipid profiles. This graph represents all adult patients who initially entered the Preventive Cardiology program and had two follow-up visits in 2007.
In 2007, the volume of patients in the Preventive Cardiology and Rehabilitation Department grew by 26 percent.
Heart & Vascular Institute 49
Cardiac Rehabilitation PatientsParticipants in our Cardiac Rehabilitation Program demonstrated marked improvements in fasting lipid profiles, indices of diabetes control, functional capacity, blood pressure and both physical and psychosocial measures.
This table represents the average entry and exit parameters of 2007 program participants (N = 4,601) for whom one or more risk factors were identified as elevated and targeted goals for optimal cardiovascular risk reduction were defined.
Entry Exit Absolute Changes
Systolic Blood Pressure (mm/Hg) 143 128 - 15
Diastolic Blood Pressure (mm/Hg) 78 73 - 5
LDL (mg/dL) 89 83 - 6
Total Cholesterol (mg/dL) 175 156 - 19
Triglycerides (mg/dL) 143 132 - 11
HDL (mg/dL) 50 46 - 4
Glucose (mg/dL) 131 118 - 13
SF-36 PCS 37.6 44.3 + 6.74
SF-36 MCS 47.8 52.2 + 4.38
Preventive Cardiology Pediatric Lipid Clinic PatientsThis graph represents all patients aged <18 years who had two follow-up visits in 2007. The Pediatric Lipid Clinic offers expert medication and lifestyle management for genetic dyslipidemic patients and their families.
350
0HDL
300
LDL Triglycerides Total Cholesterol
250
50
200
Value (mg/dL)
150
100
51.00 44.00
254.4
156.3 138.4
73.20
334.8
215.2
After 2nd Follow-up Visit
Baseline Visit
Exercise PrescriptionsThe need for physician-supervised exercise
programs is steadily increasing. Preventive
Cardiology offered 260 exercise prescriptions
in 2007 to start individuals on a safe
and effective exercise regimen. Exercise
prescriptions are office visits combined with
exercise stress testing to individually tailor
a person’s exercise program. A complete
medical history, exercise history with exercise
test results, limited physical exam,
quality-of-life questionnaire, and readiness for
change are all part of the assessment.
Outcomes 200750
Anesthesiology Cardiothoracic Anesthesiology
Relative Frequency (%)Relative Frequency (%)
Glucose Range (mg/dL)Glucose Range (mg/dL)
Cumulative Relative Frequency (%)
Postoperative Glucose ControlControlling postoperative blood glucose, a national quality measure, has been shown to reduce mortality, the incidence of infection and renal failure, the need for red blood cell transfusion and ventilator support, as well as the median ICU length of stay. Blood glucose is measured at 6 am the day after surgery.
Of 2,970 Cleveland Clinic patients undergoing heart surgery in 2007, 97 percent (2,881) achieved the benchmark level of ≤200 mg/dL, with 79 percent falling below 150 mg/dL. This degree of control was achieved with only 0.10 percent of patients developing hypoglycemia (<50 mg/dL) at the 6 am measurement. Blood glucose control was similar in patients with insulin-dependent diabetes mellitus (IDDM) and noninsulin-dependent diabetes mellitus (NIDDM) after heart surgery.
Postoperative Pain ControlCleveland Clinic cardiothoracic anesthesiologists extensively use thoracic epidural catheters for postoperative pain control in patients undergoing thoracotomy or high abdominal laparotomy procedures. Patients undergoing procedures not suited to thoracic epidural catheter placement are treated with multiple modalities.
In 2007, more than 60 percent of Cleveland Clinic thoracic and cardiovascular surgery patients reported a pain score of three or less at postoperative days one and two.
0 1 2 3 4 5 6 7 8 9 10
8080
6060
4040
2020
00
100100
7575
5050
2525
00
Relative Frequency (%)Relative Frequency (%)
Pain ScorePain Score
Cumulative Relative Frequency (%)
24-Hour Pain Score - Cardiac and Thoracic Surgery (Nonepidural) N = 2,431
6 am Glucose for All Cardiac Patients N = 2,970
24-Hour Pain Score - Cardiac and Thoracic Surgery (Epidural)N = 419
0 1 2 3 4 5 6 7 8 9 10
8080
6060
4040
2020
00
100100
7575
5050
2525
00
Relative Frequency (%)Relative Frequency (%) Cumulative Relative Frequency (%)
Heart & Vascular Institute 51
Vascular Surgery Anesthesiology
6060
4040
2020
001st Qtr. 2nd Qtr. 3rd Qtr. 4th Qtr.
N=369 N=340 N=354 N=394Percent
The Section of Anesthesia for Vascular Surgery continues its emphasis on the management of perioperative normothermia (≥36.0˚C). Although the trend in 2007 was upward, the addition of this measure in early 2008 to the Anesthesiologist Dashboard clinical practice reporting tool for staff anesthesiologists will provide data for continuous improvement.
The Department of General Anesthesiology visits vascular surgery inpatients on their second postoperative day in the hospital to evaluate the early postoperative period and to obtain patients’ responses to a standardized anesthesia experience survey. Favorable responses to the statement “I threw up or felt like throwing up” are “Disagree very much” or “Disagree moderately.”
A question in the postoperative patient satisfaction survey obtained during postoperative rounds asks for the response to the statement “I was satisfied with my anesthesia care.” Favorable responses include “Agree very much” or “Agree moderately.” Results for 2006 and 2007 for vascular surgery patients are shown here.
Perioperative Normothermia
Management of Postoperative Nausea Vomitingand
Satisfaction with Anesthesia Services
00
100100
2006N=116
Percent
2007N=287
6060
8080
4040
2020
00
100100
2006N=115
Percent
2007N=283
6060
8080
4040
2020
Outcomes 200752
Surgical Quality Improvement
Surgical Care Improvement Program (SCIP)SCIP is a national campaign aimed at reducing surgical complications by 25 percent by the year 2010. SCIP is sponsored by the Centers for Medicare and Medicaid Services (CMS) in collaboration with a number of other national partners serving on the steering committee, including the American Hospital Association (AHA), Centers for Disease Control and Prevention (CDC), Institute for Healthcare Improvement (IHI), The Joint Commission and others. Cleveland Clinic is committed to improving the care of surgical patients and participates in SCIP. A multidisciplinary team including the Surgery Institute, Anesthesiology Institute, Infectious Disease Department, Nursing Institute, and Quality and Patient Safety Institute works together to ensure that our surgical patients receive appropriate care.
Percent
0
20
100
40
60
80
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Cleveland ClinicNational Average*Top Hospitals*
Appropriate Preoperative Prophylactic Antibiotic Timing 2007
Cleveland ClinicNational Average*Top Hospitals*
Percent
0
20
100
40
60
80
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Appropriate Prophylactic Antibiotic Selection 2007
Cleveland ClinicNational Average*Top Hospitals*
Percent
0
20
100
40
60
80
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Prophylactic Antibiotics Discontinued within 24 Hours After Surgery 2007
Cleveland ClinicNational Average**Top Hospitals**
Percent
0
20
100
40
60
80
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Recommended Venous Thromboembolism Prophylaxis Received by Patient 2007
* Source:
United States Department of Health and Human Services, Hospital Compare.
Most current reported discharges July 2006 to June 2007.
“Top Hospitals” represent the top 10 percent of reporting hospitals nationwide.
National average of all reporting hospitals in the United States.
** Source:
United States Department of Health and Human Services, Hospital Compare.
Most current reported discharges January to June 2007.
“Top Hospitals” represent the top 10 percent of reporting hospitals nationwide.
National average of all reporting hospitals in the United States.
Heart & Vascular Institute 53
Recommended Venous Thromboembolism Prophylaxis Ordered 2007
Jan Feb Mar Apr May Jun Jul
Cleveland Clinic**
Aug Sep Oct Nov Dec
Percent
0
20
100
40
60
80
Surgery Patients Who Received their Beta Blocker Perioperatively 2007
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Cleveland ClinicNational Average*Top Hospitals*
Percent
0
20
100
40
60
80
* Source:
United States Department of Health and Human Services, Hospital Compare.
Most current reported discharges January to June 2007.
“Top Hospitals” represent the top 10 percent of reporting hospitals nationwide.
National average of all reporting hospitals in the United States.
** No national benchmark data available at this time
National Surgical Quality Improvement Program (NSQIP)
The American College of Surgeons’ National Surgical Quality Improvement Program is a national program that objectively measures surgical outcomes. It reports risk-adjusted 30-day mortality and morbidity outcomes. Currently, the program includes Cleveland Clinic’s surgical cases from colorectal surgery, general surgery and vascular surgery. As this program continues to grow at a national level, Cleveland Clinic is committed to expanding it to all surgical areas. We view NSQIP as a valid, independent way to document our surgical outcomes and provide a basis for ongoing performance improvement.
0
10
20
30
PercentPercent
MorbidityMortality
ExpectedObserved
NSQIP July 1, 2006 to June 30, 2007 Vascular Surgery (N = 284)
Outcomes 200754
Innovations
Cleveland Clinic Innovation CenterCleveland Clinic Innovation Center (CCI) is Cleveland Clinic’s technology commercialization arm, which has a mission to “benefit the sick through the broad and rapid deployment of Cleveland Clinic technology.” CCI facilitates innovation, creates spin-off companies, licenses technology, secures resources and establishes strategic collaborations with corporate partners.
Cardiovascular technologies supported by CCI include:
self-supported mitral and tricuspid valve annuloplasty ring•
elephant trunk vascular ring-graft•
artificial chordae for mitral valve repair •
percutaneous aortic valve graft •
dry storage for percutaneous tissue valves•
percutaneous mitral and tricuspid valve replacement •
sealable cardiac port •
Robotically Assisted Valve Surgery
Robotically assisted mitral valve repair represents a novel, minimally
invasive approach for treating mitral valve regurgitation. It allows
performance of complex mitral valve repairs with the least amount of
trauma to the patient. The operation is performed through small incisions
and ports on the right side of the chest, without the need for dividing the
breast bone. The clinical application of robotic surgery includes treatment
of coronary artery disease.
Cleveland Clinic performs the highest volume of robotic heart surgeries
among U.S. academic medical centers, and has a team of surgeons trained
in this high-tech approach.
da Vinci Surgical System. Image used with permission from Intuitive Surgical, Inc.
Heart & Vascular Institute 55
Sensei Robotic Catheter System. Images used with permission from Hansen Medical, Inc.
Robotic Catheter System to Treat Atrial FibrillationA new Food and Drug Administration-approved robotic catheter ablation system, used in the Electrophysiology Laboratory, enables placement of ablation catheters through small incisions, with improved precision and stability. The system, used to treat atrial and ventricular arrhythmias, is composed of a control catheter and an ergonomically designed, remotely placed workstation where the physician is seated during the procedure.
