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Heart & Vascular Institute
2012 Outcomes
Measuring Outcomes Promotes Quality Improvement
Measuring and understanding outcomes of medical treatments promotes quality improvement. Cleveland Clinic has created a series of Outcomes books similar to this one for its disease-based institutes. Designed for a physician audience, the Outcomes books contain a summary of many of our surgical and medical treatments, with data on patient volumes and outcomes and a review of new technologies and innovations. The Outcomes books are not a comprehensive analysis of all treatments provided at Cleveland Clinic, and omission of a particular treatment does not necessarily mean we do not offer that treatment. When there are no recognized clinical outcome measures for a specific treatment, we may report process measures associated with improved outcomes. When process measures are unavailable, we may report volume measures; a relationship has been demonstrated between volume and improved outcomes for many treatments, particularly those involving surgical techniques. In addition to these institute-based books of clinical outcomes, Cleveland Clinic supports transparent public reporting of healthcare quality data and participates in the following public reporting initiatives: • Joint Commission Performance Measurement Initiative (qualitycheck.org) • Centers for Medicare & Medicaid Services (CMS) Hospital Compare (hospitalcompare.hhs.gov) • Ohio Department of Health (ohiohospitalcompare.ohio.gov) • Cleveland Clinic Quality Performance Report (clevelandclinic.org/QPR) Our commitment to transparent reporting of accurate, timely information about patient care reflects Cleveland Clinic’s culture of continuous improvement and may help referring physicians make informed decisions.
We hope you find these data valuable, and we invite your feedback. Please send your comments and questions via email to:
OutcomesBooksFeedback@ccf.org or scan here.
To view all our Outcomes books, please visit Cleveland Clinic’s Quality and Patient Safety website at clevelandclinic.org/outcomes.
Dear Colleague:
Welcome to this 2012 Cleveland Clinic Outcomes book. We distribute Outcomes books for more than 14 specialties. These publications are unique in healthcare. Each one provides a summary overview of medical or surgical trends, innovations, and clinical data for a Cleveland Clinic specialty over the past year.
Cleveland Clinic uses data to manage outcomes across the full continuum of care. Clinical services are delivered through patient-centered institutes, each based around a single disease or organ system. Institutes combine medical and surgical services, along with research and education, under unified leadership. The individual institute defines quality benchmarks for its specialty services and reports longitudinal progress.
All Cleveland Clinic Outcomes books are available in print and online. Additional data are available through our online Quality Performance Report (clevelandclinic.org/QPR). The site offers process measure, outcome measure, and patient experience data in advance of national and state public reporting sites.
Our practice of releasing annual outcomes reports has received favorable notice from colleagues, media, and healthcare observers. We appreciate your interest and hope you find this information useful and informative.
Sincerely, Delos M. Cosgrove, MD CEO and President
Prefer an e-version?
Visit clevelandclinic.org/OutcomesOnline, and
we’ll remove you from the hard-copy mailing list
and email you when next year’s books are online.
Chairman’s Letter 4
Introduction 5
Institute Overview 6
Quality and Outcomes Measures
Surgical Overview 8
Ischemic Heart Disease 13
Cardiac Rhythm Disorders 21
Valve Disease 27
Aortic Disease 37
Hypertrophic Obstructive Cardiomyopathy 47
Congenital Heart Disease 49
Pericardial Disease 53
Heart Failure and Transplant 55
Lung and Heart-Lung Transplant 58
Peripheral Vascular Diseases 60
Venous Disease 66
what’s inside Cerebrovascular Disease 67
Thoracic Surgery 68
Preventive Cardiology and Rehabilitation 74
Anesthesia 81
Surgical Quality Improvement 82
Patient Experience — Heart & Vascular Institute 84
Cleveland Clinic — Improving Quality, Safety, and the Patient Experience 86
Innovations 92
Staff Listing 98
Contact Information 107
Institute Locations 108
Alliances and Affiliations 110
About Cleveland Clinic 112
Resources 114
Institute Resources 116
On behalf of the Sydell and Arnold Miller Family Heart & Vascular Institute, I would like to thank you for your interest in our 2012 Outcomes. This is the 15th year we have shared our clinical outcomes with physicians across the country.
Our commitment to quality, safety, innovation, and patient satisfaction helps us remain among the top U.S. hospitals year after year. Our outcomes are enhanced by our dedication to collaboration among experts in Cleveland Clinic’s various institutes. Our patients, some of whom are among the most critically ill in the world, greatly benefit from our ability to share information and develop unique treatment plans.
As the number of options to treat cardiovascular disease continues to grow, so does the challenge of selecting those that are the most effective for each patient. We believe in treating every patient with a level of care that is individualized to their particular needs while providing the greatest efficacy and safety. This requires an equally strong commitment to integrity, excellence, and education.
Bruce W. Lytle, MDChairman, Miller Family Heart & Vascular Institute
Outcomes 20124
Chairman’s Letter
Cleveland Clinic leads the nation in cardiovascular care and is home to heart, vascular, and thoracic
specialists who are among the best in the world. They work with referring physicians to coordinate
care and ensure the best possible outcomes and experience for every patient.
The Sydell and Arnold Miller Family Heart & Vascular Institute is located at Cleveland Clinic’s
main campus. Here, 189 staff physicians, 117 residents and fellows, and 1,400 nurses devote
their time and skills to caring for patients with cardiovascular, thoracic, and vascular disease.
Comprehensive care includes collaboration with 54 vascular surgery and cardiovascular intensive care
anesthesiologists and 3,000 Cleveland Clinic staff physicians in 120 medical and surgical specialties
and subspecialties.
5Sydell and Arnold Miller Family Heart & Vascular Institute
Introduction
5
Outcomes 20126
Institute Overview
Heart & Vascular Institute Overview 2012Patient Visits 431,101 Admissions 13,609Beds 416 Coronary Intensive Care 24 Heart Failure Intensive Care 10 Cardiac, Vascular, and Thoracic Surgery Intensive Care 76 Private Patient Rooms 278 Same-Day Recovery 28
Surgical ProceduresCardiac SurgeryCardiac Surgeries 4,262Valve Surgeries 2,773Coronary Artery Bypass Grafting (Isolated and Concomitant) 1,287Surgeries for Septal Myectomy 178Congenital Heart Surgeries (Adult and Pediatric) 401Robotically Assisted Cardiac Surgeries 116
Transplant SurgeryHeart Transplants 47Lung Transplants 104
Thoracic SurgeryGeneral Thoracic Surgeries 1,541Esophageal Surgeries 189
Vascular SurgeryVascular Surgeries (Open and Endovascular) 3,133Bypass Surgeries 218Arteriovenous Access Surgeries 428
The data reported in the Institute Overview reflect volumes at Cleveland Clinic’s main campus only. Data in other areas of the book may reflect volumes for main campus and other Cleveland-area Cleveland Clinic hospitals. A complete list of these hospitals can be found In the Institute Locations section of this book, which begins on Page 108.
Outcomes 2012
In 2012, patients traveled from all
50 states to Cleveland Clinic for their cardiovascular care.
Patients from 82 countries
came to Cleveland Clinic for their
cardiovascular care in 2012.
7Sydell and Arnold Miller Family Heart & Vascular Institute
Aorta SurgeryOpen Ascending Aorta and Aortic Arch Repairs 728Open Descending Aorta and Thoracoabdominal Repairs 57Open Abdominal Aortic Aneurysm Repairs 53Endovascular Descending Aorta and Thoracoabdominal Repairs 224Endovascular Abdominal Aortic Aneurysm Repairs 101
Cardiovascular Medicine Procedures Interventional Cardiology Diagnostic Cardiac Catheterizations 8,730Interventional Cardiac Procedures 1,799 Percutaneous Aortic Valvuloplasties 231 Percutaneous Mitral Valvuloplasties 20 Percutaneous Atrial Septal Defect and Patent Foramen Ovale Closures 66
Vascular Intervention Interventional Carotid Procedures 69Interventional Vascular Procedures 1,009
Electrophysiology Electrophysiology Ablations 1,486 Ablations for Atrial Fibrillation 808 Device Implants 1,502 Leads Extracted 290
Diagnostic and Cardiac Imaging Echocardiograms 72,595Cardiac Computed Tomography (CT) Scans 7,706Cardiac Magnetic Resonance Imaging (MRI) Scans 5,174Nuclear Cardiology Tests Tc-Myoview-Rest 4,394 Tc-Myoview-Stress 4,307 Rubidium Heart (PET) 508 FDG Heart (PET) 493 MUGA 109 N-13 Ammonia Heart 205Stress Tests 6,504
Thoracic and Cardiac Surgery Volume2003 – 2012
Cleveland Clinic surgeons perform procedures at the main campus and at Cleveland Clinic hospitals throughout greater Cleveland. In 2012, they performed 11,446 procedures. A complete list of Cleveland Clinic hospitals is available in the Institute Locations section, which begins on Page 108 of this book.
20122004 2006 20082003 2005 2007 20102009
14,00014,000VolumeVolume
12,00012,000
10,00010,000
8,0008,000
6,0006,000
4,0004,000
2,0002,000
00
Other Cleveland Clinic Hospitals Main Campus
2011
Outcomes 20128
The majority of surgical procedures performed in 2012 were cardiac surgery at the Heart & Vascular Institute at the main campus.
Surgical Procedure Volume by Type and Location (N = 11,446)2012
15% Other Cleveland Clinic Hospitals Thoracic (N = 1,693)15% Other Cleveland Clinic Hospitals Thoracic (N = 1,693)
37% Main Campus Cardiac (N = 4,262)37% Main Campus Cardiac (N = 4,262)
13% Main Campus Thoracic (N = 1,541)13% Main Campus Thoracic (N = 1,541)
23% Other Cleveland Clinic Hospitals Cardiac (N = 2,593)23% Other Cleveland Clinic Hospitals Cardiac (N = 2,593)
12% Other Cleveland Clinic Hospitals Other (N = 1,357)12% Other Cleveland Clinic Hospitals Other (N = 1,357)
100%100%
29% Reoperations accounted for 29% of the 4,262 cardiac surgeries performed at Cleveland Clinic’s main campus in 2012. Reoperations are more complex and are associated with greater risk than primary (first-time) operations.
Surgical Overview
8
Main Campus2012
Cardiac Surgery Hospital Volume and Mortality (N = 4,262)
O/E = Observed/expected
Observed mortality = Actual mortality
Expected mortality = Predicted number of deaths based on severity of illness
Cleveland Clinic performs more cardiac surgery than any other hospital in the United States and has the best quality outcomes (lowest observed/expected mortality ratio).
Source: University HealthSystem Consortium (UHC) Comparative Database, 2012 discharges.
5,0005,000
4,0004,000
3,0003,000
2,0002,000
1,0001,000
00
1.51.5
1.21.2
0.90.9
0.60.6
0.30.3
0.00.0
2012 Volume2012 Volume Mortality Index (O/E ratio)
F G H IEDCBAClevelandClinic
Top U.S. Hospitals
Hospital Mortality — Isolated Procedures (N = 1,445)2012
1010
88
00CABG Aortic Valve
ReplacementMitral ValveReplacement
Mitral ValveRepair
0%
0.36O/E Ratio = 0.10 0.25 0
Cleveland ClinicSTS Expected
66
44
22
Percent
Source: Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database 2012.
Abbreviations: CABG, coronary artery bypass graft.
Hospital mortality rates for isolated procedures performed at Cleveland Clinic were lower than the expected rate in 2012. Isolated procedures are those performed without any other surgical procedure.
9Sydell and Arnold Miller Family Heart & Vascular Institute
Cleveland Clinic surgeons performed 1,541 thoracic surgeries in 2012.
2008 – 2012
General Thoracic Surgery Volume
Hospital Mortality — Combined Procedures (N = 329)2012
201220112008 2009
2,0002,000
1,5001,500
500500
1,0001,000
00
VolumeVolume
2010
88
00Aortic ValveReplacement
+ CABG
Mitral ValveReplacement
+ CABG
Mitral Valve Repair+ CABG
0.18O/E Ratio = 0 0.70
Cleveland ClinicSTS Expected66
44
22
Percent
0%
Source: Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database 2012.
Abbreviations: CABG, coronary artery bypass graft.
The hospital mortality rate for combined procedures at Cleveland Clinic was lower than the expected rate for comparable hospitals in 2012. Combined procedures involve more than one procedure during surgery and are generally more complex than isolated procedures.
Outcomes 201210
Surgical Overview (continued)
Vascular Surgery VolumeMain Campus and Other Cleveland Clinic Hospitals2003 – 2012
Most of the 7,475 vascular surgeries performed in 2012 were at Cleveland Clinic’s main campus. The remainder were performed at Cleveland Clinic hospitals throughout greater Cleveland. A complete list of these locations is available on Page 108 of this book.
Primary procedures accounted for the majority of cardiovascular procedures at Cleveland Clinic in 2012. The mortality rates for both these primary procedures and reoperations were low.
The majority of thoracic surgeries performed at Cleveland Clinic in 2012 were pulmonary procedures.
Major Thoracic Surgery by Type (N = 1,541)2012
20122003 2005 20072004 2006 2008 2009 2010
8,0008,000
6,0006,000
4,0004,000
VolumeVolume
2,0002,000
002011
Other Cleveland Clinic HospitalsMain Campus
11Sydell and Arnold Miller Family Heart & Vascular Institute
11% Mediastinum/Diaphragm (N = 169)11% Mediastinum/Diaphragm (N = 169)7% Lung Transplant = 104)7% Lung Transplant = 104)
22% Pulmonary (N = 344)22% Pulmonary (N = 344)
19% Esophagus (N = 288)19% Esophagus (N = 288)
18% Trachea (N = 278)18% Trachea (N = 278)
17% Pleura (N = 268)17% Pleura (N = 268)
3% Chest Wall (N = 47)3% Chest Wall (N = 47)
1% Other (N = 12)1% Other (N = 12)2% Pericardium (N = 31)2% Pericardium (N = 31)
100%100%
Cardiovascular Surgery Volume, Incidence and Mortality2010 – 2012
4th+FirstSurgery
1st 2nd
Reoperations
10,00010,000
8,0008,000
6,0006,000
4,0004,000
2,0002,000
00
1010
88
66
44
22
00
VolumeVolume Mortality (%)
3rd
The 2012 hospital mortality rate for vascular surgery at Cleveland Clinic was 1.84%, which was well below the adjusted average at national teaching hospitals.
Vascular Surgery by Approach (N = 7,475)2012
The majority of vascular procedures in 2012 were performed using an endovascular approach. The use of endovascular surgery reduces patient morbidity and mortality and results in a shorter recovery time.
Hospital Mortality — Vascular Surgery2008 – 2012
Source: Solucient.
100%100%
51% Endovascular Surgery (N = 3,813)
49% Open Surgery (N = 3,662)
1010
88
66
44
22
00≤ 49 50–59 60–69 ≥ 8070–79
Mortality (%)
Age
Cleveland ClinicNational Teaching Hospitals
Outcomes 201212
Surgical Overview (continued)
Outcomes 201212
Cardiac Catheterization Laboratory Procedures (N = 10,818)
Cleveland Clinic is a regional and national referral center for percutaneous coronary intervention (PCI). In 2012, staff performed 10,818 procedures to treat patients with simple and complex ischemic heart disease.
The data comparisons below demonstrate outcomes at Cleveland Clinic compared with those at hospitals included in the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) CathPCI Registry® that perform more than 500 PCIs per year. Data are based on a one-year rolling average; therefore, totals reported here may differ from those reported elsewhere in this book.
Use of Adjunctive Medications Before and After PCI Procedures (N = 1,730)
2012
100
95
80Aspirin on Admission
Before Procedure
Statins Thienopyridines
At Discharge
Aspirin
90
85
PercentCleveland ClinicComparable ACC-NCDR Hospitals
One of the ACC-NCDR key performance measures is the use of appropriate adjunctive medications before and after PCI procedures. Cleveland Clinic meets or exceeds the administration rates as compared with similar high-volume interventional centers.
60
50
0Age
(> 75 years)Prior MIAcute Care
TransferPrior Heart
FailurePrior CABG Severe LV
DysfunctionMultivessel
DiseaseDiabetes
40
30
20
10
Percent Comparable ACC-NCDR HospitalsCleveland Clinic
Risk Factors Among Patients Undergoing PCI Procedures (N = 1,730)
2012
Patients who had PCI procedures at Cleveland Clinic in 2012 had more complex medical backgrounds than patients at comparable hospitals.
Abbreviations: CABG, coronary artery bypass grafting; LV, left ventricular; MI, myocardial infarction.
13Sydell and Arnold Miller Family Heart & Vascular Institute
Ischemic Heart Disease
4
3
0Composite: Death,Emergency CABG,
Stroke or Repeat TargetVessel Revascularization
Risk-Adjusted Bleeding Event
Stroke
2
1
Percent Comparable ACC-NCDR HospitalsCleveland Clinic
The rates of complications associated with PCI procedures were, in most cases, better than those at comparable hospitals.
PCI Procedure Complications
2012
Door-to-Balloon Time (N = 48)*
2012
*A total of 48 patients treated for myocardial infarction at Cleveland Clinic’s emergency department met the ACC-NCDR reporting criteria for a primary diagnosis of STEMI. Among these patients, time to reperfusion was 60 minutes.
The American College of Cardiology/American Heart Association (ACC/AHA) practice guidelines recommend PCI balloon inflation within 90 minutes of arrival in the emergency department for patients with ST-elevated myocardial infarction (STEMI). Early reperfusion reduces the risks of morbidity and mortality.
80
100
6060
0Cleveland Clinic Comparable ACC-NCDR
Hospitals ACC/AHA Goal
40
20
Minutes
60
90
2.0
1.5
0Risk-Adjusted Mortality
1.0
0.5
Percent
Comparable ACC-NCDR HospitalsCleveland Clinic
PCI Procedure Mortality
2012
In 2012, mortality rates among patients who had PCI procedures at Cleveland Clinic were lower than at comparable hospitals.
Outcomes 201214
Ischemic Heart Disease (continued)
Surgical Treatment for Ischemic Heart Disease (N = 1,287)
CABG Volume2012
CABG Volume, Primary and Reoperations2012
CABG + Other, Mortality2012The mortality rate among patients who had CABG plus another procedure at Cleveland Clinic in 2012 was lower than expected.
77% Primary Operations(N = 997)
77% Primary Operations(N = 997)
23% Reoperations(N = 290) 23% Reoperations(N = 290)
100%100%
Procedure Volume
Isolated 517
CABG + Other 770
Cleveland Clinic surgeons performed 1,287 coronary artery bypass grafting (CABG) procedures in 2012. Isolated procedures are those performed without any other operation. The majority of CABG procedures were performed in combination with another procedure.
The majority of CABG procedures done at Cleveland Clinic in 2012 were primary operations. A primary operation is the first time a patient has a particular procedure.
00
66
Cleveland Clinic(N = 770)
Expected
22
44
PercentPercent
Primary(N = 559)
Reoperation(N = 211)
66
PercentPercent
44
22
00
Expected
Cleveland Clinic
Source: University HealthSystem Consortium 2012 discharges.
15Sydell and Arnold Miller Family Heart & Vascular Institute
★★★
★★
Cleveland Clinic is among
the 15% of hospitals that
achieved an overall three-
star rating from The Society
of Thoracic Surgeons (STS)
for CABG surgery. The
rating reflects the highest
quality of cardiac surgery.
*Based on data comparisons from January 2012 through December 2012.
Primary (N = 438) Reoperation (N = 79)
44
PercentPercent
33
22
11
00
Expected
0%
Cleveland Clinic
Isolated CABG Procedures Mortality
Cleveland Clinic surgeons performed 517 isolated CABG procedures in 2012. The mortality rate was lower than expected.
Source: University HealthSystem Consortium 2012 discharges.
Source: Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database, 2012.
STS CABG Quality Ratings*
Overall
Use of Internal Mammary Artery
Medications
Avoidance of Mortality
Avoidance of Morbidity
5
4
0Cleveland Clinic
MortalityExpectedMortality
3
2
1
Percent
Isolated CABG Mortality — Primary and Reoperation2012Many patients are referred to Cleveland Clinic for CABG reoperations due to the complexity of their medical condition and higher risk of mortality. Despite these risks, mortality rates remain lower than expected.
600
400
02012
200
Volume
Outcomes 201216
Ischemic Heart Disease (continued)
Outcomes 2012
17
Primary Isolated CABG: Age-Related Risk of Mortality2012
Age Observed Mortality (%) Expected Mortality (%)
< 50 years (N = 32) 0.0 0.7
50–59 years (N = 95) 0.0 0.8
60–69 years (N = 166) 0.6 1.5
70–79 years (N = 107) 1.9 2.7
≥ 80 years (N = 38) 2.6 4.6
Total (N = 438) 0.9 1.8
5
4
0Cleveland Clinic Expected
3
2
1
Percent
Isolated CABG: Additional Outcomes
Source: Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database, 2012.
As the age of a patient increases, so does the complexity of CABG procedures. The majority of patients who had primary isolated CABG surgery at Cleveland Clinic in 2012 were Age 60 and older. Mortality rates were low.
Deep Sternal Wound Infection
2012Cleveland Clinic’s incidence of deep sternal wound infection after isolated CABG surgery was at the expected level in 2012.
17Sydell and Arnold Miller Family Heart & Vascular Institute
20
0Cleveland Clinic Expected
15
10
5
Percent
20
0Cleveland Clinic Expected
15
10
5
Percent
10
0Cleveland Clinic Expected
8
6
4
2
Percent
Ventilator Time > 24 Hours
2012It is expected that 10% of patients who have isolated CABG surgery will spend more than 24 hours on a ventilator. At Cleveland Clinic in 2012, the rate was 8.9%.
In-Hospital Reoperation
2012In 2012, the rate of in-hospital reoperation after isolated CABG surgery was lower than expected.
Postoperative Stroke
2012A total of 0.8% of patients who had isolated CABG surgery at Cleveland Clinic in 2012 had a stroke following surgery. This is lower than the expected rate of 1.1%.
Source: Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database, 2012.
Source: Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database, 2012.
Source: Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database, 2012.
Outcomes 201218
Ischemic Heart Disease (continued)
Acute Myocardial Infarction Appropriateness of Care 2011 – 2012 This composite metric, based on seven acute myocardial infarction (AMI) hospital quality process measures developed by the Centers for Medicare and Medicaid Services, shows the percentage of patients who received all the recommended care for which they were eligible. Cleveland Clinic has set a target of UHC’s 90th percentile.
0
60
40
20
80
100Percent
UHC 90th Percentile
2011 2012
97.0 97.3
10
0Cleveland Clinic Expected
8
6
4
2
Percent
100
0Q1 Q3 Q4Q2
80
60
40
20
Percent
Postoperative Renal Failure
2012The rate of postoperative renal failure among patients who had isolated CABG surgery at Cleveland Clinic in 2012 was lower than the expected rate for comparable hospitals.
Process Measures
2012Cleveland Clinic achieved and maintained 100% compliance with all Society of Thoracic Surgeons process measures in 2012. These include the use of a perioperative beta blocker; beta blocker, statin, and aspirin at discharge; and use of an internal mammary artery during isolated CABG surgery.
Source: Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database, 2012.
Source: Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database, 2012.
*These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu
19Sydell and Arnold Miller Family Heart & Vascular Institute
0
5
10
15
20
25
30
Percent
National Average*
18.320.1
Cleveland Clinic
AMI All-Cause 30-Day Mortality (N = 401)July 2009 – June 2012
AMI All-Cause 30-Day Readmission (N = 664)July 2009 – June 2012
0
5
10
15
20
25
30
Percent
National Average*
15.214.9
Cleveland Clinic
Acute Myocardial Infarction
There is no significant difference between Cleveland Clinic’s AMI patient mortality or readmissions rate and the respective national averages. To further reduce avoidable readmissions, a multidisciplinary team is tasked with improving transitions from hospital to home or post-acute facility. Specific initiatives have been implemented in each of these focus areas: communication, education, and follow-up.
The Centers for Medicare and Medicaid Services (CMS) calculates two AMI outcome measures: all-cause mortality and all-cause readmission rates. Each are based on Medicare claims and enrollment information. Cleveland Clinic’s performance appears below.
*These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu
Outcomes 201220
Ischemic Heart Disease (continued)
21Sydell and Arnold Miller Family Heart & Vascular Institute
Cardiac Rhythm Disorders
1,6001,600
00
Volume
LeadExtractions
ICDs CardioversionsPacemakers
400400
1,2001,200
800800
Ablations,by Condition
PVAI(N = 819)Non-CRT
(N = 595)(N = 219)
CRT(N = 337) (N = 1353)
Ventricular Arrhythmias(N = 236)
Other Arrhythmias(N = 381)
CRT(N = 61)
Non-CRT(N = 463)
Patients Undergoing Electrophysiology Laboratory Procedures (N = 4,952)
2012Cleveland Clinic electrophysiologists use specialized approaches to diagnose and treat patients with a wide variety of arrhythmias. They are noted for their expertise in ablation procedures and management of patients with pacemakers and defibrillators. The total number of procedures includes some that are not detailed in the graph below.*
Pulmonary Vein Antrum Isolation Procedures
Volume2008 - 2012
*Other procedures include electrophysiology study, ICD testing, temporary pacer, loop recorders, and electrophysiology specials (endomyocardial biopsy, esophageal pacing, right heart catheterization, venography, and other).
Abbreviations: CRT, cardiac resynchronization therapy; CRT, cardiac resynchronization therapy-defibrillator; ICD, implantable cardioverter defibrillator; PVAI, pulmonary vein antrum isolation.
201220112008 2009
1,0001,000
600600
800800
200200
400400
00
VolumeVolume
2010
Pulmonary vein antrum isolation (PVAI) essentially disconnects the pathway of the abnormal heart rhythm and prevents atrial fibrillation.
Outcomes 201222
Cardiac Rhythm Disorders (continued)
PVAI Complications2012The overall risk associated with PVAI in 2012 was 2.7%.
Complications Number Percent
Pericardial Tamponade/Pericardiocentesis 9 1.1
Pericardial Tamponade/Surgical 1 0.1
Cerebrovascular Accident 1 0.1
Pulmonary Vein Stenosis 2 0.2
Atrial Septal Defect 1 0.1
Pseudoaneurysm 2 0.2
Hematoma Requiring Transfusion 2 0.2
Bleeding Requiring Transfusion 1 0.1
Gastroparesis 1 0.1
Pacemaker Lead Dislodged 1 0.1
Priapism 1 0.1
Total 22 2.4
Success Rates of PVAISuccess is defined as a restored sinus rhythm without recurrence of atrial fibrillation after the patient has stopped taking antiarrhythmic medications for at least 12 months after the procedure. This is influenced by a number of factors, including the length of time the patient has been in atrial fibrillation (AF) and the presence or absence of underlying heart disease.
In a recent study of 831 patients who underwent pulmonary vein antrum isolation at Cleveland Clinic, 81% of patients with paroxysmal AF were arrhythmia-free while off antiarrhythmic drugs at 12 months post-ablation. Paroxysmal AF is defined as AF that terminates within days without cardioversion. A total of 7.8% of this patient population had AF after one year post-ablation (late-recurrence AF).
The success rate is lower for patients with persistent or long-standing persistent AF (65% for a single ablation procedure) and is affected by the presence of valvular heart disease or other underlying problems.
A total of 161 patients who had early recurrence of AF had a repeat ablation procedure. At 14 months after this ablation, 78.9% were arrhythmia-free while off antiarrhythmic drugs. Of the 27 patients who had late-recurrence AF and a repeat ablation, 74.1% were arrhythmia-free while off antiarrhythmic drugs at 17 months post-second ablation.
Reference: Hussein AA, Saliba WI, Martin DO, Bhargava M, Sherman M, Magnelli-Reyes C, Chamsi-Pasha M, John S, Williams-Andrews M, Baranowski B, Dresing T, Callahan T, Kanj M, Tchou P, Lindsay BD, Natale A, Wazni O. Natural history and long-term outcomes of ablated atrial fibrillation. Circ Arrhythm Electrophysiol. 2011 Jun;4(3):271-278.
Complications related to the use of cryoballoon ablation: Four patients experienced temporary phrenic nerve paralysis that resolved within six months of the procedure. One additional patient who experienced phrenic nerve paralysis had partial resolution by four months post-ablation and is awaiting additional follow-up testing.
Atrial septal defect was related to sheath size and required percutaneous closure.
23Sydell and Arnold Miller Family Heart & Vascular Institute
ComplicationsA major complication is defined as one that leads to prolongation of hospital stay or to another hospitalization, requires additional intervention for treatment, and/or results in significant injury or death (Aliot et al., 2009, EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias).
Complications Number Percent
Death Within 7 days 1 0.78
Death Within 30 days 1 0.78
Cardiac Arrest 1 0.78
Complete Heart Block 1 0.78
Deep Venous Thrombosis 1 0.78
Pseudoaneurysm 2 1.56
Total 7 5.46
Patients With Ejection Fraction < 50% (N = 128)
Complications Number Percent
Myocardial Infarction 1 0.93
Pericardial Tamponade/ Surgical Intervention 2 1.85
Pericardial Tamponade/ Pericardiocentesis 1 0.93
Total 4 3.71
Patients With Ejection Fraction ≥ 50% (N = 108)
Ablation of Ventricular Arrhythmia (N = 236)
2012
Cleveland Clinic is a national referral center for patients with ventricular arrhythmias. A total of 236 ablations to correct ventricular arrhythmias were performed in 2012 with a complete success rate of 81%.
The procedure was partially successful in another 16%. Partial success means at least one arrhythmia was ablated in patients who had multiple arrhythmias. A total of 3% of procedures were unsuccessful. All ventricular arrhythmias were eliminated in 81% of patients.
Volume 236
Complete Success Rate 81%
1.7average number of leads
extracted per procedure
90.7 monthsaverage lead age at removal
66.5 monthsmedian lead age at removal
2008 – 2012
Outcomes 201224
Cardiac Rhythm Disorders (continued)
2012Cleveland Clinic surgeons performed 404 procedures to treat atrial fibrillation in 2012. These included minimally invasive “keyhole” and classic Maze procedures. In most cases, the surgery included treatment for AF and another cardiac procedure. The overall mortality rate was 0.8% (N = 4).