Cleveland Clinic began using this system in June 2007 and was the first center to use it for clinical applications. It has helped improve the accuracy and efficiency of complex catheter ablation procedures, without adding procedure time or exposing the operator to radiation.
Global Cardiovascular Innovation Center
Founded in 2007, the Global Cardiovascular Innovation Center (GCIC)
is a technology commercialization consortium made possible by a $60
million grant from the State of Ohio’s Third Frontier Program. GCIC is
led by Cleveland Clinic and includes Case Western Reserve University,
the Ohio State University, the University of Cincinnati, the University of
Toledo and University Hospitals and is linked to industry and economic
development partners.
GCIC assists institutions and companies by providing resources and
funding for cardiovascular technology commercialization. GCIC seeks
to expand the thriving medical device and biotech industry located
in Ohio by leveraging partner resources and capabilities to develop
and attract new companies. Upon its completion in 2009, the GCIC
Incubator Building will be home to 20 new early stage cardiovascular
companies. By fostering technology and company development, GCIC
will create hundreds of new jobs in Ohio.
Outcomes 200756
InnovationsLargest Government Grant for Atrial Fibrillation Research
The Atrial Fibrillation Innovation Center (AFIC), an Ohio Wright Center of Innovation, is supported by the largest single government grant in the world for atrial fibrillation research. Cleveland Clinic, together with its institutional partners, Case Western Reserve University and the University of Cincinnati, and its commercial
partners, received this $23-million grant from the State of Ohio’s Third Frontier human genetics and biomedical engineering initiative.
The Center’s preclinical research facilities feature two large laboratories designed to enable both chronic and acute procedures. The lab also features a preparation room and a conference room equipped with video conferencing capabilities and the ability to view surgeries remotely. Proximal to the laboratories is a testing room, fully fitted with treadmill and telemetry equipment, permitting the monitoring of animals in an adjacent boarding area.
The AFIC labs serve as a world center for training physicians in the use of the robotic catheter ablation system for minimally invasive atrial fibrillation treatment, and a specialized multi-lumen balloon catheter system for use in pulmonary vein ablation procedures.
Sealable Cardiac Port A sealable cardiac port device is being developed at Cleveland Clinic to provide safe, transapical access to the heart chambers for percutaneous aortic and mitral valve replacement.
Sensei Robotic Catheter System. Images used with permission from Hansen Medical, Inc.
Investigation with the latest robotic systems for heart rhythm therapy
Heart & Vascular Institute 57
Artificial Chordae for Mitral Valve Repair A novel system for repairing or replacing mitral valve chordae is currently being investigated. The PreChord System consists of premeasured artificial chordae and a measuring/attachment device that mechanically attaches the new chordae with one simple maneuver — thereby reducing surgeon and patient time in the operating room.
Percutaneous Valve Repair TechnologyMyoRing is a complete, self-supported and semi-flexible annuloplasty stent-ring introduced percutaneously into the mitral or tricuspid valve annulus and deployed using balloon technology. It is made from a nickel-titanium shape-memory alloy, and the hooks allow placement without stitching. This prosthetic ring is being developed at Cleveland Clinic for use in treating valve regurgitation to restore valve function, while reestablishing the normal shape and contour of the native valve annulus. This technology will serve as a platform for developing the next generation of percutaneous valve repair devices.
Multi-lumen branches
Mid sewing ring
Distal ring radiograph markersOval sewing ring
Proximal ring(may include a prosthetic valve)
Elephant Trunk Vascular Ring-Graft This vascular ring-graft is being evaluated for surgical repair of acute and chronic aortic dissection, aortic aneurysms and peripheral blood vessel abnormalities. It features a mid-ring that reduces mismatch between the graft and descending aorta, while reducing tension on distal anastomoses to minimize bleeding and graft/tissue tearing. It also features proximal and distal rings, multi-lumen branches and a compressed graft configuration with a removable delivery sheath for ease of placement. The radiopaque markers on the rings improve visualization for endovascular and surgical elephant trunk procedures. This ring-graft potentially may be used for minimally invasive aorta repair procedures. Additionally, the graft may be Y-shaped for the repair of the iliac and femoral arteries.
Outcomes 200758
Innovations
Percutaneous Aortic Valve GraftTo replace the aortic root, a combined aortic valve stent-graft and ascending aortic prosthetic stent-graft with two side branches for the coronary arteries is being investigated for percutaneous insertion. These side branches provide optimal alignment with the coronary ostium. The design of the graft eliminates the potential for perivalvular leakage in high-risk patients with a heavily calcified or aneurysmal aorta.
Dry Storage for Percutaneous Tissue Valves A new method of preserving, crimping, storing and sterilizing tissue valves is under investigation to enable stented cardiac tissue valves to be preloaded into a cannula for percutaneous delivery.
Percutaneous Mitral and Tricuspid Valve Replacement
The unique stent framework of this valve provides secure attachment to the annulus of the mitral or tricuspid valve in percutaneous and minimally invasive valve procedures. The replacement valve may be deployed transapically via a catheter delivery system.
Heart & Vascular Institute 59
Septal Puncture Device This device is being investigated to enable clinicians to puncture the septum in a precise location under fluoroscopic guidance. It may be used in a variety of procedures requiring access to the left atrium, including percutaneous valve replacement and repair, atrial fibrillation ablation and left atrial appendage closure. This device also is compatible with echocardiography.
Lung Transplant Innovation: Bronchial Artery RevascularizationOne of the most common problems with lung transplantation is the breakdown of airway anastomoses. Bronchial healing problems and complications occur in 15 percent of our lung transplant patients, and sometimes these complications are very serious and occasionally even fatal.
Cleveland Clinic surgeons have developed a technique to revascularize the bronchial arteries that improves healing at the anastomosis. As part of a pilot study, the first bronchial artery revascularization in lung transplantation was successfully performed at Cleveland Clinic in December 2007, with primary healing of the airway.
The airway perfectly healed six weeks following en bloc double lung transplantation with a tracheal anastomosis.
Selective bronchial arteriogram that shows an internal thoracic artery providing blood flow into donor bronchial arteries.
Percutaneous Aortic Valve Conduit This conduit is being investigated to supplement blood flow through a patient’s aortic valve without disturbing any existing stenoses or other potentially obstructing material in the heart – addressing the needs of patients who are experiencing reduced cardiac output due to aortic valve disease. The conduit creates an artificial path from the left ventricle outflow tract directly to the ascending aorta. A ventricular assist device also may be included in the conduit to provide additional blood flow into the ascending aorta.
Outcomes 200760
InnovationsDysfunctional High-Density Lipoprotein CholesterolCleveland Clinic researchers identified a mechanism for how high-density liproprotein (HDL) cholesterol becomes dysfunctional in the artery wall when it is modified by myeloperoxidase (MPO), an enzyme present in white blood cells and found in atherosclerotic plaque. MPO modifies a specific region within HDL, inhibiting the ability of HDL to mature and effectively carry cholesterol from cells of the artery wall. As part of the study, an improved structure of HDL was determined. Measuring this marker could be used in clinical applications to identify those at greatest risk for developing heart attack, stroke and death. Supported by the National Institutes of Health.
Protein Carbamylation and Increased Atherosclerosis Risk
Cleveland Clinic researchers identified a molecular link between cardiovascular disease risk and smoking. Chemicals released by burning tobacco found in the blood were discovered, when combined with inflammation, to promote a reaction called carbamylation that corrupts low- and high-density lipoprotein cholesterol function, promoting cholesterol accumulation and plaque formation on arterial walls. The present studies identify carbamylation as a process that occurs much more widely than had previously been believed because it contributes to atherosclerosis in subjects with normal kidney function, and even in nonsmokers within the general population. The findings could lead to new diagnostic tests that gauge the risk of atherosclerosis, acute myocardial infarction and stroke in smokers and nonsmokers alike. Supported by the National Institutes of Health.
Source: Wang Z, Nicholls SJ, Rodriguez ER, Kummu O, Hörkkö S, Barnard J, Reynolds WF, Topol EJ, DiDonato JA, Hazen SL. Protein carbamylation links inflammation, smoking, uremia and atherogenesis. Nat Med. 2007 Oct;13(10)1176-1184.
Normal HDL is described as having “solar flare” structures, with two protruding solvent exposed loops that are important for HDL to dock with an enzyme necessary to mature the particle into an optimally effective form for carrying cholesterol cargo from the arteries to the liver for removal.
Source: Wu Z, Wagner MA, Zheng L, Parks JS, Shy JM 3rd, Smith JD, Gogonea V, Hazen SL. The refined structure of nascent HDL reveals a key functional domain for particle maturation and dysfunction. Nat Struct Mol Biol. 2007 Sep;14(9):861-868.
Solar Flares Model of Discoidal HDL
Heart & Vascular Institute 61
New Endovascular Approaches in the Treatment of Complex Aortic DiseaseWe have pioneered minimally invasive therapies for almost every type of aortic disease. Complex aneurysms and aortic dissections that involve the ascending aorta, arch branches, entire thoracoabdominal aorta and iliac arteries are frequently treated percutaneously or with a small incision in the groin under regional or local anesthesia.
This 3D reconstruction of the aortic arch demonstrates the ability to preserve the brachiocephalic vessels using branches or fenestrations. In this case, there is a thoracic endograft that has a fenestration for the left common carotid artery.
Endovascular grafting techniques have been developed to treat select abnormalities in the ascending thoracic aorta. This patient had a psuedoaneurysm from a cannulation site that was successfully treated with an ascending aortic stent-graft.
The 3D reconstruction of the aortoiliac segment clearly identifies an aortic aneurysm with a thrombus and a left common iliac aneurysm free of any thrombus. The patient had undergone a prior thoracic repair without reimplantation of the intercostal vessels. The importance of pelvic blood flow for collateral spinal cord and hip muscle perfusion has been reported. The patient was treated with an endograft incorporating an internal iliac artery branch.
Before Repair After Repair
Percutaneous Aortic Valve ReplacementsPercutaneous aortic valve replacement is being investigated as an alternative treatment option for select patients with severe aortic valve stenosis who are high-risk surgical candidates. During this transapical approach, a compressed tissue heart valve is placed on a balloon-mounted catheter that is positioned directly in the diseased aortic valve; when the balloon is inflated, the position of the implant is secured.
Cleveland Clinic is one of a few select U.S. centers participating in the PARTNER trial (Placement of Aortic Transcatheter Valves), a prospective, randomized pivotal trial evaluating the safety and effectiveness of the Edwards SAPIEN™ transcatheter heart valve in select patients with severe aortic stenosis.
Images used with permission from Edwards Lifesciences, LLC.
p y
Outcomes 200762
Innovations
HeartMate® II
VentrAssist™
Next-Generation Heart Assist DevicesCleveland Clinic continues to offer the newest technology available for support of patients with advanced heart failure. We have implanted over 500 devices to date, including in 24 patients supported with five different devices in 2007. We are currently participating in clinical trials for new mechanical circulatory support devices. These devices are compact, easier to implant, and may be used in smaller patients who previously might not have been candidates for this type of support. The devices include Thoratec Corporation’s Heartmate® II Left Ventricular Assist System and VentrAssist™ by Ventracor.
Images used with permission from Transmedics™
Beating Heart Organ Procurement A new organ procurement system maintains a beating heart for transplantation during transport to the recipient. The system stores the heart in a warm, functioning state outside the body to optimize organ preservation and allow continuous clinical evaluation.
In the fall of 2007, Cleveland Clinic’s heart failure team enrolled the first patient in a multicenter clinical feasibility study of the Transmedics™ Organ Care System (PROCEED trial – Prospective, Multi-Center, Safety and Effectiveness Evaluation of the Organ Care System Device for Cardiac Use) to evaluate the safety and efficacy of the system. This patient had an excellent outcome, was weaned easily from cardiopulmonary bypass without requiring inotropic support and was discharged from the hospital in 11 days.
Heart transplant using cold ischemic storage has traditionally been used to preserve procured organs, but this method limits organ procurement to a specific region due to time constraints. Our hope is that this new technology will allow us to travel the continental U.S. to procure hearts for transplantation without the previous adverse outcomes associated with long ischemic times.
Heart & Vascular Institute 63
Real-Time Three-Dimensional EchocardiographyThree-dimensional echocardiography is an innovative imaging technique used at Cleveland Clinic to diagnose complex valve problems and facilitate surgical and percutaneous repair of structural heart conditions. This technique displays accurate heart chamber volumes and functions, and provides detailed, real-time views of heart valves that cannot be obtained by conventional echocardiography.
A surgical view of severe posterior leaflet prolapse (mid, p2, segment)
Myxomatous Mitral Valve Disease
MDCT images of a severely calcified aortic valve. The dimensions of the aortic root, calcification of the valve leaflets, and relationship to the coronary arteries are important for planning percutaneous aortic valve replacement.
MDCT image of the entire aorta including the iliac arteries. These data are useful for precise
planning of vascular access and procedures.
High-Resolution Scanning Assists in Planning Endovascular and Surgical ProceduresCleveland Clinic Cardiovascular Imaging Center is one of a few leading cardiovascular centers refining perioperative cardiac imaging with multi-detector computed tomography (MDCT) and magnetic resonance imaging modalities. An interdisciplinary team of cardiologists and radiologists continues to develop and improve specific imaging protocols to comprehensively assess the cardiovascular system and aid in the planning of endovascular and surgical treatments of cardiac conditions.
Percutaneous Mitral Valve RepairCleveland Clinic is investigating an endovascular mitral valve repair system in the EVEREST II (Endovascular Valve Edge-to-edge REpair STudy) clinical research trial to evaluate the safety and efficacy of this clip device in reducing or eliminating mitral valve regurgitation.
Ultrasound and fluoroscopy are used to guide the placement of the clip device that connects the mitral valve leaflet edges.
Investigational device – limited by U.S. federal law to investigational use.
MitraClip™ Cardiovascular Valve Repair System. Image used with permission from Evalve, Inc.MitraClip™ Cardiovascular VImage used with permission
New Knowledge
Outcomes 200764
The Heart & Vascular Institute staff authored 799
publications in 2007. For a complete list, go to
www.clevelandclinic.org/quality/outcomes.
799 Publications
C5ResearchC5Research, Cleveland Clinic Coordinating Center for Clinical
Research, is an Academic Research Organization (ARO) that
provides clinical research services and academic expertise to
support the biotechnology, medical device and pharmaceutical
industries, the National Institutes of Health, Cleveland Clinic and
other academic and contract research organizations.
C5Research has more than 100 employees who specialize in the
planning, coordination, management and conduct of clinical trials
in cardiovascular and other therapeutic areas. C5Research services
include: project management, data management, biostatistics,
new business, research contracts and finance and seven core
laboratories. The clinical and academic expertise of Cleveland
Clinic physicians and scientists, combined with our experience and
expertise in clinical trial management, promote success through
every phase of a clinical trial.
C5Research has broadened its research scope to include
multidisciplinary studies and other medical specialties such as
bariatric surgery, gastroenterology and emergency medicine.
Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC Jr, Jacobs AK, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation. 2007 Aug 14;116(7):e148-e304.
Anwaruddin S, Askari AT, Topol EJ. Redefining risk in acute coronary syndromes using molecular medicine. J Am Coll Cardiol. 2007 Jan 23;49(3):279-289.
Arruda M, Mlcochova H, Prasad SK, Kilicaslan F, Saliba W, Patel D, Fahmy T, Morales LS, Schweikert R, Martin D, Burkhardt D, Cummings J, Bhargava M, Dresing T, Wazni O, Kanj M, Natale A. Electrical isolation of the superior vena cava: An adjunctive strategy to pulmonary vein antrum isolation improving the outcome of AF ablation. J Cardiovasc Electrophysiol. 2007 Dec;18(12):1261-1266.
Arruda MS, He DS, Friedman P, Nakagawa H, Bruce C, Azegami K, Anders R, Kozel P, Chiavetta A, Marad P, Macadam D, Jackman W, Wilber DJ. A novel mesh electrode catheter for mapping and radiofrequency delivery at the left atrium-pulmonary vein junction: a single-catheter approach to pulmonary vein antrum isolation. J Cardiovasc Electrophysiol. 2007 Feb;18(2):206-211.
Atik FA, Navia JL, Vega PR, Gonzalez-Stawinski GV, Alster JM, Gillinov AM, Svensson LG, Pettersson BG, Lytle BW, Blackstone EH. Surgical treatment of postinfarction left ventricular pseudoaneurysm. Ann Thorac Surg. 2007 Feb;83(2):526-531.
Barrows BR, Azimzadeh AM, McCulle SL, Vives-Rodriguez G, Stark WN Jr, Ambulos N, Yin J, Chen H, Balke CW, Moravec CS, Pierson RN III, Gottlieb SS, Bond M, Johnson FL. Robust gene expression with amplified RNA from biopsy-sized human heart tissue. J Mol Cell Cardiol. 2007 Jan;42(1):260-264.
Bavry AA, Bhatt DL. Drug-eluting stents: dual antiplatelet therapy for every survivor? Circulation. 2007 Aug 14;116(7):696-699.
Select Journal ArticlesThis is a representative sample of nearly 800 publications authored by the Heart & Vascular Institute in 2007. For a complete list, go to www.clevelandclinic.org/quality/outcomes.
Heart & Vascular Institute 65
Clinical Investigations
Population-centric clinical registries, quality investigations,
investigator-initiated observational clinical studies,
methodological research and development, and clinical
research education are the five interrelated thrusts of the
multidisciplinary Clinical Investigations group. Our products
include process and outcomes quality reporting, marketing
statistics, publications and presentations of new knowledge
generated from analyses of clinical cohorts, novel advanced
clinical data management tools and statistical methodology,
and presentations and publications of medical students,
residents, and fellows that demonstrate aspects of their
competency in clinical research.
We are housed in a 21,256-square-foot facility physically
laid out according to workflow. The multidisciplinary
team ranges from technicians to nurses, data managers,
computer scientists, artificial intelligence experts, statistical
programmers, and statisticians.
Formation of the Heart & Vascular Institute has afforded us
the opportunity to integrate data from registries across all its
subspecialties, provide a uniform, highly expert approach to
data analysis, and foster collaboration as never before.
Beshai JF, Grimm RA, Nagueh SF, Baker JH II, Beau SL, Greenberg SM, Pires LA, Tchou PJ. Cardiac-resynchronization therapy in heart failure with narrow QRS complexes. N Engl J Med. 2007 Dec 13;357(24):2461-2471.
Bhatt DL, Flather MD, Hacke W, Berger PB, Black HR, Boden WE, Cacoub P, Cohen EA, Creager MA, Easton JD, Hamm CW, Hankey GJ, Johnston SC, Mak KH, Mas JL, Montalescot G, Pearson TA, Steg PG, Steinhubl SR, Weber MA, Fabry-Ribaudo L, Hu T, Topol EJ, Fox KAA. Patients with prior myocardial infarction, stroke, or symptomatic peripheral arterial disease in the CHARISMA trial. J Am Coll Cardiol. 2007 May 15;49(19):1982-1988.
Bhavani SS, Tchou P, Saliba W, Gillinov AM. Surgical options for refractory ventricular tachycardia. J Card Surg. 2007 Nov;22(6):533-534.
Bhudia SK, McCarthy PM, Kumpati GS, Helou J, Hoercher KJ, Rajeswaran J, Blackstone EH. Improved outcomes after aortic valve surgery for chronic aortic regurgitation with severe left ventricular dysfunction. J Am Coll Cardiol. 2007 Apr 3;49(13):1465-1471.
Bian J, Popovic ZB, Benejam C, Kiedrowski M, Rodriguez LL, Penn MS. Effect of cell-based intercellular delivery of transcription factor GATA4 on ischemic cardiomyopathy. Circ Res. 2007 Jun 8;100(11):1626-1633.
Burkhardt JD, Wilkoff BL. Interventional electrophysiology and cardiac resynchronization therapy: delivering electrical therapies for heart failure. Circulation. 2007 Apr 24;115(16):2208-2220.
Canter CE, Shaddy RE, Bernstein D, Hsu DT, Chrisant MRK, Kirklin JK, Kanter KR, Higgins RSD, Blume ED, Rosenthal DN, Boucek MM, Uzark KC, Friedman AH, Young JB. Indications for heart transplantation in pediatric heart disease: a scientific statement from the American Heart Association Council on Cardiovascular Disease in the Young; the Councils on Clinical Cardiology, Cardiovascular Nursing, and Cardiovascular Surgery and Anesthesia; and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007 Feb 6;115(5):658-676.
Chang ASY, Smedira NG, Chang CL, Benavides MM, Myhre U, Feng J, Blackstone EH, Lytle BW. Cardiac surgery after mediastinal radiation: extent of exposure influences outcome. J Thorac Cardiovasc Surg. 2007 Feb;133(2):404-413.
Cooper LT, Baughman KL, Feldman AM, Frustaci A, Jessup M, Kuhl U, Levine GN, Narula J, Starling RC, Towbin J, Virmani R. The role of endomyocardial biopsy in the management of cardiovascular disease: a scientific statement from the American Heart Association, the American College of Cardiology, and the European Society of Cardiology. Circulation. 2007 Nov 6;116(19):2216-2233.
Di Biase L, Fahmy TS, Patel D, Bai R, Civello K, Wazni OM, Kanj M, Elayi CS, Ching CK, Khan M, Popova L, Schweikert RA, Cummings JE, Burkhardt JD, Martin DO, Bhargava M, Dresing T, Saliba W, Arruda M, Natale A. Remote magnetic navigation: human experience in pulmonary vein ablation. J Am Coll Cardiol. 2007 Aug 28;50(9):868-874.