100%100%
7% AF + CABG (N = 32; Hospital Mortality, N = 0)6% AF + Other Procedures (N = 7; Hospital Mortality, N = 0) 2% Isolated AF Procedures (N = 7; Hospital Mortality, N = 0)
21% AF + Valve Surgery + CABG (N = 100; Hospital Mortality, N = 1)
64% AF + Valve Surgery (N = 304; Hospital Mortality, N = 3)
Atrial Fibrillation Surgical Procedure Volume (N = 404)
Device Lead Extractions Leads in Place > 1 Year (N = 1,242)
2008 – 2012
Clinical Success Rate* 98%
Major Complications 1%
00
2,5002,500
VolumeVolume
ExtractionProcedures
LeadsExtracted
2,0002,000
1,5001,500
500500
1,0001,000
*Success rate is defined as removal of all the required leads without causing bleeding from the veins or heart.
Electrophysiologists at Cleveland Clinic perform the greatest number of lead extractions in the world. Many patients have complex conditions that result in referral to Cleveland Clinic physicians. Leads may need removal because of electrical malfunctions, blocked blood vessels or infection. In most cases, the leads can be removed without opening the chest or heart. Major complications are defined as those causing death or intrathoracic bleeding.
25Sydell and Arnold Miller Family Heart & Vascular Institute
Outcomes
Device Implants (N = 1,456)
Volume2012
ICDs 800
Pacemakers 656
In 2012, Cleveland Clinic physicians in the electrophysiology laboratory implanted 1,456 devices.
Sydell and Arnold Miller Family Heart & Vascular Institute
Initial Pacemaker or ICD Implantation Complications*2012
Pacemaker (N = 410) ICD (N = 389) Overall (N = 799)
N (%) N (%) N (%)
Infection < 30 Days 1 (0.24) 1 (0.26) 2 (0.25)
Infection < 90 Days 1 (0.24) 1 (0.26) 2 (0.25)
Dislodgement or Need for Lead Revision 2 (0.49) 8 (2.06) 10 (1.25)
Pericardial Effusion With Intervention 3 (0.73) 1 (0.26) 4 (0.50)
Death Within 30 days 1 (0.24) 0 1 (0.13)
Total 8 (1.94) 11 (2.84) 19 (2.38)
*Initial implant refers to patients with no prior device implants, including devices for bradycardia and tachycardia. Exclusions include devices such as laptop and loop recorders, as well as replacement and device upgrades to ICD or CRT devices.
15,000
12,000
9,000
6,000
3,000
02009 2010 2011 20122007 2008
Volume Remote Pacemaker Transmissions 5,091
Remote ICD Transmissions 8,485
Remote Device Evaluations Volume (N = 13,576)2007 - 2012
1,000
800
600
400
200
0AutonomicReflex/HRV
BloodVolume
Tilt Table Hemodynamic
Volume
Device Clinic Evaluations Volume (N = 34,520)2012
Pacemaker Evaluations 17,231
ICD Evaluations 17,289
Cleveland Clinic was the first hospital in the country to integrate a patient database for pacemaker and implantable cardioverter defibrillator follow-up with electronic medical records. This innovative approach to follow-up allows staff to keep track of patients’ health conditions regardless of their location. Remote monitoring is also associated with increased longevity and decreased need for in-person follow-up.
The institute uses the MyChart® function in Epic, Cleveland Clinic’s electronic medical record system, to quickly notify patients of their device status.
Outcomes 201226
Cardiac Rhythm Disorders (continued)
Evaluation of Patients With Syncope
2012Cleveland Clinic electrophysiologists and neurologists work collaboratively to evaluate patients with unexplained loss of consciousness (syncope). Evaluation includes blood volume studies, tilt table testing, hemodynamic testing, and heart rate variability (HRV) and autonomic reflex testing.
AVR MVR AVR + CABG
MV Repair
600600
400400
200200
00
PercentPercent
Cleveland ClinicSTS Average Volume
27Sydell and Arnold Miller Family Heart & Vascular Institute
3,0003,000
2,0002,000
1,0001,000
002008 2009 2010
VolumeVolume
2011 2012
Cleveland Clinic surgeons performed 2,773 valve surgeries in 2012. The majority were primary operations (N = 1,936).
Cleveland Clinic performs more valve surgeries than any other hospital in the United States.
Valve Surgery
Volume (N = 2,773)
2008 – 2012
Comparative Valve Volume
2012
Source: Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database, 2012.
Valve Disease
27
Abbreviations: AVR, aortic valve replacement; CABG, coronary artery bypass grafting; MV, mitral valve; MVR, mitral valve replacement.
Cleveland Clinic recently received The Society of Thoracic Surgeons’ (STS)prestigious three-star rating for aortic valve replacement. The rating is awarded to hospitals across the country that demonstrate the highest quality of cardiac surgery. Cleveland Clinic was awarded the rating based on data comparisons from July 2011 through June 2012.
Outcomes 201228
Distribution of Isolated and Combined Valve Operations (N = 2,773)
Seventy percent of the valve surgeries performed at Cleveland Clinic in 2012 were combined primary procedures. Reoperations, which are typically more complex, accounted for 30% of the total volume.
17% Combined Valve Reoperations (N = 467)17% Combined Valve Reoperations (N = 467)
13% Isolated Valve Reoperations (N = 370)13% Isolated Valve Reoperations (N = 370)
35% Isolated Primary Valve Surgeries (N = 961)35% Isolated Primary Valve Surgeries (N = 961)
35% Combined Primary Valve Surgeries (N = 975)35% Combined Primary Valve Surgeries (N = 975)100%100%
30%30%
2012
★★★
Valve Disease (continued)
28
IsolatedAVR
SeptalMyectomy
AVR+ CABG
IsolatedMVR
MVR+ CABG
IsolatedMV Repair
88
66
44
22
00
PercentPercent
Cleveland ClinicSTS Expected
0% 0%
Valve Surgery Mortality
2012
The 2012 mortality rates for all types of valve surgery were lower than expected at Cleveland Clinic.
Source: University HealthSystem Consortium (UHC) Comparative Database, January through November 2012 discharges.
Abbreviations: AVR, aortic valve replacement; CABG, coronary artery bypass grafting; MV, mitral valve; MVR, mitral valve replacement.
29Sydell and Arnold Miller Family Heart & Vascular Institute
Distribution of Isolated and Combined Valve Operations (N = 2,773)
Aortic Valve Surgery
Volume (N = 1,745)
2008 – 2012
Cleveland Clinic continues to be the leader in aortic valve (AV) procedures. A total of 1,745 operations were done in 2012. The majority (88%) were valve replacements. Valve repairs and valve-sparing surgery each accounted for 6% of the total volume.
2012
2,0002,000
1,0001,000
1,5001,500
500500
00
AV-SparingAV RepairAV Replacement
AV-SparingAV RepairAV Replacement
2009
Volume
2008 2010 2011
Despite the complexity of aortic valve replacement in combination with other procedures, the mortality rates for both primary procedures and reoperations were low.
Source: Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database, 2012.
Combined Aortic Valve Replacement Mortality
2012
00
66
Primary Reoperation
22
44
PercentPercent
29
Outcomes 201230
Mitral Valve Surgery
Volume (N = 1,219)
2012
The majority (68%) of mitral valve procedures done at Cleveland Clinic in 2012 were repairs (N = 828). Thirty-two percent were replacements (N = 391).
1,0001,000
800800
600600
00
Volume
Replace Repair
400400
200200
Valve Disease (continued)
The complication rates for patients who had an isolated aortic valve replacement procedure at Cleveland Clinic in 2012 were lower than expected.
Isolated Aortic Valve Replacement Complications
2012
00
1010
Deep SternalWound Infection
0%
PostopStroke
PostopRenal Failure
PostopReoperation
(Any)
22
66
88
44
PercentPercent
Cleveland ClinicSTS Expected
Source: Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database, 2012.
31Sydell and Arnold Miller Family Heart & Vascular Institute
Mitral Valve Surgery Volume – Repair vs. Replacement
2008 – 2012
Mitral valve repair is the preferred treatment for patients with mitral valve disease. Valve repair, rather than replacement, is associated with better survival, improved lifestyle, better preservation of heart function, and lower risk of stroke and infection (endocarditis). Patients do not need anticoagulation therapy following the procedure. The majority of mitral valve repairs at Cleveland Clinic are performed using a minimally invasive technique.
0
60
40
20
80Percent
20112008 2009
Replacement
Repair
2010 2012
Isolated Mitral Valve Surgery Hospital Mortality
2012
The 2012 mortality rates for patients who had isolated mitral valve surgery at Cleveland Clinic (replacement, 1%; repair, 0%) were below the expected rates (repair, 1%; replacement, 4.3%).
00
66
Replace
Cleveland ClinicSTS Expected
Repair
0%
22
44
PercentPercent
Source: Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database, 2012.
Outcomes 201232
180180
150150
120120
9090
6060
3030
002008 2009 2010
Volume2424
2020
1616
1212
88
44
00
ReoperationMortality (%)
Primary
2011 2012
Bacterial (infective) endocarditis is a life-threatening infection of the heart valves or the heart’s inner lining (endocardium). The condition causes growths on or holes in the valves or scarring of the valve tissue, most often resulting in a leaky heart valve. Cleveland Clinic surgeons treat patients with infective endocarditis, including those with advanced disease and prosthetic valve endocarditis.
In 2012, Cleveland Clinic surgeons performed 97 surgical procedures to treat patients with infective endocarditis.
Surgical Treatment of Infective Endocarditis
Volume and Hospital Mortality2008 – 2012
Valve Disease (continued)
32
Valve Replacement Prostheses Volume and Type2008 – 2012
Bioprostheses (biologic tissue valves) were used in the majority of valve replacement procedures performed at Cleveland Clinic in 2012. Bioprostheses are preferred in most cases because they are durable, and most patients do not require lifelong anticoagulant therapy after surgery.
0
1,500
1,000
500
2,000Volume
2008 2009 2010 2011
Mechanical
Bioprostheses
2012Allografts
Percutaneous Mitral Valvuloplasty Volume and Hospital Mortality
A total of 13 patients had percutaneous mitral valvuloplasty at Cleveland Clinic in 2012. This procedure is associated with a consistent 0% mortality rate and shorter recovery compared with traditional surgery.
2008 2009 2010
3030
2020
1010
00
3030
2020
1010
00
Volume Mortality (%)
2011 2012
33Sydell and Arnold Miller Family Heart & Vascular Institute
2008 – 2012
Robotically Assisted Mitral Valve Repair Volume
Cleveland Clinic surgeons performed 116 robotically assisted mitral valve repair surgeries in 2012 — more than any other U. S. academic hospital.
00
300300
2008 2009 2010
100100
200200
VolumeVolume
20122011
0% Hospital MortalityThe hospital mortality rate for robotically assisted valve surgeries was 0% in 2012.
The expected rate was 2.5%.
Source: University HealthSystem Consortium 2012 discharges.
33
2008 – 2012
Outcomes 201234
PARTNER II Trial Cleveland Clinic is currently recruiting patients for the second arm of the Placement of Aortic Transcatheter Valves (PARTNER II) trial. This phase involves a randomized study of patients who have a moderately high risk associated with traditional surgery to treat severe aortic stenosis. Researchers are studying the use of percutaneous aortic valve replacement in this patient population. The procedure is done through the transfemoral or left subclavian artery or via a transapical approach. Research also includes an approach through the ascending aorta via a mini-J incision.
Percutaneous Valve Treatments
Cleveland Clinic is a national leader in the use of percutaneous treatment options for patients with valve disease.
*Sources: 1. Kodali SK, O’Neill WW, Moses JW, et al. Early and late (one year) outcomes following transcatheter aortic valve implantation in patients with severe aortic
stenosis (from the United States REVIVAL trial). Am J Cardiol. 2011 Apr 1;107(7):1058-1064. 2. Svensson LG, Dewey T, Kapadia S, et al. United States feasibility study of
transcatheter insertion of a stented aortic valve by the left ventricular apex. Ann Thorac Surg. 2008 Jul;86(1):46-54. 3. Leon MB, Smith CR, Mack M, et al. Transcatheter
Aortic-Valve Implantation for Aortic Stenosis in Patients Who Cannot Undergo Surgery. N Engl J Med. 2010;363:1597-1607. 4. Smith CR, Leon MB, Mack MJ, et al.
Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med. 2011 Jun 9;364(23) 2187-2198.
Transcatheter Aortic Valve Replacement Volume and Hospital Mortality
2008 – 2012
In 2012, Cleveland Clinic performed 154 percutaneous aortic valve replacements. The procedure, also referred to as transcatheter aortic valve replacement (TAVR), is FDA-approved to treat patients who meet specific criteria. Cleveland Clinic continues to participate in the Placement of Aortic Transcatheter Valves (PARTNER) trial to assess use of this procedure to treat other patient populations.
00
200200Volume
2008 2009 2010
150150
100100
5050
00
1616
1212
88
44
2012
Cleveland Clinic
2011
Expected*
Mortality (%)
Valve Disease (continued)
35Sydell and Arnold Miller Family Heart & Vascular Institute
00
100100Volume
Transfemoral
0%
Transapical
8080
4040
2020
6060
00
5050
3030
4040
1010
2020
Mortality (%)
TAVR Volume and Hospital Mortality, by Approach (N = 154)
2012
Transfemoral Aortic Valve Replacement Volume and 30-Day Mortality
2008 - 2012
00
100100Volume
2008 2009 2010 2011
8080
6060
2020
4040
00
1010
88
66
22
44
Mortality (%)
2012
The transfemoral approach was used most often for Cleveland Clinic patients who had TAVR in 2012.
Cleveland Clinic was one of the first hospitals to perform the TAVR procedure. The femoral approach has been consistently associated with low mortality. TAVR is used to treat some of the most critically ill patients with aortic valve disease.
Transfemoral (TF)
TF
TA
Transapical (TA)
4th+FirstSurgery
1st 2nd
Reoperations
88
66
44
22
00
PercentPercent
3rd
0% 0%
Cleveland ClinicSTS Expected
Outcomes 201236
Valve Disease (continued)
Valve Surgery Volume and Incidence of Reoperation2010 – 2012
2012
4th+FirstSurgery
1st 2nd
Reoperations
5,0005,000
4,0004,000
3,0003,000
2,0002,000
1,0001,000
00
VolumeVolume
3rd
Valve Surgery Mortality by Reoperation
36
Source: Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database, 2012.
The majority of valve procedures at Cleveland Clinic are first-time operations. However, the surgeons have extensive experience in treating patients who need a reoperation.
Patients who require another valve surgery are at somewhat increased risk, as their overall health status will have worsened over time. Highly experienced surgical and postoperative care teams at Cleveland Clinic use systematic, evidence-based protocols to provide optimal patient care and reduce the risk of mortality.
The majority of the 1,163 aortic surgeries performed at Cleveland Clinic in 2012 were open repairs of the ascending aorta/arch.
1,5001,500
1,0001,000
500500
00
Volume 2012 Totals
20052003 2007 2009 20102004 2006 2008
Open Ascending/Arch Repair (N = 728) Open Ascending/Arch Repair (N = 728)
Open Descending/ThoracoabdominalRepair (N = 57)
Open Descending/ThoracoabdominalRepair (N = 57)
Endovascular Descending/ThoracoabdominalRepair (N = 224)
Endovascular Descending/ThoracoabdominalRepair (N = 224)
Open AbdominalRepair (N = 53)Open AbdominalRepair (N = 53)
Endovascular AbdominalRepair (N = 101)Endovascular AbdominalRepair (N = 101)2011 2012
37Sydell and Arnold Miller Family Heart & Vascular Institute
Aortic Disease
Cleveland Clinic uses a comprehensive, multidisciplinary approach to treat patients with
aortic disease. Using conventional, minimally invasive, and endovascular techniques,
surgeons treat all sections of the aorta, from the aortic valve to the blood supply to the
pelvic vasculature.
Aortic Surgery Volume and Type
2003 – 2012
Cleveland Clinic’s Acute Aortic Treatment Center provides rapid transport, treatment, and follow-up for patients with aortic dissection and impending aneurysm rupture. More than 4,200 patients were transported by Cleveland Clinic’s Critical Care Transport team in 2012. More than one-third of the patients transported were treated in the Heart & Vascular Institute, and many had acute aortic syndromes.
Call 877.379.CODE (2633) to expedite the transfer of patients with acute aortic syndromes.
Sydell and Arnold Miller Family Heart & Vascular Institute
ArchAscending
aorta
Descending thoracic aorta
Abdominal aorta
Thoracoabdominal aorta
37
Outcomes 201238
Open Ascending Aorta and Arch Disease Surgery Volume2008 – 2012
In 2012, Cleveland Clinic surgeons performed 728 open repairs of the ascending aorta and arch.
Pacesetters
5.1% Cleveland Clinic
21.6% National average mortality for acute ascending dissection
The operative mortality rate for patients who undergo surgery for an acute ascending aortic dissection at Cleveland Clinic is more than three times lower (5.1%) than at other high-volume hospitals. According to a nationwide study involving more than 5,000 patients, operative mortality decreased steadily over a 10-year period, and the rate was lower among higher-volume hospitals. The mortality rate for low-volume hospitals was 27.4% and 16% for high-volume centers. The overall average was 21.6%.
Chikwe J, Cavallaro P, Itagaki S, Seigerman M, Diluozzo G, Adams DH. National outcomes in acute aortic dissection: influence of surgeon and institutional volume on operative mortality. Ann Thorac Surg. 2013 May;95(5):1563-1569.
Elective Ascending Aorta and Arch Surgery Volume, Stroke, and Mortality2008 – 2012
Emergency Ascending Aorta and Arch Surgery Volume and Mortality2008 – 2012
Emergency treatment of the ascending aorta and arch accounted for 197 aortic procedures in 2012. These procedures are particularly challenging, yet Cleveland Clinic surgeons maintained a 5.1 percent mortality rate.
In 2012, Cleveland Clinic surgeons performed 531 elective ascending aorta and arch surgeries. The rate of stroke was 0.6%, and the mortality rate was 0.4%.
20122011
800800
400400
200200
002008 2009
600600
Volume
2010
201200
250250300300350350
150150200200
1001005050
00
3535
2020
3030
1515
2525
1010
Volume Volume Hospital Mortality (%)
2008 2009 2010
5
2011
201200
600600
400400
200200
00
1212
88
44
Volume Volume Stroke (%)Hospital Mortality (%)
2008 2009 2010 2011
Aortic Disease (continued)
38
39Sydell and Arnold Miller Family Heart & Vascular Institute
Aortic Arch Aneurysm Repairs (N = 193)
Aortic arch aneurysms are one of the most complicated conditions to treat. Despite the complexity, Cleveland Clinic surgeons consistently maintain low rates of stroke and mortality for both elective and emergency procedures.
Elective Arch Aneurysm Operations Volume, Stroke, and Mortality (N = 144)2008 – 2012
Emergency and Urgent Arch Aneurysm Operations Volume, Stroke, and Mortality (N = 49)
2008 – 2012
201200
200200
100100
5050
150150
VolumeVolumeStroke (%)Hospital Mortality (%)
20102008 200900
2020
1515
1010
5
2011
201200
2525
1515
2020
1010
VolumeVolumeStroke (%)Hospital Mortality (%)
5
20102008 200900
150150
9090
6060
3030
120120
2011
3-D reconstruction of an aortic arch aneurysm complicating a chronic aortic dissection.
3-D reconstruction of an aortic arch branch graft. There are branches for the innominate and left common carotid arteries. This technique allows treatment of very complex anatomy without opening the chest.
39
1. Svensson LG, Kim KH, Blackstone EH, Alster JM, McCarthy PM, Greenberg RK, Sabik JF, D’Agostino RS, Lytle BW, Cosgrove DM. Elephant trunk procedure: newer indications and uses. Ann Thorac Surg. 2004 Jul;78(1):109-116; discussion 109-116.
2. Lima B, Roselli EE, Soltesz EG, Johnston DR, Pujara AC, Idrees J, Svensson LG. Modified and “reverse” frozen elephant trunk repairs for extensive disease and complications after stent grafting. Ann Thorac Surg. 2012 Jan;93(1):103-109.
3. Roselli EE, Sepulveda E, Pujara AC, Idrees J, Nowicki E. Distal landing zone open fenestration facilitates endovascular elephant trunk completion and false lumen thrombosis. Ann Thorac Surg. 2011 Dec;92(6):2078-2084.
4. Roselli EE, Rafael A, Soltesz EG, Canale L, Lytle BW. Simplified frozen elephant trunk repair for acute DeBakey type I dissection. J Thorac Cardiovasc Surg. 2013 Mar;145(3 Suppl):S197-S201.
5. Idrees J, Keshavamurthy S, Subramanian S, Clair DG, Svensson LG, Roselli EE. Hybrid repair of Kommerell diverticulum. J Thorac Cardiovasc Surg. 2013 Mar 24.
Outcomes 201240
Aortic Disease (continued)
Elephant Trunks: Modified, Frozen and Reverse, and Simplified
Cleveland Clinic surgeons are internationally recognized as some of the best-trained surgeons to treat patients with extensive thoracic aneurysmal disease. They use a comprehensive, multidisciplinary approach that allows each patient to receive the best possible individual treatment.
Patients with arch and multisegment thoracic aortic disease require complex operations to achieve durable repair. Cleveland Clinic cardiovascular surgeons have led the way in developing new ways to apply “elephant trunk” strategies that are tailored to the specifics of each patient’s anatomy, disease process, and morphology.1 Some patients require a single-stage hybrid approach that combines open and endovascular techniques, or the so-called frozen elephant trunk.2 Others require a two-stage stent-graft-first approach, also known as reverse frozen elephant trunk.2 Other variations of these hybrid techniques have been applied to specific pathologies such as Kommerell’s diverticulum and acute or chronic aortic dissection.3,4,5
Postoperative CT scan in a patient after single-stage frozen elephant trunk repair for an extensive ascending, total arch descending aneurysm.
Hybrid frozen elephant trunk repair for Kommerell’s diverticulum with right-sided aortic arch.5
Simplified frozen elephant trunk for extended repair of acute DeBakey 1 aortic dissection.4
41Sydell and Arnold Miller Family Heart & Vascular Institute
Cleveland Clinic surgeons have extensive experience in treating patients with DTA disease that requires repair, including patients who have the most complex cases. In 2012, the mortality rate for elective repairs remained low. The rate for emergency repairs was reduced to less than 10% overall.
Cleveland Clinic is leading the first in-human device trial of a novel stent graft. The device has a built-in branch to accommodate the left subclavian artery at the time of descending aortic stent grafting. It is currently estimated that the left subclavian artery is covered in more than 40% of thoracic stent graft cases. The trial is part of a new program within the U.S. FDA Innovation Pathway to bring first-in-the-world technology to patients in the United States.
Novel device used in first-in-world trial
Descending Thoracic Aortic Disease
The majority of the 780 DTA repairs performed at Cleveland Clinic from 2008 through 2012 were done using an endovascular approach.
DTA Repair Volume and Type (N = 780)
DTA Repair Hospital Mortality
2008 – 2012
2008 – 2012
21% Open Elective (N = 167)21% Open Elective (N = 167)
9% Open Emergency (N = 67)9% Open Emergency (N = 67)
47% Endovascular Elective (N = 368)47% Endovascular Elective (N = 368)
23% Endovascular Emergency (N = 178)23% Endovascular Emergency (N = 178)100%100%
1515
1010
55
00Emergency
0%
Open
2008–20112012
Elective
Mortality (%)
Emergency
Endovascular
Elective
Aortic dissections and ruptured aneurysms commonly occur in the descending thoracic aorta (DTA). Patients with these conditions need prompt evaluation and treatment. Cleveland Clinic surgeons use open and endovascular repair techniques.
41
Durability of Branched Endografts
Cleveland Clinic surgeons are the most experienced in the world in the use of fenestrated endografts. Because the technology is so new, the durability of these repairs is still being evaluated. Over the course of nine years, fenestrated endografts have been used to treat 650 patients at Cleveland Clinic. Analysis of these patients shows that the 30-day, one-year, and five-year rates of freedom from intervention were 98%, 94%, and 84%, respectively. The rates of reintervention were 0.6% for celiac stents, 4% for superior mesenteric artery stents, 6% for right renal artery stents and 5% for left renal artery stents. These data support continued use of endovascular techniques for treatment of patients with thoracoabdominal aneurysms1.
1 Mastracci TM, Greenberg RK, Eagleton MJ, Hernandez AV. Durability of branches in branched and fenestrated endografts. J Vasc Surg. 2013 Apr;57(4):926-933; discussion 933.
Outcomes 201242
Aortic Disease (continued)
Improving Spinal Cord Function after Thoracoabdominal Aortic Aneurysm Repair
Spinal cord injury after thoracoabdominal aortic aneurysm (TAAA) repair can be a challenging complication that impedes recovery and has a major impact on the quality of a patient’s life. Cleveland Clinic surgeons have adopted a staged approach to treatment. This means that not all stents are placed at once. Instead, the patient has them placed over the course of several procedures, and the aneurysm is gradually repaired. This has been shown to decrease the severity of spinal ischemia after surgery. The staged approach also helps preserve the collateral beds, leading to a 50% reduction in spinal cord ischemia among patients who had all collateral vessels preserved1.
1 Eagleton MJ, Hypogastric and Subclavian Artery Patency Affects Onset and Recovery of Spinal Cord Ischemia Associated with Aortic Endografting, Shah SK, Petkovsek D, Mastracci TM, Greenberg RK. Submitted for publication, J Vasc Surg 2013.
43Sydell and Arnold Miller Family Heart & Vascular Institute
Thoracoabdominal aneurysm stent graft
TAAA Surgeries by Type
TAAA Surgeries The most challenging aortic procedures involve patients with TAAA. Cleveland Clinic surgeons have extensive experience using both open and endovascular techniques to treat these patients.
Type I Aneurysms involve most or all of the descending thoracic aorta to the level of the renal arteries.
Type IV Aneurysms involve the upper half or all of the abdominal aorta.
Type III Aneurysms involve the lower portion of the descending thoracic aorta, extending to the abdominal aorta below the level of the renal arteries.
Type II Aneurysms involve most or all of the descending thoracic aorta, with abdominal extension to below the renal arteries.
Crawford Classification of Aortic Aneurysms
2008 – 2012
5050
4040
3030
2020
00Type I Type II
EndovascularOpen
Type III Type IV
1010
Percent
In 2012, the majority of TAAA surgeries involved patients with Type IV aneurysms.
43
New off-the-shelf options for emergency TAAA procedures
Pararenal Branch Devices have small pivot branches that accommodate many different renal artery positions. These are new off-the-shelf endovascular options that can be used to treat patients with justarenal aneurysms. They also provide an advanced treatment option for ruptured or symptomatic justarenal aneurysm procedures. Mortality rates are high with traditional treatment options; however, this innovative technique has the potential to improve survival rates1.
1 Wong S, Greenberg RK, Brown CR, Mastracci TM, Bena J, Eagleton MJ. Endovascular repair of aortoiliac aneurysmal disease with the helical iliac bifurcation device and the bifurcated-bifurcated iliac bifurcation device. J Vasc Surg. 2013 Jun 20.
Outcomes 201244
Aortic Disease (continued)
TAAA Surgery Volume and Type
TAAA Surgery Mortality
The complex nature of TAAA procedures is associated with a greater risk of mortality. Cleveland Clinic continuously strives to maintain the lowest mortality rates possible. In 2012, the mortality rate for endovascular branch vessel procedures was 3.09%. The rate for open elective repairs was 6.9%. Emergency repairs require open surgery. The mortality rate for these procedures was 15.28%.
From 2008 through 2012, Cleveland Clinic surgeons performed 727 procedures to treat patients with TAAAs.
2008 – 2012
2008 – 2012
34% Open Surgeries (N = 249)34% Open Surgeries (N = 249)
66% Endovascular Branch Vessel Grafts (N = 478)66% Endovascular Branch Vessel Grafts (N = 478)
100%100%
3030
2020
1010
00
Elective Emergency
OpenEndovascular
2008–20112012
Percent
Open
45Sydell and Arnold Miller Family Heart & Vascular Institute
Abdominal Aortic AneurysmsThe abdominal aorta is second to the ascending aorta for aneurysm formation. Cleveland Clinic treats patients with abdominal aortic aneurysms (AAAs) both below and adjacent to the renal arteries. Surgeons use both open and endovascular repair procedures.
AAA Procedure Volume and Type
The majority of the 945 AAA repair procedures performed at Cleveland Clinic from 2008 to 2012 were endovascular.
Open AAA Repair Volume and Type (N = 381)
Cleveland Clinic surgeons performed 381 open AAA repairs from 2008 through 2012. Although open repairs are associated with greater risk, the institute maintains high volumes and excellent outcomes.
2008 – 2012
2008 – 2012
40% Open (N = 381)40% Open (N = 381)
60% Endovascular (N = 564)60% Endovascular (N = 564)
100%100%
16% Emergency (N = 62)16% Emergency (N = 62)
84% Elective (N = 319)84% Elective (N = 319)100%100%
Rescuing Failed Endografts
Endovascular abdominal aortic aneurysm repairs (EVAR) fail in approximately 1% of patients treated. Failure can be due to progression of aneurysmal degeneration of the aortic wall in the sealing segment or due to device component failure. Cleveland Clinic has the world’s largest experience with conversion of EVAR to open repair. It has performed more than 100 of these procedures. Even when done electively, this procedure has been associated in most cases with a mortality rate as high as 20%. Cleveland Clinic has published a 3.3% mortality rate for elective EVAR conversions, which is less than the 4% mortality rate for elective, original open AAA repair found in the Medicare population.
—Lyden S, Turney E, The First Hundred Late EVAR Explants, Presented at Society of Vascular Surgery Annual Meeting 2013
45
Outcomes 201246
Aortic Disease (continued)
Endovascular AAA Repair Volume and Type
Cleveland Clinic surgeons performed 564 endovascular AAA repair procedures from 2008 to 2012. A total of 56 fenestrated grafts were used to repair juxtarenal aneurysms.
The mortality rate for elective endovascular AAA repair was 1.28% in 2012. The rate for emergency repairs was 14.29%.
Endovascular AAA Repair Mortality
Open AAA Repair Mortality2008 – 2012
2008 – 2012
2008 – 2012
4040
3030
2020
1010
00Elective
(N = 319)
2008–20112012
Emergency(N = 62)
0%
Percent
0%
10% Emergency (N = 57)10% Emergency (N = 57)
90% Elective (N = 507)90% Elective (N = 507)100%100%
2020
1616
1212
88
00Elective
(N = 507)Emergency(N = 57)
0%44
Percent
2008–20112012
In 2012, Cleveland Clinic surgeons achieved a 0% mortality rate for elective open AAA repairs. The mortality rate for emergency open AAA repairs was 14.29%.
0% mortality rate for patients with juxtarenal aneurysms treated with fenestrated graft procedures (N = 56) from 2008 to 2012.