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Outcomes 200766
Dumont E, Gillinov AM, Blackstone EH, Sabik JF III, Svensson LG, Mihaljevic T, Houghtaling PL, Lytle BW. Reoperation after mitral valve repair for degenerative disease. Ann Thorac Surg. 2007 Aug;84(2):444-450.
Dyke CM, Aldea G, Koster A, Smedira N, Avery E, Aronson S, Spiess BD, Lincoff AM. Off-pump coronary artery bypass with bivalirudin for patients with heparin-induced thrombocytopenia or antiplatelet factor four/heparin antibodies. Ann Thorac Surg. 2007 Sep;84(3):836-839.
Eagleton MJ, Schaffer JL. The vascular surgery operating room: Development of an up-to-date operating room that will meet the demands of the vascular surgery patient and team. Endovascular Today. 2007 Aug;6(8):25-30.
Einstein AJ, Moser KW, Thompson RC, Cerqueira MD, Henzlova MJ. Radiation dose to patients from cardiac diagnostic imaging. Circulation. 2007 Sep 11;116(11):1290-1305.
Ellis SG, Colombo A, Grube E, Popma J, Koglin J, Dawkins KD, Stone GW. Incidence, timing, and correlates of stent thrombosis with the polymeric paclitaxel drug-eluting stent: a TAXUS II, IV, V, and VI meta-analysis of 3,445 patients followed for up to 3 years. J Am Coll Cardiol. 2007 Mar 13;49(10):1043-1051.
Fonarow GC, Abraham WT, Albert NM, Stough WG, Gheorghiade M, Greenberg BH, O’Connor CM, Pieper K, Sun JL, Yancy C, Young JB. Association between performance measures and clinical outcomes for patients hospitalized with heart failure. JAMA. 2007 Jan 3;297(1):61-70.
Fonseca C, Lindahl GE, Ponticos M, Sestini P, Renzoni EA, Holmes AM, Spagnolo P, Pantelidis P, Leoni P, McHugh N, Stock CJ, Shi-Wen X, Denton CP, Black CM, Welsh KI, du Bois RM, Abraham DJ. A polymorphism in the CTGF promoter region associated with systemic sclerosis. N Engl J Med. 2007 Sep 20;357(12):1210-1220.
George KM, Pettersson GB. Reoperative quadrivalvular surgery including Ross reversal for complex left ventricular outflow tract obstruction. J Heart Valve Dis. 2007 Nov;16(6):690-691.
Gillinov AM, Svensson LG. Ablation of atrial fibrillation with minimally invasive mitral surgery. Ann Thorac Surg. 2007 Sep;84(3):1041-1042.
Gillinov AM. Choice of surgical lesion set: answers from the data. Ann Thorac Surg. 2007 Nov;84(5):1786-1792.
Gillinov AM. Advances in surgical treatment of atrial fibrillation. Stroke. 2007 Feb;38(2):618-623.
Gillinov AM, Banbury MK. Pre-measured artificial chordae for mitral valve repair. Ann Thorac Surg. 2007 Dec;84(6):2127-2129.
Goel S, Clair DG, Carman TL. An 18-year-old with effort-related arm swelling. Cleve Clin J Med. 2007 Apr;74(4):283-288.
Gonzalez-Stawinski GV, Cook DJ, Chui J, Gupta S, Navia JL, Hoercher K, Taylor DO, Yamani MH, Starling RC, Smedira NG. A comparative analysis between survivors and nonsurvivors with antibody mediated cardiac allograft rejection. J Surg Res. 2007 Oct;142(2):233-238.
Gonzalez-Stawinski GV, Cook DJ, Smedira NG, Navia JL, Taylor DO, Yamani MH, Hoercher K, Starling RC, Banbury MK. Attrition from heart transplant waiting list for patients on ventricular assist devices is not affected by desensitization strategies. Transplant Proc. 2007 Jun;39(5):1571-1572.
Gonzalez-Stawinski G. Early and late outcomes of cardiac surgery in patients with liver cirrhosis. Liver Transpl. 2007 Jul;13(7):956.
Griffin BP. Statins in aortic stenosis: new data from a prospective clinical trial. J Am Coll Cardiol. 2007 Feb 6;49(5):562-564.
Haulon S, Greenberg RK, Pfaff K, Francis C, Koussa M, West K. Branched grafting for aortoiliac aneurysms. Eur J Vasc Endovasc Surg. 2007 May;33(5):567-574.
Higashiura W, Greenberg RK, Katz E, Geiger L, Bathurst S. Predictive factors, morphologic effects, and proposed treatment paradigm for type II endoleaks after repair of infrarenal abdominal aortic aneurysms. J Vasc Interv Radiol. 2007 Aug;18(8):975-981.
Iskandrian AE, Bateman TM, Belardinelli L, Blackburn B, Cerqueira MD, Hendel RC, Lieu H, Mahmarian JJ, Olmsted A, Underwood SR, Vitola J, Wang W. Adenosine versus regadenoson comparative evaluation in myocardial perfusion imaging: results of the ADVANCE phase 3 multicenter international trial. J Nucl Cardiol. 2007 Sep;14(5):645-658.
Jane-Wit D, Altuntas CZ, Johnson JM, Yong S, Wickley PJ, Clark P, Wang Q, Popovic ZB, Penn MS, Damron DS, Perez DM, Tuohy VK. Beta1-adrenergic receptor autoantibodies mediate dilated cardiomyopathy by agonistically inducing cardiomyocyte apoptosis. Circulation. 2007 Jul 24;116(4):399-410.
Kanj MH, Wazni O, Fahmy T, Thal S, Patel D, Elay C, Di Biase L, Arruda M, Saliba W, Schweikert RA, Cummings JE, Burkhardt JD, Martin DO, Pelargonio G, Dello Russo A, Casella M, Santarelli P, Potenza D, Fanelli R, Massaro R, Forleo G, Natale A. Pulmonary vein antral isolation using an open irrigation ablation catheter for the treatment of atrial fibrillation: a randomized pilot study. J Am Coll Cardiol. 2007 Apr 17;49(15):1634-1641.
Kashyap VS, Sepulveda RN, Bena JF, Nally JV, Poggio ED, Greenberg RK, Yadav JS, Ouriel K. The management of renal artery atherosclerosis for renal salvage: Does stenting help? J Vasc Surg. 2007 Jan;45(1):101-108.\
Heart & Vascular Institute 67
King SB III, Aversano T, Ballard WL, Beekman RH III, Cowley MJ, Ellis SG, Faxon DP, Hannan EL, Hirshfeld JW Jr, Jacobs AK, Kellett MA Jr, Kimmel SE, Landzberg JS, McKeever LS, Moscucci M, Pomerantz RM, Smith KM, Vetrovec GW, Creager MA, Holmes DR Jr, Newby LK, Weitz HH, Merli G, Pina I, Rodgers GP, Tracy CM. ACCF/AHA/SCAI 2007 update of the clinical competence statement on cardiac interventional procedures: a report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training (writing Committee to Update the 1998 Clinical Competence Statement on Recommendations for the Assessment and Maintenance of Proficiency in Coronary Interventional Procedures). Circulation. 2007 Jul 3;116(1):98-124.
Koch CG, Li L, Lauer M, Sabik J, Starr NJ, Blackstone EH. Effect of functional health-related quality of life on long-term survival after cardiac surgery. Circulation. 2007 Feb 13;115(6):692-699.
Lauer MS, Martino D, Ishwaran H, Blackstone EH. Quantitative measures of electrocardiographic left ventricular mass, conduction, and repolarization, and long-term survival after coronary artery bypass grafting. Circulation. 2007 Aug 21;116(8):888-893.
Lauer MS, Murthy SC, Blackstone EH, Okereke IC, Rice TW. [18F]fluorodeoxyglucose uptake by positron emission tomography for diagnosis of suspected lung cancer: Impact of verification bias. Arch Intern Med. 2007 Jan 22;167(2):161-165.
Lin R, Svensson L, Gupta R, Lytle B, Krieger D. Chronic ischemic cerebral white matter disease is a risk factor for nonfocal neurologic injury after total aortic arch replacement. J Thorac Cardiovasc Surg. 2007 Apr;133(4):1059-1065.
Lincoff AM, Wolski K, Nicholls SJ, Nissen SE. Pioglitazone and risk of cardiovascular events in patients with type 2 diabetes mellitus: a meta-analysis of randomized trials. JAMA. 2007 Sep 12;298(10):1180-1188.
Little SG, Rice TW, Bybel B, Mason DP, Murthy SC, Falk GW, Rybicki LA, Blackstone EH. Is FDG-PET indicated for superficial esophageal cancer? Eur J Cardiothorac Surg. 2007 May;31(5):791-796.
London B, Albert C, Anderson ME, Giles WR, Van Wagoner DR, Balk E, Billman GE, Chung M, Lands W, Leaf A, McAnulty J, Martens JR, Costello RB, Lathrop DA. Omega-3 fatty acids and cardiac arrhythmias: prior studies and recommendations for future research: a report from the National Heart, Lung, and Blood Institute and Office Of Dietary Supplements Omega-3 Fatty Acids and their Role in Cardiac Arrhythmogenesis Workshop. Circulation. 2007 Sep 4;116(10):e320-e335.
Lytle BW. Percutaneous aortic valve replacement. J Thorac Cardiovasc Surg. 2007 Feb;133(2):299.
Mason DP, Solovera-Rozas M, Feng J, Rajeswaran J, Thuita L, Murthy SC, Budev MM, Mehta AC, Haug M III, McNeill AM, Pettersson GB, Blackstone EH. Dialysis after lung transplantation: prevalence, risk factors and outcome. J Heart Lung Transplant. 2007 Nov;26(11):1155-1162.
Mason DP, Brizzio ME, Alster JM, McNeill AM, Murthy SC, Budev MM, Mehta AC, Minai OA, Pettersson GB, Blackstone EH. Lung transplantation for idiopathic pulmonary fibrosis. Ann Thorac Surg. 2007 Oct;84(4):1121-1128.
Mason DP, Marsh DH, Alster JM, Murthy SC, McNeill AM, Budev MM, Mehta AC, Pettersson GB, Blackstone EH. Atrial fibrillation after lung transplantation: timing, risk factors, and treatment. Ann Thorac Surg. 2007 Dec;84(6):1878-1884.
Maybaum S, Mancini D, Xydas S, Starling RC, Aaronson K, Pagani FD, Miller LW, Margulies K, McRee S, Frazier OH, Torre-Amione G. Cardiac improvement during mechanical circulatory support: a prospective multicenter study of the LVAD Working Group. Circulation. 2007 May 15;115(19):2497-2505.