Hypertrophic obstructive cardiomyopathy (HOCM) is thickening of the lower chambers of the heart. The septal muscle, which divides the right and left chambers, is especially affected. The condition can impede blood flow from the heart to the aorta. Cleveland Clinic physicians use a comprehensive approach to diagnose and treat patients with HOCM. This approach includes a physical exam, EKGs, chest X-ray, and MRI. Cleveland Clinic has a special interest in HOCM and is actively screening patients and their family members for genetic abnormalities associated with the disease.
Patient Volume
2012
250
200
150
0
100
50
25
20
15
0
10
5
2008N = 168
2012N = 178
2009N = 188
2010N = 2003
2011N = 183
Volume Mortality (%)
HOCM Surgeries
2008 – 2012
Total HOCM Outpatient Visits 1,630
New Patients With HOCM 389
47Sydell and Arnold Miller Family Heart & Vascular Institute
2,443 septal
myectomies
have been
performed at
Cleveland Clinic
since 1967.
Hypertrophic Obstructive Cardiomyopathy
Cleveland Clinic surgeons are national leaders in treating patients with HOCM. A total of 178 surgical procedures were performed to treat patients with this condition in 2012. The mortality rate was 0.6%.
Surgical Procedure Distribution (N = 178)
2012 Septal myectomy is used to treat patients with HOCM. Patients who require this procedure often require additional procedures.
9% Septal Myectomy + Valve + Other (N = 16)7% Septal Myectomy + Other (N = 12)5% Septal Myectomy + Coronary Artery Bypass (N = 10)2% Septal Myectomy + Coronary Artery Bypass + Valve (N = 3)2% Septal Myectomy + Coronary Artery Bypass + Other (N = 3)1% Septal Myectomy + Coronary Artery Bypass + Valve + Other (N = 2)
33% Septal Myectomy + Valve (N = 59)
100%100%
41% Isolated Septal Myectomy (N = 73)
Septal Myectomy Mortality
2012
Outcomes 201248
6
4
0
Percent
ExpectedObserved
2
Source: University HealthSystem Consortium (UHC) Comparative Database, 2012 discharges.
Cleveland Clinic has excellent outcomes for patients who have a septal myectomy. In 2012, the expected mortality rate was 3%; however, Cleveland Clinic surgeons achieved a 0.6% mortality rate.
Hypertrophic Obstructive Cardiomyopathy (continued)
49Sydell and Arnold Miller Family Heart & Vascular Institute
Adult Congenital Cases 214
Complex Congenital Cases 138
Complex Congenital Interventions 28
Success Rate 100%
30-Day Mortality 0%
Percutaneous Interventional Procedures for Adult Congenital Heart Disease
Volume and Outcomes (N = 214)2012
*Based on one complication, including stroke, myocardial infarction, or need for surgery. Abbreviations: ASD, atrial septal defect; PFO, patent foramen ovale.
Percutaneous Closure Procedures
Volume and Outcomes (N = 66)2012
Congenital Heart Disease
Congenital heart disease affects an estimated 1 million people in America. Each year, approximately 1 in every 120 babies born in the United States has a congenital heart defect. In some cases, the disease is life-threatening at birth. However, many people with a congenital heart condition do not know about it for years. Experts at Cleveland Clinic have extensive experience in the diagnosis and treatment of patients with all forms of congenital heart disease. The Center for Pediatric and Adult Congenital Heart Disease’s services are further enhanced by the Special Delivery Unit. The unit provides in utero diagnosis of complex heart conditions and immediate treatment after birth.
Many of the 214 patients who received interventional treatment for congenital heart disease had complex cases. Despite this increased level of care, Cleveland Clinic physicians achieved a 100% success rate and 0% mortality.
A total of 66 patients had percutaneous closure procedures at Cleveland Clinic in 2012. The success rate was 99%, with 0% mortality.
Percutaneous ASD Closures 28
Percutaneous PFO Closures 38
Successful Repair* 99%
30-Day Mortality 0%
Patients Requiring Repeat Procedure 1%
Adult Congenital Heart Disease Volume (N = 1,450)
2012Cleveland Clinic’s Adult Congenital Heart Disease Center is staffed by cardiologists who specialize in adult care, pediatric care, intervention, and cardiovascular surgery. This collaboration offers patients unique care and treatment options designed to provide the best outcomes possible for their particular needs. The center saw 1,450 patients in 2012, including 487 new referrals.
Total Adult Congenital Heart Disease Patient Visits 1,450
New Referral Visits for Adult Congenital Heart Disease 487
Congenital Heart Disease
Outcomes 201250 Outcomes 201250
Congenital Heart Surgery Mortality (Adult and Pediatric)
2012Cleveland Clinic’s Department of Congenital Heart Surgery treats adults and children using a wide variety of treatments. The mortality rate associated with these procedures was 1.3% in 2012, which was well below the expected rate of 3.6%. 00
66
Cleveland Clinic Expected
22
44
PercentPercent
Pediatric Congenital Heart Surgery Volume and Type (N = 117)
2012
5050
ArterialSwitch ±
VSD Repair
ArterialSwitch ±
VSD Repair
ASDRepairASD
RepairCompleteAV CanalRepair
CompleteAV CanalRepair
FontanFontanECMOECMO NorwoodNorwood OtherOther PDAClosure
PDAClosure
PAPA TOFRepairTOF
RepairRV to PAConduitRV to PAConduit
TransplantTransplant AorticValve
Surgery
AorticValve
Surgery
VSDRepairVSD
Repair
VolumeVolume
4040
3030
2020
1010
00
In 2012, Cleveland Clinic surgeons performed 117 pediatric congenital heart surgeries of varying complexity. The procedures within the majority “other” category included coarctation repair, truncus arteriosus repair, etc.
These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu.
Abbreviations: ASD, atrial septal defect; AV, atrioventricular; ECMO, extracorporeal membrane oxygenation; PA, pulmonary artery; PDA, patent ductus arteriosus; RV, right ventricle; TOF, tetralogy of Fallot; VSD, ventricular septal defect.
Congenital Heart Disease (continued)
51Sydell and Arnold Miller Family Heart & Vascular Institute
Treatment of Patient With Persistent Left Superior Vena Cava
During normal heart development, the heart starts with two superior vena cavae. The left superior vena cava usually regresses but can persist in some cases. This normally has no consequences other than rerouting the venous blood flow from the left arm into the coronary sinus (a venous structure), which becomes larger than normal. In rare cases, the persistent left superior vena cava can abnormally connect to the left atrium. In such cases, blood low in oxygen can drain into the left atrium (where blood high in oxygen coming back from the lungs normally drains).
A patient with prior operative repairs of atrial and ventricular septal defects presented to the Adult Congenital Heart Disease Clinic with progressive fatigue and diminished oxygen saturation at rest that worsened with exercise. CT scan imaging suggested the presence of an abnormal communication between the persistent left superior vena cava and the left atrium. Treatment involved catheterization and placement of sheaths (IV lines) in the left neck and right groin. The right superior vena cava was injected by a catheter placed via the right groin (SVC = superior vena cava; RA = right atrium).
Adult Congenital Heart Surgery Volume and Type (N = 284)
2012
6060
AAOCARepairAAOCARepair
AortaSurgeryAortaSurgery
ASDRepairASDRepair
CABGCABGAorticValveSurgery
AorticValveSurgery
Coarc-tationRepair
Coarc-tationRepair
CoronaryArterySurgery
CoronaryArterySurgery
HeartTrans-plant
HeartTrans-plant
MitralValveSurgery
MitralValveSurgery
OtherCongen-
italCardiac
OtherCongen-
italCardiac
SeptalMyec-tomy
SeptalMyec-tomy
PVCRepairPVCRepair
PulmonicValveSurgery
PulmonicValveSurgery
TricuspidValveSurgery
TricuspidValveSurgery
VADVAD
VolumeVolume
5050
4040
3030
2020
1010
00
Abbreviations: AAOCA, anomalous aortic origin of a coronary artery; ASD, atrial septal defect; CABG, coronary artery bypass grafting; PVC, premature ventricular contraction; VAD, ventricular assist device.
Outcomes 201252
Treatment of Patient With Persistent Left Superior Vena Cava
The persistent left superior vena cava (LSVC) was injected through a catheter placed via the left neck (upper right of picture). This showed a communication to the left atrium, through which a catheter was placed (arrow).
This diagram shows superimposed anatomic borders, which cannot be seen without separate contrast injections (LA = left atrium; RA = right atrium; SVC = superior vena cava). The arrow points to the abnormal communication from the LSVC to the LA.
The final injection of the LSVC shows the Amplatzer Vascular Plug II in good position (arrow). There is no longer any blood flow beyond it. The patient’s oxygen saturation increased after the procedure, and the fatigue significantly improved.
An 8 mm Amplatzer™ Vascular Plug II was placed into the abnormal communication. The device needs to be carefully sized and placed to adequately occlude the defect and prevent dislodgement (arrow). It is critically important to perform angiograms before delivering the device. Flow is expected to be seen initially beyond the device.
Congenital Heart Disease (continued)
53Sydell and Arnold Miller Family Heart & Vascular Institute
Pericardial Disease
30% of patients seen at
Cleveland Clinic for
pericardial disease
were from outside
the state of Ohio.
Patients
traveled from
34 states for treatment.
Pericardial disease includes a group of conditions that affect the pericardium, the double-layered sac that surrounds the heart. Cleveland Clinic’s Center for the Diagnosis and Treatment of Pericardial Disease is dedicated to the diagnosis and treatment of patients with acute, recurrent, and constrictive pericarditis. Its multispecialty approach includes cardiologists, surgeons, and imaging specialists, which enhances collaboration in the management of these diseases. In 2012, there were 1,232 visits to the Pericardial Disease Center.
Recurrent pericarditis and pericardial effusion with pericarditis were the most common reasons patients were seen at Cleveland Clinic’s Center for the Diagnosis and Treatment of Pericardial Disease in 2012. A total of 74% of patients with pericardial syndromes had conditions associated with pericardial effusion.
Pericardial Disease Syndromes in Outpatient Clinic Volume, New and Consult (N = 507)
2012
Pericardial Disease: Patient Volume
2008 – 2012
Acute Pericarditis
Recurrent Pericarditis
Constrictive Pericarditis
Without Pericarditis
With Pericarditis
Pericardial Disease Syndromes
300300
VolumeVolume
200200
100100
00
233
144163
269
75
Pericardial Effusion
900900
1,2001,200 New ConsultEstablishedNew ConsultEstablished
00
Volume
2008 2009 2010 2011 2012
300300
600600
507
725
53
Thickened pericardium
Outcomes 201254
The most commonly performed pericardial procedures in 2012 were window surgery and pericardiocentesis. During window surgery, an opening is made in the pericardium through a small chest incision. The fluid is drained and a diagnosis can be made. Pericardiectomy is the removal of a portion of or the entire pericardium.
Pericardial Procedures (N = 158)
2012
41% Window (N = 64)41% Window (N = 64)
40% Pericardiocentesis (N = 64)40% Pericardiocentesis (N = 64)
19% Pericardiectomy (N = 30)19% Pericardiectomy (N = 30)
100%100%
Pericardial Disease Etiology (N = 507)
2012The majority of patients with pericardial disease who were seen at Cleveland Clinic in 2012 had disease that was idiopathic in nature.
8% Viral (N = 41)8% Viral (N = 41)4% Autoimmune (N = 20)4% Autoimmune (N = 20)3% Other (N = 15)3% Other (N = 15)
64% Idiopathic (N = 324)64% Idiopathic (N = 324)
21% Postoperative Cardiac Surgery (N = 107)21% Postoperative Cardiac Surgery (N = 107)
100%100%
Pericardiocentesis is used to drain large pericardial effusions. This percutaneous procedure is used for patients whose condition develops postoperatively or from a viral or idiopathic cause. The procedure is guided by echocardiography, which helps improve outcomes.
A. Cardiac MRI showing acute pericarditis and pericardial late gadolinium enhancement, (see arrow) which indicates activity of the disease.
B. Cardiac MRI post-treatment showing resolution of inflammation with no late gadolinium enhancement.
A B
Pericardial Disease (continued)
1,617 Heart transplants have
been performed at
Cleveland Clinic since
the Cardiac Transplant
Program began in 1984.
100
Survival (%)
90
80
70
501 year N = 1161/1/09 to 6/30/11
3 years N = 1357/1/06 to 12/31/08
Expected*Observed
60
Time Since Transplant
Heart Transplant Patient Survival
There are 146 transplant centers in the United States. In 2012, Cleveland Clinic was one of two that had better-than-expected one-year survival rates for patients who had a heart transplant. Three-year survival rates are also better than expected.
Cleveland Clinic has one of the largest cardiac transplant programs in the country and is the leading center in Ohio.
Heart Transplant Volume
July 2008 – June 2012
*Expected based on risk adjustment. Source: Scientific Registry of Transplant Recipients. Center and OPO-Specific Reports, March 2012. Ohio, Heart Centers, Cleveland Clinic. Table 11. srtr.org
2010 2011 20122008 2009
Volume
0
80
60
40
20
In 2012, Cleveland Clinic performed 47 heart transplant procedures.
55Sydell and Arnold Miller Family Heart & Vascular Institute 55
Heart Failure and Transplant
20
15
10
0Observed Expected
5
Percent
Mechanical Circulatory Support Device Volume
2008 – 2012
80
40
60
02008 2009 2010
N = 48 76 51201156
20
Volume
Bridge-to-TransplantDestination Therapy
201261
Left Ventricular Assist Device In-Hospital Mortality
2008 – 2012Mortality rates among patients who are placed on a left ventricular assist device have been reduced since 2008. Cleveland Clinic continues to make improvements to further reduce these rates.
50
30
40
02008 2009 2010 2011 2012
20
10
Percent
Cleveland Clinic has 25 years of experience using mechanical circulatory support devices in patients with heart failure. These devices help preserve heart function until transplantation (bridge-to-transplant) or are used as a final treatment option (destination therapy).
Ventricular Assist Device Mortality
2012The mortality rate among Cleveland Clinic patients placed on ventricular assist devices was much lower than expected in 2012.
Source: University HealthSystem Consortium (UHC) Comparative Database, January through November 2012 discharges.
Outcomes 201256
Heart Failure and Transplant (continued)
57Sydell and Arnold Miller Family Heart & Vascular Institute
Heart Failure All-Cause 30-Day Mortality (N = 777)July 2009 – June 2012
Heart Failure Appropriateness of Care2011 – 2012
Heart Failure All-Cause 30-Day Readmissions (N = 1,078)July 2009 – June 2012
The Centers for Medicare and Medicaid Services (CMS) calculates two heart failure outcome measures: all-cause mortality and all-cause readmission rates, each based on Medicare claims and enrollment information. Cleveland Clinic’s performance appears below.
There is no significant difference between Cleveland Clinic’s heart failure patient mortality or readmissions rate and the respective national averages. To further reduce avoidable readmissions, a multidisciplinary team is tasked with improving transitions from hospital to home or post-acute facility. Specific initiatives have been implemented in each of these focus areas: communication, education, and follow-up.
This composite metric, based on three heart failure hospital quality process measures developed by CMS, shows the percentage of patients who received all the recommended care for which they were eligible. Cleveland Clinic has set and exceeded a target of UHC’s 90th percentile.