Meadows TA, Bhatt DL. Clinical aspects of platelet inhibitors and thrombus formation. Circ Res. 2007 May 11;100(9):1261-1275.
Mihaljevic T, Lam BK, Rajeswaran J, Takagaki M, Lauer MS, Gillinov AM, Blackstone EH, Lytle BW. Impact of mitral valve annuloplasty combined with revascularization in patients with functional ischemic mitral regurgitation. J Am Coll Cardiol. 2007 Jun 5;49(22):2191-2201.
Moon MC, Morales JP, Greenberg RK. The aortic arch and ascending aorta: are they within the endovascular realm? Semin Vasc Surg. 2007 Jun;20(2):97-107.
Mosca L, Banka CL, Benjamin EJ, Berra K, Bushnell C, Dolor RJ, Ganiats TG, Gomes AS, Gornik HL, Gracia C, Gulati M, Haan CK, Judelson DR, Keenan N, Kelepouris E, Michos ED, Newby LK, Oparil S, Ouyang P, Oz MC, Petitti D, Pinn VW, Redberg RF, Scott R, Sherif K, Smith SC Jr, Sopko G, Steinhorn RH, Stone NJ, Taubert KA, Todd BA, Urbina E, Wenger NK. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. J Am Coll Cardiol. 2007 Mar 20;49(11):1230-1250.
Murthy S, Gonzalez-Stawinski GV, Rozas MS, Gildea TR, Dumot JA. Palliation of malignant aerodigestive fistulae with self-expanding metallic stents. Dis Esophagus. 2007;20(5):386-389.
Murthy SC, Arroliga AC, Walts PA, Feng J, Yared JP, Lytle BW, Blackstone EH. Ventilatory dependency after cardiovascular surgery. J Thorac Cardiovasc Surg. 2007 Aug;134(2):484-490.
Murthy SC, Blackstone EH, Gildea TR, Gonzalez-Stawinski GV, Feng J, Budev M, Mason DP, Pettersson GB, Mehta AC. Impact of anastomotic airway complications after lung transplantation. Ann Thorac Surg. 2007 Aug;84(2):401-409,409.e1-e4.
Navia JL, Roselli EE, Atik FA, Gonzalez-Stawinski GV, Smedira NG. Orthotopic heart transplantation through minimally invasive approach. Asian Cardiovasc Thorac Ann. 2007 Oct;15(5):446-448.
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Navia JL, Doi K, Atik FA, Fukamachi K, Kopcak MW Jr, Dessoffy R, Ruda-Vega P, Garcia M, Houghtaling PL, Martin M, Blackstone EH, McCarthy PM, Lytle BW. Acute in vivo evaluation of a new stentless mitral valve. J Thorac Cardiovasc Surg. 2007 Apr;133(4):986-994.
Nicholls SJ, Tuzcu EM, Sipahi I, Grasso AW, Schoenhagen P, Hu T, Wolski K, Crowe T, Desai MY, Hazen SL, Kapadia SR, Nissen SE. Statins, high-density lipoprotein cholesterol, and regression of coronary atherosclerosis. JAMA. 2007 Feb 7;297(5):499-508.
Nissen SE, Tardif JC, Nicholls SJ, Revkin JH, Shear CL, Duggan WT, Ruzyllo W, Bachinsky WB, Lasala GP, Tuzcu EM. Effect of torcetrapib on the progression of coronary atherosclerosis. N Engl J Med. 2007 Mar 29;356(13):1304-1316.
Nissen SE, Nicholls SJ, Wolski K, Howey DC, McErlean E, Wang MD, Gomez EV, Russo JM. Effects of a potent and selective PPAR-alpha agonist in patients with atherogenic dyslipidemia or hypercholesterolemia: two randomized controlled trials. JAMA. 2007 Mar 28;297(12):1362-1373.
Nissen SE, Wolski K. Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. N Engl J Med. 2007 Jun 14;356(24):2457-2471.
Penn MS. Patient and cellular characteristics determine efficacy of cell therapy. Circ Res. 2007 Apr 27;100(8):1101-1103.
Pettersson GB, Crucean AC. Segmental approach to repair of regurgitant bicuspid aortic valves. Operative Techniques in Thoracic and Cardiovascular Surgery. 2007 Spring;12(1):14-24.
Rajeswaran J, Blackstone EH. Interval estimation for individual categories in cumulative logit models. Stat Med. 2007 Sep 30;26(22):4150-4162.
Reznik SI, Rice TW, Murthy SC, Mason DP, Apperson-Hansen C, Blackstone EH. Assessment of a pathophysiology-directed treatment for symptomatic epiphrenic diverticulum. Dis Esophagus. 2007;20(4):320-327.
Rice TW, Mason DP, Murthy SC, Zuccaro G Jr, Adelstein DJ, Rybicki LA, Blackstone EH. T2N0M0 esophageal cancer. J Thorac Cardiovasc Surg. 2007 Feb;133(2):317-324.
Rice TW, Blackstone EH. Does a biologic prosthesis really reduce recurrence after laparoscopic paraesophageal hernia repair? Ann Surg. 2007 Dec;246(6):1116-1117.
Roselli EE, Greenberg RK, Pfaff K, Francis C, Svensson LG, Lytle BW. Endovascular treatment of thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg. 2007 Jun;133(6):1474-1482.
Sabik JF III, Blackstone EH, Firstenberg M, Lytle BW. A benchmark for evaluating innovative treatment of left main coronary disease. Circulation. 2007 Sep 11;116(11 Suppl):I232-I239.
Shea KJ, Sopko NA, Ludrosky K, Hoercher K, Smedira NG, Taylor DO, Starling RC, Gonzalez-Stawinski GV. The effect of a donor’s history of active substance on outcomes following orthotopic heart transplantation. Eur J Cardiothorac Surg. 2007 Mar;31(3):452-456.
Shemin RJ, Cox JL, Gillinov AM, Blackstone EH, Bridges CR. Guidelines for reporting data and outcomes for the surgical treatment of atrial fibrillation. Ann Thorac Surg. 2007 Mar;83(3):1225-1230.
Shishehbor MH, Lauer MS, Singh IM, Chew DP, Karha J, Brener SJ, Moliterno DJ, Ellis SG, Topol EJ, Bhatt DL. In unstable angina or non-ST-segment acute coronary syndrome, should patients with multivessel coronary artery disease undergo multivessel or culprit-only stenting? J Am Coll Cardiol. 2007 Feb 27;49(8):849-854.
Sipahi I, Tuzcu EM, Wolski KE, Nicholls SJ, Schoenhagen P, Hu B, Balog C, Shishehbor M, Magyar WA, Crowe TD, Kapadia S, Nissen SE. Beta-blockers and progression of coronary atherosclerosis: pooled analysis of 4 intravascular ultrasonography trials. Ann Intern Med. 2007 Jul 3;147(1):10-18.
Starling RC, Jessup M, Oh JK, Sabbah HN, Acker MA, Mann DL, Kubo SH. Sustained benefits of the CorCap Cardiac Support Device on left ventricular remodeling: three year follow-up results from the Acorn clinical trial. Ann Thorac Surg. 2007 Oct;84(4):1236-1242.
Steg PG, Bhatt DL, Wilson PWF, D’Agostino R Sr, Ohman EM, Rother J, Liau CS, Hirsch AT, Mas JL, Ikeda Y, Pencina MJ, Goto S. One-year cardiovascular event rates in outpatients with atherothrombosis. JAMA. 2007 Mar 21;297(11):1197-1206.
Stone GW, Bertrand ME, Moses JW, Ohman EM, Lincoff AM, Ware JH, Pocock SJ, McLaurin BT, Cox DA, Jafar MZ, Chandna H, Hartmann F, Leisch F, Strasser RH, Desaga M, Stuckey TD, Zelman RB, Lieber IH, Cohen DJ, Mehran R, White HD. Routine upstream initiation vs deferred selective use of glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: the ACUITY Timing trial. JAMA. 2007 Feb 14;297(6):591-602.
Stone GW, Moses JW, Ellis SG, Schofer J, Dawkins KD, Morice MC, Colombo A, Schampaert E, Grube E, Kirtane AJ, Cutlip DE, Fahy M, Pocock SJ, Mehran R, Leon MB. Safety and efficacy of sirolimus- and paclitaxel-eluting coronary stents. N Engl J Med. 2007 Mar 8;356(10):998-1008.
Stone GW, Ellis SG, Colombo A, Dawkins KD, Grube E, Cutlip DE, Friedman M, Baim DS, Koglin J. Offsetting impact of thrombosis and restenosis on the occurrence of death and myocardial infarction after paclitaxel-eluting and bare metal stent implantation. Circulation. 2007 Jun 5;115(22):2842-2847.
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Svensson LG, Blackstone EH, Feng J, de Oliveira D, Gillinov AM, Thamilarasan M, Grimm RA, Griffin B, Hammer D, Williams T, Gladish DH, Lytle BW. Are Marfan syndrome and marfanoid patients distinguishable on long-term follow-up? Ann Thorac Surg. 2007 Mar;83(3):1067-1074.
Svensson LG, Gillinov AM, Blackstone EH, Houghtaling PL, Kim KH, Pettersson GB, Smedira NG, Banbury MK, Lytle BW. Does right thoracotomy increase the risk of mitral valve reoperation? J Thorac Cardiovasc Surg. 2007 Sep;134(3):677-682.
Svensson LG, Deglurkar I, Ung J, Pettersson G, Gillinov AM, D’Agostino RS, Lytle BW. Aortic valve repair and root preservation by remodeling, reimplantation, and tailoring: technical aspects and early outcome. J Card Surg. 2007 Nov;22(6):473-479.
Tang WHW, Francis GS, Morrow DA, Newby LK, Cannon CP, Jesse RL, Storrow AB, Christenson RH, Apple FS, Ravkilde J, Wu AHB. National Academy of Clinical Biochemistry Laboratory Medicine practice guidelines: Clinical utilization of cardiac biomarker testing in heart failure. Circulation. 2007 Jul 31;116(5):e99-e109.
Tang WHW, Tong W, Troughton RW, Martin MG, Shrestha K, Borowski A, Jasper S, Hazen SL, Klein AL. Prognostic value and echocardiographic determinants of plasma myeloperoxidase levels in chronic heart failure. J Am Coll Cardiol. 2007 Jun 19;49(24):2364-2370.
Tang WHW, Francis GS. The year in heart failure. J Am Coll Cardiol. 2007 Dec 11;50(24):2344-2351.
Temes RT. Thoracentesis. N Engl J Med. 2007 Feb 8;356(6):641-642.
Tulsyan N, Kashyap VS, Greenberg RK, Sarac TP, Clair DG, Pierce G, Ouriel K. The endovascular management of visceral artery aneurysms and pseudoaneurysms. J Vasc Surg. 2007 Feb;45(2):276-283.