Heart Failure
*Source: medicare.gov/hospitalcompare
0
15
10
5
20
25Percent
National Average*
11.79.7
Cleveland Clinic0
15
10
5
20
25Percent
National Average*Cleveland Clinic
23.024.5
0
60
80
100
40
20
Percent
*These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu
96.9 94.4
UHC 90th Percentile, 2012*
2011 20121,163 1,433N =
Outcomes 201258
Lung and Heart-Lung Transplant
Lung Transplant Procedures2008 – 2012
Primary Disease of Lung Transplant Recipients (N = 104)
Source: Scientific Registry of Transplant Recipients. March 2012. Ohio, Lung Centers, Cleveland Clinic. Table 7. srtr.org
Cleveland Clinic’s Lung and Heart-Lung Transplant Program is the best in Ohio and among the top programs in the country. In 2012, surgeons transplanted 104 lungs.
January 2011 – December 2011
2012
160160Liver-LungHeart-LungDouble LungSingle Lung
Liver-LungHeart-LungDouble LungSingle Lung
00
Volume
2009 20102008
4040
120120
8080
2011
56.2% Idiopathic Pulmonary Fibrosis (N = 59)56.2% Idiopathic Pulmonary Fibrosis (N = 59)
24.8% Emphysema/Chronic Obstructive Pulmonary Disease (N = 26)24.8% Emphysema/Chronic Obstructive Pulmonary Disease (N = 26)
10.5% Cystic Fibrosis (N = 11)10.5% Cystic Fibrosis (N = 11)5.7% Idiopathic Pulmonary Arterial Hypertension (N = 6)5.7% Idiopathic Pulmonary Arterial Hypertension (N = 6)2.9% Other (N = 3)2.9% Other (N = 3)
100%100%
46% of patients who received lung transplants at Cleveland Clinic in 2012 were from outside the state of Ohio.
59Sydell and Arnold Miller Family Heart & Vascular Institute
Ambulatory ECMOPatients waiting for lung transplantation can become poorer candidates while waiting because of the use of extracorporeal membrane oxygenation (ECMO). This is a method used in very ill patients to add oxygen and to remove carbon dioxide from the blood.
Traditionally, ECMO requires the patient to stay in bed. This causes the muscles to weaken, and patients become less likely to be eligible for transplantation.
Cleveland Clinic is aggressively developing ambulatory ECMO technology to improve transplant candidacy, save lives, and improve outcomes.
Wait List Mortality
Lung Transplant Survival*
Waiting Time for Lung Transplant Patients awaiting lung transplantation have a shorter waiting time at Cleveland Clinic compared with hospitals throughout the region.
The mortality rate among Cleveland Clinic patients waiting for a lung transplantation is lower than expected.
Patients who undergo lung transplantation at Cleveland Clinic live longer than the expected rate after three years.
* Expected survival rate based on risk adjustment. Not statistically significant. Source: Scientific Registry of Transplant Recipients. March 2013, Ohio, Lung Centers, Cleveland Clinic. Table 10. srtr.org.
Source: Scientific Registry of Transplant Recipients. March 2013, Ohio, Lung Centers, Cleveland Clinic. Table 6. srtr.org.
*Expected survival rate based on risk adjustment. Statistically significant. Source: Scientific Registry of Transplant Recipients. March 2012, Ohio, Lung Centers, Cleveland Clinic. Table 3. srtr.org.
The difference between observed and expected mortality is not statistically significant.
January 2006 – June 2011
January 2010 – December 2011
100Survival (%)
80
60
40
01 Month
Time After Transplant
3 Years7/1/06 to 12/31/08
N = 160
1 Year
ExpectedObserved
20
1/1/09 to 6/30/11N = 313
88
44
22
00Cleveland Clinic Region United States
66
Median Months
1.0Mortality (%)
0.8
0.6
01/1/10 to 12/31/10
(N = 96)1/1/11 to 12/31/11
(N = 138)
Expected*Observed
0.4
0.2
In 2012,
99% of venous
duplex ultrasound
studies were read
in 24 hours; 99%
of all other vascular
studies were finalized
within 48 hours.
Lower Extremity Interventional Procedures
Cleveland Clinic’s team of vascular surgeons and interventional cardiologists performs a variety of procedures to treat patients with peripheral artery conditions. They are skilled at angioplasty, atherectomy, stenting, thrombectomy, and thrombolysis.
Outcomes 201260
2012 Volume
Bypass 153
Thrombectomy 48
60
Peripheral Vascular Diseases
Lower Extremity Surgery Volume and Mortality (N = 201)
A total of 153 lower extremity bypass surgeries were performed in 2012. The 30-day mortality rate was 2%. Cleveland Clinic’s vascular surgeons have expertise in this area and find an autologous vein for graft 75% of the time.
Lower Extremity Interventional Procedure Volume2012
Angioplasty 253
Atherectomy 9
Stenting 239
Thrombolysis 99
2012 30-Day Mortality (%)
Bypass 2%
44% Venous Duplex (N = 16,372)44% Venous Duplex (N = 16,372)
38% Arterial Duplex (N = 14,442)38% Arterial Duplex (N = 14,442)
18% Physiologic Testing (N = 6,583)18% Physiologic Testing (N = 6,583)
100%100%
Executive Health Screening Program
2011 - 2012
The Executive Health Screening Program is designed to identify any potential peripheral vascular disorders that can affect a patient’s health and well-being. The exam can identify problems such as carotid artery stenosis, which is a risk factor for stroke; peripheral arterial disease, which can indicate an increased risk of heart attack and stroke and can impair function and quality of life; and abdominal aortic aneurysm (AAA). Ruptured AAAs are almost entirely preventable if an AAA is identified and monitored; however, about 15,000 people die each year in the United States due to ruptured AAAs.
600600
400400
200200
002011 2012
Volume
61Sydell and Arnold Miller Family Heart & Vascular Institute
All Cleveland Clinic vascular lab technologists are certified registered vascular technologists, which exemplifies Cleveland Clinic’s commitment to quality patient care. Each year, they perform a high volume of ultrasounds.
The Noninvasive Vascular Laboratory provides service seven days a week to diagnose arterial and venous disorders throughout the vascular tree and for follow-up after revascularization procedures, such as bypass grafts and stents. In 2012, 37,397 vascular lab studies were performed.
Noninvasive Vascular Lab Ultrasound Study Distribution (N = 37,397)
2012
Fibromuscular Dysplasia
Fibromuscular dysplasia (FMD) is a vascular condition in which there is abnormal cell growth in the walls of medium and large arteries. This can cause the arteries to become narrowed (stenosis) and can also lead to aneurysm and dissection. Cleveland Clinic’s FMD program is dedicated to caring for and educating patients with FMD. It conducts research to better understand the condition and treatment options. In 2012, a total of 169 patients seen in the program had a primary diagnosis of FMD, and 148 patients had a secondary diagnosis of FMD.
Lower Extremity Wound Clinic Volume
2008 – 2012
In 2012, a total of 1,397 patients were treated in the Lower Extremity Wound Clinic.
Fibromuscular Dysplasia — Patient Volume
400400
300300
200200
100100
002008 2009 2010 2011 2012
Volume
2,0002,000
1,5001,500
1,0001,000
500500
002008 2009 2010 2011 2012
Volume
Thrombosis Center
Cleveland Clinic’s Thrombosis Center was established in 2009. It includes a multidisciplinary group of specialists in vascular medicine, vascular surgery, adult and pediatric care, hematology, interventional radiology, cardiology, cardiac surgery, and laboratory medicine. The group works together to provide the best possible treatment to patients with deep vein thrombosis, pulmonary embolism, and hypercoagulable states. In 2012, a total of 1,840 patients with a primary thrombosis diagnosis were seen at Cleveland Clinic’s main campus.
2008 – 2012
Outcomes 201262
Peripheral Vascular Diseases
150150
120120
9090
6060
002010 2011 2012
3030
Volume
Iliac Stenting
2010 – 2012
Hybrid Procedures Trends (Endarterectomy With Stent)
2010 – 2012
8080
6060
4040
2020
002011 2012
Volume
Iliac endarterectomy with stent has replaced aortic femoral bypass Cleveland Clinic’s treatment of choice for complex aorto-iliac artery occlusive disease.
In 2012, Cleveland Clinic performed 128 stent procedures for the treatment of iliac occlusive disease. Stent use has been increasing steadily over the past few years. This method of treatment is highly successful in re-establishing blood flow with minimal complications. The images above show before and after a stent procedure.
Common Iliac Occlusion
Aortic Occlusion
Before
Before
After
After
63Sydell and Arnold Miller Family Heart & Vascular Institute
Visceral Stenting Trends
2010 – 2012
4040
3030
2020
1010
00
44
33
22
11
002010 2011 2012
Volume 30-Day Mortality (%)
Mesenteric Stenting
Cleveland Clinic has shown improved outcomes using brachial artery access over the traditional femoral approach to treat critically ill patients who have acute mesenteric ischemia. Minimally invasive stenting continues to lower mortality.
SMA Stenosis SMA Stent
Visceral Stenting Trends
2010 – 2012
4040
3030
2020
1010
002010
Chronic: 557.1 (SMA, Celiac, IMA)Acute: 557.0 (SMA, Celiac, IMA)
2011 2012
Volume
Chronic mesenteric ischemia is a condition caused by blockages to the intestinal (visceral) blood vessels. Cleveland Clinic has led the change in clinical practice from primarily surgical bypass to endovascular stenting. It has seen steady growth year over year in its procedure volumes.
Outcomes 201264
Peripheral Vascular Diseases
Tibial Bypass Trends
2011 – 2012
6060
4040
2020
002011
VeinProsthetic
2012
Volume
Cleveland Clinic can use autologous (a patient’s own vein) conduits in 75% of its bypasses. Vein bypass has better results than prosthetic conduits. Vein bypasses have a 70% five-year patency and greater than 90% limb salvage rates. Prosthetic conduits are used in patients without alternatives and have a 20% patency at two years. Practitioners strive to find and use all venous conduit sources (saphenous vein, arm vein, and femoral vein).
Angioplasty Trends
2011 – 2012
120120
100100
8080
2020
00
20112012
AllAngioplasties
TibialAngioplasty
Femoral-PoplitealAngioplasty
4040
6060
Volume
Tibial angioplasty intervention is the primary choice in the treatment of rest pain, ulcers, and gangrene. In addition to tibial angioplasty, femoral-popliteal angioplasty is used in the treatment of claudication.
65Sydell and Arnold Miller Family Heart & Vascular Institute
SaphenofemoralJunction
Femoral Artery
Femoral Vein
Laser Fiber
Greater Saphenous
Vein
Outcomes 201266
Venous Disease
Venous Disease Treated at Cleveland Clinic
The physicians in the departments of Vascular Medicine and Vascular Surgery offer a full range of therapies for patients with venous diseases. The total number of venous procedures increases annually.
Varicose Veins
Varicose veins are the most common venous disorder. Treatment starts with conservative therapy, including properly fitting support stockings, skin care, and a regular walking program. If this is not sufficient to alleviate symptoms, a comprehensive evaluation is performed to identify any underlying venous abnormalities. Appropriate treatment, ranging from sclerotherapy to endovenous ablation, can then be planned.
Endovenous Ablation
Endovenous ablation is the preferred treatment for patients with valvular incompetency of the great saphenous vein. The procedure is minimally invasive and can be performed under local anesthesia in an outpatient setting. Endovenous ablation is associated with better outcomes than vein stripping, and the use of newer, longer-wavelength lasers allows patients to experience less post-procedure pain.
Deep Venous Thrombosis (DVT)
Patients with DVT are usually treated with long-term anticoagulation, but the use of early thrombolysis can decrease long-term complications of DVT. Consequently, the use of lytic therapy in treatment has increased. In addition, evaluation and treatment of the underlying cause of the DVT, such as a blood clotting disorder, are essential to minimize recurrence.
Other Venous Procedures
Venous balloon angioplasties may be required to relieve venous obstruction that causes swelling or poor flow for dialysis access. In 2012, 104 venous angioplasties were performed and 32 iliac vein stents were placed. All patients who had iliac stents placed for May-Thurner syndrome (compression of the left iliac wall) had patent stents at follow-up.
In 2012, Cleveland Clinic conducted a study to identify the prevalence of lower extremity deep vein thrombosis (DVT) among patients transferred from outside facilities. Patients were screened upon admission. A total of 10.3% of patients had DVT. The data were used to increase awareness among Cleveland Clinic healthcare providers and develop ways to focus on treatment to prevent complications.
Carotid artery stenosis is the cause of more than half of all temporary and permanent strokes. Patients with hypertension, coronary artery disease, and peripheral artery disease are at increased risk of developing carotid artery stenosis. This risk can be reduced through early diagnosis with vascular ultrasound and through disease management with medications such as antiplatelet and antihypertensive agents. Cleveland Clinic incorporates the most current technology and methods to care for patients with cerebrovascular disease. These include specialized ultrasound laboratories and advanced medical treatments, such as open carotid surgery and minimally invasive carotid artery stenting procedures.
Source: University HealthSystem Consortium (UHC) Comparative Database, 2012 discharges.
2012
Cerebrovascular Disease Treatment Mortality
55
44
22
33
11
000% 0%0%
CarotidStenting
Endarterectomy
Percent
ObservedExpected
The mortality rate for patients treated for cerebrovascular disease at Cleveland Clinic’s main campus was below the expected rate.
Noninvasive vascular laboratory and advanced multiplanar angiography are used to diagnose and treat many cerebrovascular pathologies. The Cerebrovascular Center has offices at various Cleveland Clinic locations. Staff members include accredited technicians and physician reviewers who maintain national standards for diagnosis and reporting. Efficient and standardized reporting provides accurate and timely information to the healthcare providers in the Cleveland Clinic system and to referring physicians.
67Sydell and Arnold Miller Family Heart & Vascular Institute 67
*For all procedures performed at Cleveland Clinic’s main campus.
2008 – 2012Procedural Complications* N MI (%) Stroke (%) Mortality (%)
Carotid Stenting 437 0.5 1.8 0.2
Diagnostic Angiograms 638 0.3 0.5 0.5
Carotid Endarterectomy 684 1.8 2.5 0.9
Cerebrovascular Disease
The Heart & Vascular Institute is currently enrolling patients in medical, surgical and endovascular trials involving cerebrovascular disease. These national trials represent the most up-to-date therapies available to patients with atherosclerotic carotid diseases. Ongoing registries are also available for patients who are eligible. In addition, both minimally invasive and open surgeries are performed for cerebrovascular debranching to expand the application of thoracic stent grafting technology in patients with thoracic aneurysms.
Carotid artery stenosis
Carotid
artery
stenosis
Outcomes 201268
General Thoracic Surgery Volume and Mortality2008 – 2012
Cleveland Clinic surgeons performed 1,541 thoracic surgery procedures in 2012. The mortality rate was 1.5%.
Cleveland Clinic thoracic surgeons treat patients with a wide variety of diseases of the lung and esophagus. The staff is composed of specialists in lung and esophageal cancer, lung failure, airway disease, swallowing disorders, and other diseases. Diagnosis and treatment approaches include the most advanced techniques, such as minimally invasive surgery.
2008 2009 2010
2,0002,000
1,5001,500
1,0001,000
500500
00
6.06.0
4.54.5
3.03.0
1.51.5
00
Surgical VolumeSurgical Volume Mortality (%)
20122011
Thoracic Surgery
Outcomes 2012
69Sydell and Arnold Miller Family Heart & Vascular Institute
The majority of major thoracic surgical procedures at Cleveland Clinic in 2012 were pulmonary procedures.