Verma A, Minor S, Kilicaslan F, Patel D, Hao S, Beheiry S, Lakkireddy D, Elayi SC, Cummings J, Martin DO, Burkhardt JD, Schweikert RA, Saliba W, Tchou PJ, Natale A. Incidence of atrial arrhythmias detected by permanent pacemakers (PPM) post-pulmonary vein antrum isolation (PVAI) for atrial fibrillation (AF): correlation with symptomatic recurrence. J Cardiovasc Electrophysiol. 2007 Jun;18(6):601-606.
Videtic GMM, Adelstein DJ, Mekhail TM, Rice TW, Stevens GHJ, Lee SY, Suh JH. Validation of the RTOG recursive partitioning analysis (RPA) classification for small-cell lung cancer-only brain metastases. Int J Radiat Oncol Biol Phys. 2007 Jan 1;67(1):240-243.
Wang Z, Nicholls SJ, Rodriguez ER, Kummu O, Horkko S, Barnard J, Reynolds WF, Topol EJ, DiDonato JA, Hazen SL. Protein carbamylation links inflammation, smoking, uremia and atherogenesis. Nat Med. 2007 Oct;13(10):1176-1184.
Wazni OM, Beheiry S, Fahmy T, Barrett C, Hao S, Patel D, Di Biase L, Martin DO, Kanj M, Arruda M, Cummings J, Schweikert R, Saliba W, Natale A. Atrial fibrillation ablation in patients with therapeutic international normalized ratio: comparison of strategies of anticoagulation management in the periprocedural period. Circulation. 2007 Nov 27;116(22):2531-2534.
Yared JP, Bakri MH, Erzurum SC, Moravec CS, Laskowski DM, Van Wagoner DR, Mascha E, Thornton J. Effect of dexamethasone on atrial fibrillation after cardiac surgery: prospective, randomized, double-blind, placebo-controlled trial. J Cardiothorac Vasc Anesth. 2007 Feb;21(1):68-75.
Zhang M, Mal N, Kiedrowski M, Chacko M, Askari AT, Popovic ZB, Koc ON, Penn MS. SDF-1 expression by mesenchymal stem cells results in trophic support of cardiac myocytes after myocardial infarction. FASEB J. 2007 Oct;21(12):3197-3207.
BooksAskari AT, Messerli AW, Lincoff AM. Management Strategies in Antithrombotic Therapy. Chichester, England; Hoboken, NJ: John Wiley and Sons; 2007.
Ellenbogen KA, Kay GN, Lau CP, Wilkoff BL. Clinical Cardiac Pacing, Defibrillation and Resynchronization Therapy. 3rd ed. Philadelphia, PA: Saunders Elsevier; 2007.
Griffin BP, Rimmerman CM, Topol EJ. The Cleveland Clinic Cardiology Board Review. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.
McCarthy PM, Young JB. Heart Failure: A Combined Medical and Surgical Approach. Malden, MA: Blackwell Futura; 2007.
Natale A, Wazni O. Handbook of Cardiac Electrophysiology. London, England: Informa Healthcare; 2007.
Nixon JV, Aurigemma GP, Bolger AF, Chaitman BR, Crawford MH, Fletcher GF, Francis GS, Gersony WM, Harrington RA, Ott P, Wenger NK, Alpert JS. The AHA Clinical Cardiac Consult. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.
Penn MS. Stem Cells and Myocardial Regeneration. Totowa, NJ: Humana Press; 2007.
Shiota T. 3D Echocardiography. London, England: Informa Healthcare; 2007.
Young JB, Narula J. Heart Failure, Part I. Philadelphia, PA: Saunders, 2007. Cardiology Clinics; v.25(4).
Heart & Vascular Institute Staff Directory
Outcomes 200770
Heart & Vascular Institute LeadershipBruce W. Lytle, MD, Chairman, Heart & Vascular Institute
Daniel Clair, MD, Chairman, Vascular Surgery
Steven E. Nissen, MD, Chairman, Cardiovascular Medicine
Joseph F. Sabik, MD, Chairman, Thoracic and Cardiovascular Surgery
Quality Review Offlcers, Heart & Vascular Institute Frederick A. Heupler, Jr., MD
Nicholas G. Smedira, MD
Sunita Srivastava, MD
Thoracic and Cardiovascular SurgeryJoseph F. Sabik, MD, Chairman
Cardiovascular Surgery
Eugene H. Blackstone, MD
A. Marc Gillinov, MD
Gonzalo Gonzalez-Stawinski, MD
Douglas Johnston, MD
Bruce W. Lytle, MD
Tomislav Mihaljevic, MD
José L. Navia, MD
Gosta B. Pettersson, MD, PhD, Vice-Chairman
Eric E. Roselli, MD
Joseph F. Sabik, MD
Nicholas G. Smedira, MD
Edward Soltesz, MD
Lars G. Svensson, MD, PhD
Thoracic Surgery
Thomas W. Rice, MD, Section Head
David P. Mason, MD
Sudish C. Murthy, MD, PhD
Vascular Surgery Daniel Clair, MD, Chairman
Linda Graham, MD, Vice-Chair
Matthew Eagleton, MD
Roy K. Greenberg, MD
Vikram Kashyap, MD, FACS
Leonard Krajewski, MD
Sean Lyden, MD
Tara Mastracci, MD
Patrick O‘Hara, MD
Timur Sarac, MD
Sunita Srivastava, MD
Cardiovascular MedicineSteven E. Nissen, MD, Chairman
Randall C. Starling, MD, MPH, Vice-Chairman
E. Murat Tuzcu, MD, Vice-Chairman
A. Michael Lincoff, MD, Vice-Chairman
Cardiac Electrophysiology and Pacing
Bruce D. Lindsay, MD, Section Head
Mandeep Bhargava, MD
Lon W. Castle, MD
Mina K. Chung, MD
Jennifer E. Cummings, MD
Thomas Dresing, MD
Thomas B. Edel, MD
Fetnat Fouad-Tarazi, MD
Fredrick J. Jaeger, DO
Mohamed Kanj, MD
David O. Martin, MD, MPH
Robert D. Mosteller, MD
Walid I. Saliba, MD
Heart & Vascular Institute 71
Adam Grasso, MD, PhD
Heather L. Gornik, MD, RVT
Donald F. Hammer, MD
Joel B. Holland, MD
Julie Huang, MD
Fuad Y. Jubran, MD
Vidyasagar Kalahasti, MD
Richard Krasuski, MD
Girish Mood, MD*
Steven E. Nissen, MD
Marc S. Penn, MD, PhD
Mehdi Razavi, MD
Curtis Rimmerman, MD
Michael B. Rocco, MD
Michael B. Rollins, MD
Mustaphasahim Shaaraoui, MD*
Terrence G. Tulisiak, MD
Donald A. Underwood, MD
Bennett Werner, MD
*Hospitalists
Heart Failure and Cardiac Transplant Medicine
Randall C. Starling, MD, MPH, Section Head
Corinne Bott-Silverman, MD
Mazen A. Hanna, MD
Robert E. Hobbs, MD
Eileen Hsich, MD
Karen B. James, MD
Christine Moravec, PhD
Gustavo Rincon, MD
W.H. Wilson Tang, MD
David O. Taylor, MD
James B. Young, MD
Richard Sterba, MD
Patrick J. Tchou, MD
Oussama Wazni, MD
Bruce L. Wilkoff, MD
Cardiac Electrophysiology and Pacing - Syncope Clinic
Fetnat Fouad-Tarazi, MD
Frederick J. Jaeger, DO
Cardiovascular Imaging
James D. Thomas, MD, Section Head
Manuel Cerqueira, MD*
Ronan Curtin, MD
Milind Desai, MD
Scott Flamm, MD*
Brian P. Griffin, MD
Richard A. Grimm, DO
Wael Jaber, MD
Allan L. Klein, MD
Harry M. Lever, MD
Chiara Liguori, MD
Venugopal Menon, MD
L. Leonardo Rodriguez, MD
Paul Schoenhagen, MD*
Ellen Mayer Sabik, MD
Takahiro Shiota, MD
Srikanth Sola, MD
William James Stewart, MD
Maran Thamilarasan, MD
*Joint appointment with Radiology
Clinical Cardiology
Gary S. Francis, MD, Section Head
Arman T. Askari, MD
Ajay Bhargava, MD
Caroline Casserly, MD, MBA
Michael Faulx, MD
Adriana Fodor, MD
Heart & Vascular Institute Staff Directory
Outcomes 200772
Invasive Cardiology
Stephen Ellis, MD, Section Head
Christopher Bajzer, MD*
Corinne Bott-Silverman, MD
Sorin Brener, MD
Leslie Cho, MD*
Khosrow Dorosti, MD
Michael Faulx, MD
Irving Franco, MD*
Mazen A. Hanna, MD
Frederick A. Heupler, Jr., MD
Robert E. Hobbs, MD
Vidyasagar Kalahasti, MD
Samir Kapadia, MD*†
Richard Krasuski, MD†
A. Michael Lincoff, MD*
Ravi N. Nair, MD
Marc S. Penn, MD, PhD
Russell E. Raymond, DO*
Gustavo Rincon, MD
Conrad C. Simpfendorfer, MD*
E. Murat Tuzcu, MD*†
Patrick L. Whitlow, MD*
*Coronary Interventionalists †Interventionalists who also perform percutaneous structural heart procedures
Preventive Cardiology and Rehabilitation
Stanley L. Hazen, MD, PhD, Section Head
Leslie Cho, MD, Medical Director
Gordon Blackburn, PhD, Program Director, Cardiac Rehabilitation
John Campbell, MD Department of General Internal Medicine
Byron Hoogwerf, MD Department of Endocrinology
Julie Huang, MD Department of Cardiovascular Medicine
Sangeeta Kashyap, MD Department of Endocrinology
Richard Lorber, MD Department of Pediatric Cardiology
Leo Pozuelo, MD Department of Psychiatry and Psychology
Michael B. Rocco, MD Department of Cardiovascular Medicine
Douglas Rogers, MD Head, Section of Pediatric Endocrinology
Paul Schoenhagen, MD Department of Diagnostic Radiology
Vascular Medicine
John R. Bartholomew, MD, Section Head
Firas Al Solaiman, MD, RVT
Christopher Bajzer, MD*
Deepak Bhatt, MD*
Carmel Celestin, MD
Carmen Fonseca, MD
Marcelo Gomes, MD
Heather L. Gornik, MD, RVT
Douglas Joseph, DO, RVT
Samir Kapadia, MD*
Michael Maier, DPM, CWS
William Ruschhaupt, MD
Patrick L. Whitlow, MD*
*Vascular interventionalists who perform interventional and endovascular procedures
Women’s Cardiovascular Center
Leslie Cho, MD Director
Julie Huang, MD
Ellen Mayer Sabik, MD
Heart & Vascular Institute 73
Some physicians may practice in multiple locations.