2012
Major Thoracic Surgery by Type (N = 1,541)
Pulmonary Resection Volume and Mortality2008 – 2012
44
33
22
11
002008 2009 2010
Volume400400
300300
200200
100100
00
Mortality (%)
20122011
Cleveland Clinic performed 318 pulmonary resections in 2012 and had a low 0% mortality.
11% Mediastinum/Diaphragm (N = 169)11% Mediastinum/Diaphragm (N = 169)7% Lung Transplant (N= 104)7% Lung Transplant (N= 104)
22% Pulmonary (N = 344)22% Pulmonary (N = 344)
19% Esophagus (N = 288)19% Esophagus (N = 288)
18% Trachea (N = 278)18% Trachea (N = 278)
17% Pleura (N = 268)17% Pleura (N = 268)
3% Chest Wall (N = 47)3% Chest Wall (N = 47)
1% Other (N = 12)1% Other (N = 12)2% Pericardium (N = 31)2% Pericardium (N = 31)
100%100%
Outcomes 201270
Distribution of Pulmonary Resections by Type (N = 318)2012
Pulmonary Resection Postoperative Length of Stay (N = 318)
Video-assisted procedures allow for shorter length of stay for patients undergoing pulmonary resection.
2012
Lobectomies accounted for the majority of pulmonary resections at Cleveland Clinic in 2012. In addition to open procedures, surgeons perform video-assisted surgeries (VATS) and minimally invasive techniques.
29% Open Lobectomy (N = 93)29% Open Lobectomy (N = 93)
6% Open Wedge (N = 19) 6% Open Wedge (N = 19)
22% Video-Assisted Lobectomy (N = 69)22% Video-Assisted Lobectomy (N = 69)
18% Video-Assisted Wedge (N = 59)18% Video-Assisted Wedge (N = 59)
5% Segmentectomy (N = 15) 5% Segmentectomy (N = 15) 4% Other VATS (N = 12) 4% Other VATS (N = 12)
7% Pneumonectomy (N = 21) 7% Pneumonectomy (N = 21) 9% Other Open (N = 30) 9% Other Open (N = 30)
100%100%
66OpenVATSOpenVATS
00
Days
WedgeResection
Segmentectomy Lobectomy Pneumonectomy
22
44
70
Thoracic Surgery (continued)
*University HealthSystem Consortium (UHC) Comparative Database, 2012 discharges.
71Sydell and Arnold Miller Family Heart & Vascular Institute
Lobectomy for Stage I Lung Cancers
Major Pulmonary Resections Operative Mortality
8080
100100
VATS/RoboticOpenVATS/RoboticOpen
00
Volume
20112010 2012
4040
2020
6060 48%33%
61%
2012
0%
2.0
1.5
1.0
0.5
02011 UHC
Expected2008 2009 2010
Percent
Combined Morbidity and Mortality for Pulmonary Resections for Lung Cancer, July 2009 – June 2012
Min0.53
25th0.89
Cleveland Clinic
Median1.02
75th1.19
Max2.04
= STS standardized incidence ratioSource: STS General Thoracic Surgery Database, July 2009–June 2012.
2010 – 2012
2008 – 2012
Risk-Adjusted Standardized Incidence Eligible Procedures Unadjusted Rate Rate (95% CI) Ratio (95% CI)
458 7.2% 7.1% (5.2%, 9.2%) 0.85 (0.62, 1.11)
Cleveland Clinic surgeons are steadily increasing the use of video-assisted/robotic techniques to perform lobectomies for patients with Stage I lung cancer. These techniques are less invasive than open procedures and can help improve outcomes.
The mortality rate for patients who had major pulmonary resections in 2012 was 0%. Cleveland Clinic consistently achieves mortality rates below the expected rate.
Cleveland Clinic surgeons performed 318 major pulmonary resections in 2012 without a single death. The risk-adjusted rate of morbidity or mortality following a pulmonary resection for lung cancer is in the lowest quartile in the country.
Outcomes 201272
Esophageal Surgery Volume2008 – 2012
Lobectomy Length of Stay2012
In 2012, Cleveland Clinic thoracic surgeons performed 189 esophageal operations. One-year mortality was 1.6%. Procedures included resections for cancer and reoperative surgery for motility and reflux disorders.
The expected one-year mortality rate following esophagectomy was 3.3%. Cleveland Clinic surgeons achieved a 1.5% mortality rate in 2012.
Cleveland Clinic surgeons use video-assisted techniques for lobectomy whenever possible. This type of procedure allows for a shorter length of stay and quicker return to a patient’s normal activities.
6
0Open Lobectomy
(N = 93)
Median (Days)
Video-AssistedLobectomy(N = 69)
4
2
2012201020092008
Volume400400
300300
200200
100100
002011
Esophagectomy Mortality One Year After Surgery2012
4
Percent
3
2
0Expected
1
Observed Source: University HealthSystem Consortium (UHC) Comparative Database, 2012 discharges.
Thoracic Surgery (continued)
73Sydell and Arnold Miller Family Heart & Vascular Institute
The majority of esophageal surgeries done in 2012 were paraesophageal hernia repairs. Cleveland Clinic surgeons treat patients who have a variety of high volumes benign and malignant esophageal conditions.
Risk-Adjusted Standardized Incidence Eligible Procedures Unadjusted Rate Rate (95% CI) Ratio (95% CI)
141 28.4% 27.6% (21.4%, 34.3%) 0.97 (0.76, 1.21)
Distribution of Esophageal Surgeries by Indication (N = 189)
Combined Morbidity/Mortality for Esophagectomy for Esophageal Cancer, July 2009 – June 2012
2012
29% Cancer (N = 54)29% Cancer (N = 54)
10% Reflux (N = 19)10% Reflux (N = 19)9% Achalasia (N = 18)9% Achalasia (N = 18)
11% Other (N = 20)11% Other (N = 20)
36% Paraesophageal Hernia Repair (N = 68)36% Paraesophageal Hernia Repair (N = 68)
5% Esophageal Reconstruction (N = 10)5% Esophageal Reconstruction (N = 10)
100%100%
Min0.59
25th0.96
Cleveland Clinic
Median1.05
75th1.17
Max1.58
= STS standardized incidence ratio Source: STS General Thoracic Surgery Database, July 2009–June 2012.
2012 Volume
Prevention Outpatient Visits 8,561
Phase I Rehab 8,330
Phase II Rehab 3,952
Phase III Rehab 3,082
LDL Levels Among Statin-Tolerant Adults
Patients taking statins for both primary and secondary prevention experienced reductions in low-density lipoprotein (LDL) cholesterol levels. Patients were seen at baseline and had at least two follow-up visits within one year. The time between visits varied from patient to patient.
Primary Prevention, Statin-Tolerant Adults (N = 658 in 2012) 2007 – 2012
140
120
100
80
160
2007 2008 2009 2010 2011 201282 mg/dL 2nd Follow-up
121 mg/dL Baseline
LDL Value
64
78
92
106
50
120
63 mg/dL 2nd Follow-up
79 mg/dL Baseline
LDL Value
2007 2008 2009 2010 2011 2012
Secondary Prevention, Statin-Tolerant Adults (N = 324 in 2012) 2007 – 2012
74 Outcomes 2012
Preventive Cardiology and Rehabilitation
The Section of Preventive Cardiology and Rehabilitation at Cleveland Clinic provides patients with a comprehensive assessment to identify traditional and emerging nontraditional cardiovascular risk factors. It collaborates with referring physicians to create individualized treatment plans. Patients typically have a limited number of visits and return to their primary care or referring physician for care.
Primary Prevention, Statin-Intolerant Adults (N = 152 in 2012) 2007 – 2012
140
120
100
80
160
2007 20092008 2011 20122010
97 mg/dL 2nd Follow-up
131 mg/dL Baseline
LDL Value
112
84
98
70
140
126
81 mg/dL 2nd Follow-up
132 mg/dL Baseline
LDL Value
2007 20092008 2011 20122010
LDL Levels Among Statin-Intolerant Adults
Patients referred to the prevention clinic who could not tolerate statins still experienced reductions in LDL levels. Patients had at least two follow-up visits within a year.
Secondary Prevention, Statin-Intolerant Adults (N = 135 in 2012) 2007 – 2012
75Sydell and Arnold Miller Family Heart & Vascular Institute
Blood Pressure Among Primary and Secondary Prevention Patients (N = 947)
2012
120
150
0Systolic Diastolic
90
60
30
Value (mmHg)
7077
2nd Follow-upBaseline124 122
Patients who were seen in the prevention clinic for both primary and secondary prevention experienced reductions in blood pressure. All patients had at least two follow-up visits within a year.
300
0HDL
250
LDL Triglycerides Total Cholesterol
200
50
150
100
Value (mg/dL)
50.55 45.05
271.36
116.41
204.32
136.22
105.5
2nd Follow-upBaseline
199.5
Pediatric Preventive Cardiology and Metabolic Clinic Lipid Levels (N = 95)
2012
The Pediatric Preventive Cardiology and Metabolic Clinic offers expert assessment, lifestyle management advice, medication, and monitoring for patients aged < 21 years with cardiometabolic dyslipidemia as well as genetic dyslipidemia. Data are for patients with genetic dyslipidemia who had at least one follow-up visit in 2012.
76 Outcomes 2012
Preventive Cardiology and Rehabilitation (continued)
Outcomes 2012
Exercise Prescriptions
2009 – 2012 Cleveland Clinic’s exercise prescriptions are designed to help patients start an exercise program. The prescription is written after the patient’s fitness level is determined. It provides the information about the recommended frequency, intensity, type, and length of exercise sessions.
20112010 20122009
Volume
0
450
360
270
180
90
Patients seen in the prevention clinic who had diabetes reduced HbA1c levels during the course of their treatment. All patients were seen at baseline and had at least two follow-up visits within a year.
0
2
4
6
8
Percent
2nd Follow-up
6.56.9
Baseline
HbA1c Levels Among Patients With Diabetes (N = 298)
2012
77Sydell and Arnold Miller Family Heart & Vascular Institute
Cardiac Rehabilitation
Outcomes measured in the Cardiac Rehabilitation Program include those related to functional capacity, quality of life, blood pressure, and weight.
Improvement in Exercise Capacity by Exercise Stress Test (N = 246)2012
The metabolic equivalent of task (MET) is the ratio of the working metabolic rate to the resting metabolic rate. Each 1-MET increase in functional capacity reduces the risk of mortality by 8% to 12%. The average predicted reduction in mortality for patients in the program based on improvement in functional capacity (METs) was approximately 16%.
9
4Before Cardiac Rehab
METs
After Cardiac Rehab
Change = +1.6
7
8
5
6
8.2
6.6
Cardiac Rehabilitation
Improvement in Systolic Blood Pressure (N = 246)2012
Among patients who completed the Cardiac Rehabilitation Program, 86% achieved normal blood pressure (< 140/90 mmHg). The average improvement was 10 mmHg.
140
80Before Cardiac Rehab
Systolic Blood Pressure (mmHg)
After Cardiac Rehab
110
136
124
Data represent all cardiac rehab patients with both entry and exit visits in 2012.
Data represent all cardiac rehab patients with both entry and exit visits in 2012.
78 Outcomes 2012
Preventive Cardiology and Rehabilitation (continued)
Cardiac Rehabilitation
Improvement in Weight (N = 278)2012
216
200Entry
208.2
Weight (lbs.)
Exit
212
204
208
212.6
Patients who completed the Cardiac Rehabilitation Program lost an average of 4.5 pounds.
Data represent all cardiac rehab patients with both entry and exit visits in 2012.
20,000
02009
15,000
2008 2010 2011 2012
10,000
5,000
Volume
Phase 3Phase 2Phase 1
Cardiac Rehab Volume2008 - 2012
7979Sydell and Arnold Miller Family Heart & Vascular Institute 79
Improvement in Quality of Life Assessment (N = 246)2012
60
0
50
Physical Summary Score
MentalSummary Score
40
10
30
20
Exit
Entry
SF-36 Score
Quality of life is measured using the SF-36® Health Survey. This is a validated measure that tracks overall wellness of patients in cardiac rehabilitation. Patients who completed the program experienced improved physical and emotional quality of life.
The Weigh to a Healthy Heart
2011 – 2012The Weigh to a Healthy Heart is a comprehensive 11-week weight loss program designed to help prevent cardiovascular disease. The program is guided by a team of dietitians, physicians, exercise physiologists, and behavioral counselors. Patients receive an exercise prescription and participate in private nutrition sessions, group exercise classes, lipid and fasting sugar testing, and weekly group support sessions. They also get help creating a grocery list.
In 2012, patients who attended more than 75% of the classes lost an average of 8 pounds. Those who attended fewer than 75% of the classes lost an average of 5 pounds.
Mean Weight Loss Over 11 Weeks
2011 5 pounds
2012 8 pounds
Outcomes 201280
Preventive Cardiology and Rehabilitation (continued)
81Sydell and Arnold Miller Family Heart & Vascular Institute
Cardiopulmonary Arrests
2009 – 2012
Survival-to-Discharge Rate
2009 – 2012
The Critical Response and Resuscitation team has three primary goals:
• Reduce nursing unit cardiopulmonary arrests (CPA)
• Improve post-CPA survival to discharge
•Maintain regulatory compliance
Anesthesia
00
200200
2009 2010 2011 2012
100100
150150
5050
NumberNumber
Includes: MET→CPA, ARC→CPA
Cleveland ClinicHeart & Vascular Institute
40
20
0
60
2009 2010 2011 2012
Cleveland Clinic
500 bed comparison hospital
Percent
Includes: MET→CPA, ARC→CPA
The team works together with the Miller Family Heart & Vascular Institute staff to improve outcomes.
3.88 4.39
20Percent
16
12
030-Day Mortality 30-Day Morbidity
ExpectedCleveland Clinic
8
4
Vascular Surgery 30-Day Mortality and Morbidity (N = 438) July 2011 – June 2012
In addition to overall surgical performance, NSQIP data specific to vascular surgery are provided.
There was no significant difference between vascular surgery observed and expected mortality or morbidity rates.
Outcomes 201282
Surgical Quality Improvement
Overall mortality was significantly lower than expected, and overall morbidity was significantly higher than expected.
Cleveland ClinicOverall Multispecialty 30-Day Mortality (N = 4,988)
July 2011 – June 2012
Cleveland ClinicOverall Multispecialty 30-Day Morbidity (N = 4,988)
July 2011 – June 2012
National Surgical Quality Improvement Program
The American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) objectively measures and reports risk-adjusted surgical outcomes based on a defined sampling and abstraction methodology. These outcomes data reflect Cleveland Clinic’s NSQIP performance benchmarked against more than 350 participating hospitals.
Percent
ExpectedObserved
5
4
3
2
1
0
Percent
ExpectedObserved
12
8
10
6
4
2
0
55
44
33
00Cardiac Events Pneumonia Surgical Site
InfectionsUrinary Tract
Infections
22
11
Percent
N = 438 437 435 438
Cleveland ClinicExpected
Vascular Surgery Complications July 2011 – June 2012
There was no significant difference between vascular surgery observed and expected complication rates.
83Sydell and Arnold Miller Family Heart & Vascular Institute
Cleveland Clinic Surgical Appropriateness of Care 2011 – 2012
Cleveland Clinic has set a target of UHC’s 90th percentile, and results are trending positively.