For a detailed list including staff photos, please visit
www.clevelandclinic.org/staff.
Clinical Investigations
Eugene H. Blackstone, MD, Director
Edward Nowicki, MD
Vascular Surgery Research
Roy K. Greenberg, MD, Director of Endovascular Research
C5Research (Cleveland Clinic Coordinating Center for Clinical Research)
A. Michael Lincoff, MD, Director
Associate Directors of C5Research
Deepak Bhatt, MD
Heather L. Gornik, MD, M.H.S., MMSc
Wael A. Jaber, MD
David Martin, MD, MPH
Stephen Nicholls, MD, PhD
W.H. Wilson Tang, MD
Oussama Wazni, MD
Patrick Whitlow, MD
C5Research Core Laboratory Directors
Arman T. Askari, MD
Roy K. Greenberg, MD
Stanley L. Hazen, MD, PhD
Wael A. Jaber, MD
Douglas E. Joseph, DO, RVT
Venu Menon, MD
Stephen J. Nicholls, MD, PhD
Heart & Vascular Institute Staff Directory
Outcomes 200774
Regional Medical Practice
Cleveland Clinic Avon Lake Family Health Center
Bret Butler, MD, Vascular Surgery
Cleveland Clinic Beachwood Family Health and Surgery Center
Joel B. Holland, MD, Cardiovascular Medicine
Vikram Kashyap, MD, Vascular Surgery
Darryl Miller, MD, Cardiovascular Medicine
Michael B. Rocco, MD, Cardiovascular Medicine
Sunita Srivastava, MD, Vascular Surgery
Emad Zakhary, MD, Vascular Surgery
Cleveland Clinic Elyria Chestnut Commons Family Health Center
Daniel Clair, MD, Vascular Surgery
Cleveland Clinic in Florida -- Cardiovascular Medicine
Craig Asher, MD
Howard S. Bush, MD
Bernardo Fernandez, MD
Kenneth R. Fromkin, MD
Marcelo Eduardo Helguera, MD
Gian M. Novaro, MD
Sergio Pinski, MD
Michael Shen, MD, MS
Cleveland Clinic Independence Family Health Center
Neal Hadro, MD, Vascular Surgery
Michael B. Rollins, MD, Cardiovascular Medicine
Cleveland Clinic Lorain Family Health and Surgery Center
Brett Butler, MD, Vascular Surgery
Sean Lyden, MD, Vascular Surgery
Samuel Puccinelli, Jr., MD, Cardiovascular Medicine
Richard Sterba, MD, Pediatric Cardiology
Cleveland Clinic Solon Family Health Center
Joseph Martin, MD, Cardiovascular Medicine
Cleveland Clinic Strongsville Family Health and Surgery Center
Matthew Eagleton, MD, Vascular Surgery
Tara Mastracci, MD, Vascular Surgery
Terrence G. Tulisiak, MD, Cardiovascular Medicine
Cleveland Clinic Westlake Family Health Center
Brett Butler, MD, Vascular Surgery
Caroline Casserly, MD, MBA, Cardiovascular Medicine
Lon W. Castle, MD, Cardiovascular Medicine
Thomas B. Edel, MD, Cardiovascular Medicine
Robert D. Mosteller, MD, Cardiovascular Medicine
Ashoka Nautiyal, MD, Cardiovascular Medicine
Samuel Puccinelli, Jr., MD, Cardiovascular Medicine
Curtis Rimmerman, MD, Cardiovascular Medicine
Cleveland Clinic Willoughby Hills Family Health Center
J. Michael Koch, MD, Cardiovascular Medicine
Emad Zakhary, MD, Vascular Surgery
Heart & Vascular Institute 75
Thomas G. Santoscoy, MD, Thoracic and Cardiovascular Surgery
Donna J. Waite, MD, Thoracic and Cardiovascular Surgery
Emad Zakhary, MD, Vascular Surgery
LakeWest HospitalRami Akhrass, MD, Thoracic and Cardiovascular Surgery
Mark Botham, MD, Thoracic and Cardiovascular Surgery
Thomas G. Santoscoy, MD, Thoracic and Cardiovascular Surgery
Donna J. Waite, MD, Thoracic and Cardiovascular Surgery
Marymount HospitalNeal Hadro, MD, Vascular Surgery
Gregory Schnier, MD, Vascular Surgery
R. Thomas Temes, MD, Thoracic and Cardiovascular Surgery
Donna J. Waite, MD, Thoracic and Cardiovascular Surgery
McLeod Heart & Vascular InstituteFred Holland, II, MD, Thoracic and Cardiovascular Surgery
Gregory Jones, MD, Thoracic and Cardiovascular Surgery
Robert Phillips Jr., MD, Thoracic and Cardiovascular Surgery
MetroHealth Medical CenterRami Akhrass, MD, Thoracic and Cardiovascular Surgery
Inderjit S. Gill, MD, Thoracic and Cardiovascular Surgery
Joseph A. Lahorra, MD, Thoracic and Cardiovascular Surgery
R. Thomas Temes, MD, Thoracic and Cardiovascular Surgery
Rochester General HospitalEli Becker, MD, Thoracic and Cardiovascular Surgery
David Cheeran, MD, Thoracic and Cardiovascular Surgery
Ronald Kirshner, MD, Thoracic and Cardiovascular Surgery
Cleveland Clinic Wooster
Kenneth E. Shafer, MD, Cardiovascular Medicine
Bennett Werner, MD, Cardiovascular Medicine
Richard Sterba, MD, Pediatric Cardiology
Affiliate Programs
Cape Fear Valley Health SystemAli Husain, MD, Thoracic and Cardiovascular Surgery
Robert Maughan, MD, Thoracic and Cardiovascular Surgery
Chester County Hospital Verdi DiSesa, MD, Thoracic and Cardiovascular Surgery
Martin LeBoutillier, III, MD, Thoracic and Cardiovascular Surgery
Cleveland Clinic in Florida W. Douglas Boyd, MD, Thoracic and Cardiovascular Surgery
Mercedes Dullum, MD, Thoracic and Cardiovascular Surgery
Keith Mortman, MD, Thoracic and Cardiovascular Surgery
EMH Regional Medical CenterAltagracia M. Chavez, MD, Thoracic and Cardiovascular Surgery
Michael S. Mikhail, MD, Thoracic and Cardiovascular Surgery
Fairview HospitalBrett Butler, MD, Vascular Surgery
Inderjit S. Gill, MD, Thoracic and Cardiovascular Surgery
R. Thomas Temes, MD, Thoracic and Cardiovascular Surgery
Joseph A. Lahorra, MD, Thoracic and Cardiovascular Surgery
Hillcrest HospitalGeorge Anton, MD, Vascular Surgery
Mark J. Botham, MD, Thoracic and Cardiovascular Surgery
Anthony Rizzo, MD, Vascular Surgery
Outcomes 200776
Patient Experience
0
20
40
60
100
Cleveland Clinic
Total Cleveland Clinic Survey Respondents = 4,725
HCAHPS National Average
Percent “9” or “10”Percent “9” or “10”
80
0
20
40
60
100
Cleveland Clinic HCAHPS National Average
Percent “Yes, definitely”Percent “Yes, definitely”
80
Total Cleveland Clinic Survey Respondents = 4725
Overall Rating of Care (0 worst - 10 best scale) October 2006 - June 2007
Would Recommend Facility October 2006 - June 2007
Inpatient - Cleveland ClinicWith the support of the Center for Medicare and Medicaid Services (CMS) and its partner organizations, the first national standard patient experience survey was implemented in late 2006. Adult medical, surgical, and obstetrics and gynecology patients treated at acute care hospitals across the country are included in the survey. Results collected for initial public reporting, published on www.hospitalcompare.gov in March 2008, are shown here.
We ask our patients about their experiences and satisfaction with the services provided by our staff. Although our patients are already indicating we provide excellent care, we are committed to continuous improvement.
Excellent Very Good Good Fair Poor
PercentPercent
00
100100
6060
8080
4040
2020
Excellent Very Good Good Fair Poor
PercentPercent
00
100100
6060
8080
4040
2020
ExtremelyLikely
VeryLikely
SomewhatLikely
SomewhatUnlikely
VeryUnlikely
PercentPercent
00
100100
6060
8080
4040
2020
Overall Rating of Care - 2007(N = 6,573)
Outpatient - Heart & Vascular Institute
Rating of Provider - Ambulatory Setting 2007(N = 6,585)
Recommend Provider - Ambulatory Setting 2007(N = 6,427)
Heart & Vascular Institute 77
Live Web ChatsIn 2007 Cleveland Clinic began offering live web chat events. Patients and the community can post questions about specific cardiovascular topics and receive online answers from our Heart & Vascular Institute experts. The web chat transcripts are posted after the events so they can be viewed by a wider audience. To view a list of chat transcripts, go to http://www.clevelandclinic.org/heart/webchat.
We have hosted web chats on a wide variety of cardiovascular topics, with answers posted by cardiologists, vascular medicine specialists, cardiovascular surgeons, and other health care professionals. Cleveland Clinic web chats provide information but are not intended to take the place of advice provided by a physician.
PodCastsDownloadable audio programs and video presentations are available online at www.clevelandclinic.org/heart. A wide variety of cardiovascular topics are available including cardiovascular disease risk factors and diagnosis, heart failure, abnormal heart rhythms, coronary artery disease, valve disease, great vessel disease, thoracic surgery and women and heart failure.
Patient and Family Health & Education CenterThe Patient and Family Health & Education
Center, opening in the fall 2008, will provide
education, health information, support and
resources to patients and visitors. The Education
Center will feature a library of educational
handouts as well as current journals and other
publications; computer terminals with Internet
access; audio and video education programs;
and health education classes for patients and
caregivers. The library will be staffed by health
educators and will house our Heart & Vascular
Institute Resource Nurses and support staff.
Healing SolutionsCleveland Clinic Heart & Vascular Institute piloted a Healing Solutions program, offering a host of complimentary wellness services, to patients on one of its inpatient nursing units in late 2007.
This innovative program made pastoral care, social work, holistic nursing, and the touch therapies of massage, Healing Touch and Reiki, part of the team approach that addresses the well-being of our patients and families.
In a survey of pilot participants, 93 percent of participants said they found the services helpful. Ninety percent of those surveyed said they would recommend the services to others.
The pilot program hopes to create a truly caring community, looking at needs beyond the physical – as body, mind and spirit are all important to each patient’s wellbeing. The initiative is part of a larger movement at Cleveland Clinic, led by newly appointed Chief Experience Officer M. Bridget Duffy, MD, to enhance the quality of the hospital experience for patients and their families. These efforts reinforce Cleveland Clinic’s mission: “Patients First.”
The program will be introduced to other floors of the Heart & Vascular Institute and throughout Cleveland Clinic as it is tailored to meet the needs of various patient populations.
Outcomes 200778
Patient Experience (continued)
Never Giving Up HopeOn November 28, 2007, Marianne Cooke, a 32-year-old single mother of two from Arnett, West Virginia, wasn’t feeling well and decided to take a hot bath. As she was climbing into the tub, she suddenly felt dizzy and fell. The water continued running as Marianne blacked out. She could hear her 2-year-old crying and calling for her, but she couldn’t move.
Twenty hours later, a maintenance man investigating a complaint of leaking water found Marianne unconscious on the floor and her son sitting in the water crying next to his Mom. And so began the heroic efforts to save her.
Still unconscious, she was placed on life support at a nearby hospital. Emergency physicians repeatedly asked her parents to sign a “Do Not Resuscitate” order. “She is brain dead,” they told her mother.
Hours later, Marianne was airlifted to a West Virginia teaching hospital. Tests revealed a tumor inside her heart had broken apart, causing clots throughout her body, triggering a massive stroke. Doctors now knew the extent of the problem, and that they weren’t equipped to fix it.
Marianne’s parents didn’t give up. Ten other hospitals refused her case, saying it was too risky. Finally, three days later, a deteriorating Marianne was airlifted to Cleveland Clinic where cardiac and vascular surgeons removed the heart tumor and the blood clots in an eight-hour operation.
“Pieces of the tumor had broken off and were speeding down her arteries like race cars, lodging in her brain, her legs, her feet…,” Cleveland Clinic cardiac surgeon A. Marc Gillinov, MD, said. This most intricate of operations by Dr. Gillinov and vascular surgeon Sean Lyden, MD, demonstrates the multidisciplinary collaboration that routinely benefits patients, such as Marianne, at the Heart & Vascular Institute.
The clots in Marianne’s brain were too numerous and difficult to remove safely, but fortunately, her brain was able to adapt to compensate for the functions from the damaged areas. Eight days later, Marianne started to move a toe. The recovery had begun.
After Christmas, Marianne was released to a nursing home where therapists predicted she would remain for a year. But less than three months after her collapse, Marianne returned home, walking and talking, and ever so grateful.
In all, Marianne lost vision in one eye and may end up losing a toe from the lack of circulation. But her prognosis is good. She and her family say they don’t know much about miracles. But this, they say, certainly comes close.
Heart & Vascular Institute 79
Cleveland Clinic Overview Online Services
Cleveland Clinic, founded in 1921, is a nonprofit multispecialty academic medical center that integrates clinical and hospital care with research and education. Today, 1,800 Cleveland Clinic physicians and scientists practice in 120 medical specialties and subspecialties, annually recording more than 3 million patient visits and more than 70,000 surgeries.
In 2007, Cleveland Clinic restructured its practice, bundling all clinical specialties into integrated practice units called institutes. An institute combines all the specialties surrounding a specific organ or disease system under a single roof. Each institute has a single leadership and focuses the energies of multiple professionals onto the patient. From access and communication to billing and point-of-care service, institutes will improve the patient experience at Cleveland Clinic.
Cleveland Clinic’s main campus, with 37 buildings on 140 acres in Cleveland, Ohio, includes a 1,000-bed hospital, outpatient clinic, specialty institutes and supporting labs and facilities. Cleveland Clinic also operates 14 family health centers; eight community hospitals; two affiliate hospitals; a 150-bed hospital and clinic in Weston, Fla.; and health and wellness centers in Palm Beach, Fla., and Toronto, Canada. Cleveland Clinic Abu Dhabi (United Arab Emirates), a multispecialty care hospital and clinic, is scheduled to open in 2011.
At the Cleveland Clinic Lerner Research Institute, hundreds of principal investigators, project scientists, research associates and postdoctoral fellows are involved in laboratory-based research. Total annual research expenditures exceed $150 million from federal agencies, non-federal societies and associations, and endowment funds. In an effort to bring research from bench to bedside, Cleveland Clinic physicians are involved in more than 2,400 clinical studies at any given time.
In September 2004, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University opened and will graduate its first 32 students as physician-scientists in 2009.
Cleveland Clinic is consistently ranked among the top hospitals in America by U.S.News & World Report, and our heart and heart surgery program has been ranked No. 1 since 1995.
For more information about Cleveland Clinic, visit clevelandclinic.org.
eCleveland CliniceCleveland Clinic uses state-of-the-art digital information systems to offer several services, including remote second opinions to patients around the world; personalized medical record access for patients; patient treatment progress for referring physicians (see below); and imaging interpretations by our subspecialty trained radiologists. For more information, please visit eclevelandclinic.org.
DrConnectOnline Access to Your Patient’s Treatment Progress
Whether you are referring from near or far, DrConnect can streamline communication from Cleveland Clinic physicians to your office. This online tool offers you secure access to your patient’s treatment progress at Cleveland Clinic. With one-click convenience, you can track your patient’s care using the secure DrConnect website. To establish a DrConnect account, visit eclevelandclinic.org or email [email protected].
MyConsultMyConsult Remote Second Medical Opinion is a secure online service providing specialist consultations and remote second opinions for more than 600 life-threatening and life-altering diagnoses. The MyConsult service is particularly valuable for people who wish to avoid the time and expense of travel. For more information, visit eclevelandclinic.org/myconsult, email [email protected] or call 800.223.2273, ext 43223.
Outcomes 200780
Referral Contact Information
Heart & Vascular Institute
On the Web at clevelandclinic.org/heart
General Patient Referral
24/7 hospital transfers or physician consults 800.553.5056
Thoracic and Cardiovascular Surgery Evaluation
Nurse practice managers will expedite patient record review with a Cleveland Clinic surgeon and address questions
216.444.3500 or toll-free 877.8.HEART1
Cardiovascular Medicine Appointments/Referrals
216.444.4467 or 800.223.2273, ext. 44467
Vascular Surgery Appointments/Referrals
216.444.4508 or 800.223.2273, ext. 44508
Heart & Vascular Institute Resource Center
For questions or concerns about heart disease, or to schedule a second opinion Monday through Friday, 8:30 a.m. to 4 p.m.
216.445.9288 or toll-free 866.289.6911
General Information
216.444.2200 or 216.444.2000
Medical Concierge for Out-of-State Patients
Complimentary assistance for out-of-state patients and families 800.223.2273, ext. 55580, or email [email protected]
International Center
Complimentary assistance for international patients and families 800.884.9551 or 216.444.6404 or visit clevelandclinic.org/ic
Cleveland Clinic in Florida
866.293.7866
For address corrections or changes, please call 800.890.2467
clevelandclinic.org
LocationsCleveland Clinic Heart & Vascular Institute physicians see patients at the locations below. Please inquire about availability of specific services at each location when calling.
Main Campus
9500 Euclid Avenue Cleveland, OH 44195
216.444.2200 or toll-free 866.223.2273
Cleveland Clinic Family Health Centers
Beachwood Family Health and Surgery Center
26900 Cedar Road Beachwood, OH 44122
216.839.3000 or toll-free 866.318.2491
Cardiovascular medicine, vascular surgery
Heart & Vascular Institute 81
Independence Family Health Center
5001 Rockside Road Crown Centre II Independence, OH 44131
216.986.4000
Vascular surgery
Lorain Family Health and Surgery Center
5700 Cooper Foster Park Road Lorain, OH 44053
440.204.7400 or 800.272.2676
Pediatric cardiovascular medicine, vascular surgery
Strongsville Family Health and Surgery Center
16761 SouthPark Center Strongsville, OH 44136
440.878.2500 or 800.239.1098
Cardiovascular medicine, vascular medicine, vascular surgery
Westlake Family Health Center
30033 Clemens Road Westlake, OH 44145
440.899.5555 or 800.599.7771
Cardiovascular medicine, thoracic and cardiovascular surgery
Willoughby Hills Family Health Center
2570 SOM Center Road Willoughby Hills, OH 44094
440.943.2500 or 800.807.2888
Cardiovascular medicine, vascular surgery
Cleveland Clinic Wooster
1740 Cleveland Road Wooster, OH 44691
330.287.4500 or 800.451.9870
Adult and pediatric cardiovascular medicine
Heart & Vascular Institute Regional Centers
Cape Fear Valley Health System
Cardiothoracic Surgery 1638 Owen Drive Fayetteville, NC 28304
910.609.4000 capefearvalley.com
The Chester County Hospital
Cardiothoracic Surgery, 2nd Floor 701 E. Marshall Street West Chester, PA 19390
610.738.2690 cchosp.com
Cleveland Clinic in Florida
2950 Cleveland Clinic Boulevard Weston, Florida 33331
954.659.5320 clevelandclinic.org/florida
Cardiovascular medicine, vascular medicine, cardiothoracic surgery, thoracic surgery
EMH Regional Medical Center
Gates Medical Building, Suite 101 630 East River Street Elyria, OH 44035
440.284.1504 emh-healthcare.org
Cardiothoracic surgery
Euclid Hospital
18901 Lake Shore Boulevard Euclid, OH 44119
216.531.9000 euclidhospital.org
Cardiovascular medicine
Outcomes 200782
Fairview Hospital
Cardiothoracic Surgery, Fairview Physicians’ Center 18101 Lorain Avenue Cleveland, OH 44111
216.476.7310 fairviewhospital.org
Cardiothoracic surgery, vascular surgery
Hillcrest Hospital
Hillcrest Hospital Atrium 6780 Mayfield Road, Suite 400 Mayfield Heights, OH 44124
440.449.9300 hillcresthospital.org
Cardiothoracic surgery, vascular surgery
LakeWest Hospital
LakeWest Medical Building, Suite 280 36000 Euclid Avenue Willoughby, OH 44094-4662
440.918.4640 lhs.net
Cardiothoracic surgery
Marymount Hospital
12300 McCracken Road Garfield Heights, OH 44125
216.587.4280 marymount.org
Vascular surgery
McLeod Heart & Vascular Institute
Cardiothoracic Surgery 555 East Cheves Street Florence, SC 29506
843.777.2000 mcleodhealth.org
MetroHealth Medical Center
Cardiothoracic Surgery 2500 MetroHealth Drive Cleveland, OH 44109
216.778.4304 metrohealth.org
Rochester General Hospital
Cardiothoracic Surgery 1445 Portland Avenue Rochester, NY 14621
585.544.6550 rochestergeneralhospital.org
Locations (continued)
9500 Euclid Avenue, Cleveland OH 44195,
© The Cleveland Clinic Foundation 2008, 7/08
Cleveland Clinic is a nonprofit multispecialty academic medical center. Founded in 1921, it is dedicated to providing quality specialized care and includes an outpatient clinic, a hospital with more than 1,000 staffed beds, an education institute and a research institute.
www.clevelandclinic.org/heart
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