Surgical Care Improvement Program (SCIP) — Appropriateness of Care
This composite metric, based on 10 hospital surgical quality process measures developed by the Centers for Medicare & Medicaid Services, shows the percentage of patients who received all the recommended care for which they were eligible.
0
60
80
100
40
20
Percent
*These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu.
92.3 93.0
UHC 90th Percentile, 2012*
2011 2012
N = 1,501 1,293
Cleveland Clinic is dedicated to delivering excellent clinical outcomes and the best possible experience for patients and their families. Patient feedback is critical in driving priorities and assessing results. Based on this feedback, Cleveland Clinic’s Office of Patient Experience implements training programs to improve service and communication as well as educational initiatives to help patients understand what to expect when they are in Cleveland Clinic’s care.
Outpatient — Heart & Vascular Institute
*Response options: Very Good, Good, Fair, Poor, Very PoorEach bar represents a composite score based on responses to multiple survey questions.
Source: Press Ganey, a national hospital survey vendor.
100
80
0
60
40
20
Percent Best Response*
Appt Access/Check-in
Clinic Wait Timesand Comfort
Nurse andAssistant
Physician Concern for Needsand Privacy
OverallAssessment
2012 (N = 4,597)2011 (N = 4,626)
2011 – 2012
Outcomes 201284
Patient Experience — Heart & Vascular Institute
HCAHPS Overall Assessment 2011 – 2012
Inpatient – Miller Family Heart & Vascular Institute
The Centers for Medicare and Medicaid Services (CMS) requires United States hospitals that treat Medicare patients to participate in the national Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a standardized tool that measures patients’ perspectives of hospital care. Results collected for public reporting are available at medicare.gov/hospitalcompare/search.html
The guiding principle of Cleveland Clinic is “Patients First,” and improving the patient experience is a major strategic organizational goal. The Office of Patient Experience collaborates with physician and nursing leadership to establish best practices and implement standardized protocols that ensure delivery of patient-centered care.
HCAHPS Domains of Care 2011 – 2012
100
80
0
60
86.7%
40
20
Percent Best Response*
Rate Hospital Would Recommend
% 9 or 10(0 – 10 scale)
% “definitely yes”*
*Response options: Definitely Yes, Probably Yes, Probably No, Definitely No
Source: Press Ganey, a national hospital survey vendor
2012 (N = 4,347)2011 (N = 4,112)
89.7% 90.3%87.3%
100
80
0
60
40
20
Percent Best Response*
DischargeInformation Given
% yes
Doctor Communication
Nurse Communication
PainManagement
RoomClean
New MedicationsCommunication
Responsivenessto Needs
Quiet atNight
*Except for “Room Clean” and “Quiet at Night,” each bar represents a composite score based on responses to multiple survey questions.
Source: Press Ganey, a national hospital survey vendor
% always(Options: always, usually, sometimes, never)
2012 (N = 4,347)2011 (N = 4,112)
85Sydell and Arnold Miller Family Heart & Vascular Institute
Outcomes 201286
Cleveland Clinic — Improving Quality, Safety, and the Patient Experience
Overview
Cleveland Clinic health system uses a scorecard approach to measure and monitor quality, safety, and patient experience. Real-time dashboard data are leveraged in each location to drive performance improvement. Although not an exact match to publicly reported data, more timely internal data create transparency at all organizational levels and support improved care in all clinical locations. The following measures are examples of health system 2012 quality and safety focus areas. Throughout this section, “Cleveland Clinic” refers to the academic medical center or “main campus,” and those results are shown.
Cleveland Clinic Core Measures Appropriateness of Care 2011 – 2012
Cleveland Clinic monitors 30-day readmission rates for any reason to any of its system hospitals. Unplanned readmissions are actively reviewed for improvement opportunities. Strategies associated with communication, education, and follow-up have been implemented for several high-risk conditions, including heart failure and pneumonia. These practices are being expanded and enhanced to reduce overall avoidable readmissions.
Cleveland Clinic’s goal is for all patients to receive all the recommended care for their condition. An aggregated “all or nothing” measurement approach to monitoring multiple publicly reported process-of-care measures for heart failure, acute myocardial infarction, pneumonia, and surgery patients yields results consistently above 94%.
All-Cause 30-Day Readmission Rate to Any Cleveland Clinic Hospital 2011 – 2012
80
100
0Q1 Q2
2011 2012
Q3 Q4 Q1 Q2 Q3 Q4
60
40
20
Percent of Patients
Cleveland Clinic PerformanceCleveland Clinic Target
1614
18
0Q1 Q2
2011 2012
Q3 Q4 Q1 Q2 Q3 Q4
12
10
8
6
4
2
Percent of Discharges
Cleveland Clinic Performance
87Sydell and Arnold Miller Family Heart & Vascular Institute
Cleveland Clinic Overall In-Hospital Mortality Observed/Expected Ratio2011 – 2012
The Agency for Healthcare Research and Quality’s Patient Safety Indicator 4 (AHRQ PSI 4) reports deaths among patients with serious treatable complications. Cleveland Clinic performs in the top third of UHC’s academic medical centers for this measure.
*These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu
Cleveland Clinic’s observed/expected (O/E) mortality ratio outperformed the University HealthSystem Consortium (UHC) academic medical center 50th percentile throughout 2012 based on the UHC 2012 risk model. Ratios less than 1.0 indicate mortality performance “better than” expected in UHC’s risk adjustment model.
Cleveland Clinic Deaths Among Surgical Patients With Serious Treatable Complications (PSI 4) Rate per 1,000 Eligible Patients2011 – 2012
1.2
0.0Q1 Q2
2011 2012
Q3 Q4 Q1 Q2 Q3 Q4
0.8
1.0
0.6
0.4
0.2
O/E Ratio
Cleveland Clinic PerformanceUHC* 50th Percentile(Academic Medical Center)
180
0Q1 Q2
2011 2012
Q3 Q4 Q1 Q2 Q3 Q4
120
140
160
100
80
60
40
20
Rate per 1,000 Patients
Cleveland Clinic PerformanceUHC* 50th Percentile(Academic Medical Center)
Outcomes 201288
Cleveland Clinic — Improving Quality, Safety, and the Patient Experience
Cleveland Clinic continues to improve its performance with respect to postoperative blood clots (AHRQ Patient Safety Indicator 12). Improved screening and prevention strategies have led to a 45% reduction in these events over the past two years.
Cleveland Clinic has implemented several strategies to reduce central line-associated bloodstream infections (CLABSI), including a central-line bundle of insertion, maintenance, and removal best practices. In 2012, Cleveland Clinic initiated focused reviews of every CLABSI occurrence and is introducing equipment and technology to support reductions in CLABSI rates in its high-risk critical care population.
Cleveland Clinic Postoperative Blood Clot Rate (PSI 12) per 1,000 Eligible Patients2011 – 2012
Cleveland Clinic Central Line-Associated Bloodstream Infection—ICU Rate per 1,000 Line Days2010 – 2012
20
0Q1 Q2
2011 2012
Q3 Q4 Q1 Q2 Q3 Q4
141618
1210
8642
Rate per 1,000 Patients
Cleveland Clinic PerformanceUHC* 50th Percentile(Academic Medical Center)
3.5
0.0Q1 Q2
20112010 2012
Q3 Q4 Q1 Q2 Q3 Q4
2.5
3.0
2.0
1.5
1.0
0.5
Rate per 1,000 Line Days
Q1 Q2 Q3 Q4
Cleveland Clinic PerformanceCleveland Clinic Target
*These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu
89Sydell and Arnold Miller Family Heart & Vascular Institute
A pressure ulcer is an injury to the skin that can be caused by pressure, moisture, or friction. These sometimes occur when patients have difficulty changing positions on their own. Cleveland Clinic caregivers have been trained to provide appropriate skin care and regular repositioning help while taking advantage of special devices and mattresses to reduce pressure for high-risk patients. In addition, they actively look for hospital-acquired pressure ulcers and treat them quickly if they occur.
Nationally, falls are a leading cause of hospital patient injury. Cleveland Clinic fall prevention efforts include identifying patients who are at risk for falls, checking on them frequently, assisting them to the bathroom, and providing nonskid footwear. Caregivers make sure patients have all necessary items, including a call light, within easy reach.
Cleveland Clinic Hospital-Acquired Pressure Ulcers Prevalence2011 – 2012
Cleveland Clinic Falls Rate per 1,000 Patient Days2011 – 2012
*The National Database of Nursing Quality Indicators® (NDNQI®) is owned by the American Nurses Association. The database collects and evaluates unit-specific nurse-sensitive data from hospitals domestically and globally, with > 1900 hospitals participating. The comparison data represented here are based on a third of all hospitals in the U.S. participating. © 2012, American Nurses Association, All Rights Reserved. www.nursingquality.org
4.0
0.0Q1 Q2
2011 2012
Q3 Q4 Q1 Q2 Q3 Q4
3.5
3.0
2.5
2.0
1.5
1.0
0.5
Rate per 1,000 Patient Days
Cleveland Clinic PerformanceNDNQI®* 50th Percentile(Academic Medical Center)
5
0Q1 Q2
2011 2012
Q3 Q4 Q1 Q2 Q3 Q4
4
3
2
1
Percent
Cleveland Clinic PerformanceNDNQI®* 50th Percentile(Academic Medical Center)
Outcomes 201290
Cleveland Clinic — Improving Quality, Safety, and the Patient Experience
Cleveland Clinic HCAHPS Overall Assessment 2011 – 2012
Patient Experience
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is a standardized national tool used to measure patients’ perspectives of hospital care. Results collected for public reporting are available at medicare.gov/hospitalcompare.
100
80
0
60
40
20
Percent Best Response*
Recommend Hospital(% Definitely Yes)*
Hospital Rating(% 9 or 10)0–10 Scale
*Response options: Definitely Yes, Probably Yes, Probably No, Definitely No
Source: Centers for Medicare & Medicaid Services and Press Ganey, a national hospital survey vendor
2012 (N = 11,190)
National AverageJuly 1, 2011 – June 30, 2012
2011 (N = 10,378)
84.9 80.880.084.0
91Sydell and Arnold Miller Family Heart & Vascular Institute
The guiding principle of Cleveland Clinic is “Patients First,” and improving the patient experience is a major strategic organizational goal. The Office of Patient Experience collaborates with physician and nursing leadership to establish best practices and implement standardized protocols that ensure delivery of patient-centered care.
Cleveland Clinic HCAHPS Domains of Care 2011 – 2012
100
80
0
60
40
20
Percent Best Response*
DischargeInformation
% Yes
Doctor Communication
Nurse Communication
PainManagement
RoomClean
New MedicationsCommunication
Responsivenessto Needs
Quiet atNight
*Except for “Room Clean” and “Quiet at Night,” each bar represents a composite score based on responses to multiple survey questions. Source: Centers for Medicare & Medicaid Services and Press Ganey, a national hospital survey vendor
% Always(Options: Always, Usually, Sometimes, Never)
2012 (N = 11,190)2011 (N = 10,378)
National AverageJuly 1, 2011 – June 30, 2012
Outcomes 201292
Innovations
The Global Cardiovascular Innovation Center (GCIC) has awarded a total of more than $18 million to more than 54 companies and projects. The organization has helped create more than 525 jobs in Ohio.
The GCIC is part of the Cleveland Clinic Innovation Center (CCIC), which is Cleveland Clinic’s technology commercialization arm. Its mission is to “benefit the sick through the broad and rapid deployment of Cleveland Clinic technology.” The center facilitates innovation, creates spin-off companies, licenses technology, secures resources, and establishes strategic collaborations with corporate partners.
Outcomes 20129292
Kapsus Device
In recent years, there has been increased interest in developing new ways to treat structural heart pathology. These include procedures such as transcatheter aortic valve replacement, mitral valve treatment in patients with congestive heart failure, and closure of the left atrial appendage to reduce the risk of stroke. To help facilitate transseptal access to the left atrium, Cleveland Clinic researchers developed the Kapsus device. The technology represents the first major change in 50 years for transseptal access to the left atrium. The design allows for improved repeatability, safety, and speed in these procedures.
93Sydell and Arnold Miller Family Heart & Vascular Institute
Centerline Analysis Software
Endovascular repair of aortic aneurysms and dissections is critically dependent on a proper understanding of the geometry of a patient’s arteries. Cleveland Clinic researchers have developed an automated system that extracts the centerlines of the aorta and branch vessels from a patient’s CT scan and then builds a complete mathematical model of the relevant vasculature. Unlike the data stored in a CT scan, this model represents the anatomy in a way that can be easily manipulated and understood by computer software. Software developed by Cleveland Clinic utilizes these models to help design and implant endovascular devices. This technology will make minimally invasive vascular repairs safer, more effective, and more widely available.
Link Between Carnitine and Atherosclerosis
Researchers at Cleveland Clinic have shown that carnitine, a compound abundant in red meat and added as a supplement to popular energy drinks, is linked to the development of atherosclerosis. Bacteria living in the human digestive tract metabolize carnitine, turning it into trimethylamine-N-oxide (TMAO). In 2011, the researchers linked TMAO to the promotion of atherosclerosis. The study also shows that a diet high in carnitine promotes the growth of the bacteria that metabolize carnitine, thus compounding the problem by producing even more TMAO. In addition, TMAO alters the metabolism of cholesterol on different levels, as shown in the accompanying illustration. This research is expected to lead to development of new diagnostic tests for cardiac risks and new potential therapies for patients with cardiovascular disease.
Outcomes 201294
Innovations (continued)
Absorb™ Stent
The Absorb stent (Abbott Laboratories; Abbott Park, Ill.) is a polymer-based stent/vascular scaffold that is completely bioresorbable. Researchers at Cleveland Clinic are comparing the early and long-term results of Absorb with those of the most advanced permanent metallic and polymer drug-eluting stents. The device is used to treat patients with coronary artery disease. Permanent polymer stents can lead to arterial inflammation and stent thrombosis. The Absorb stent dissolves once the artery can stay open. This allows the artery to function naturally, expanding and contracting to meet the heart’s need for blood. Absorb may also reduce the need for long-term anticoagulant therapy.
XVIVO Lung Perfusion System
The majority of lungs donated for transplant (about 80%) cannot be used because they are infected or damaged or because they contain too much fluid. However, Cleveland Clinic researchers are testing a way to make many of these lungs usable. The XVIVO system involves infusing the lungs with a solution while they are attached to a ventilator. The lungs can then be transplanted. Approximately 1,600 people are waiting for lung transplant. FDA approval of this system would expand the availability of lungs for transplant and improve survival among those on the donor wait list.
Subcutaneous Defibrillation
Sudden cardiac death is the leading cause of death in the United States. Cleveland Clinic is among a select group of U.S. hospitals using a new device to treat and prevent sudden cardiac death. The subcutaneous implantable defibrillator allows the leads to be tunneled under the skin. Traditional implantable devices require either open heart surgery or lead placement in veins. Such placement can result in malfunction and other complications. In addition to reducing these risks, the technology provides an additional treatment option for patients who are unable to have transvenous lead placement.
95Sydell and Arnold Miller Family Heart & Vascular Institute 95Sydell and Arnold Miller Family Heart & Vascular Institute
Outcomes 201296
Innovations (continued)
SIMPLICITY-HTN III
Renal Denervation for Resistant Hypertension
Cleveland Clinic is involved in the SIMPLICITY-HTN III trial. This multicenter trial is designed to study the efficacy of renal
denervation — a novel therapy for patients with resistant hypertension. Up to 20% of patients with hypertension cannot
achieve normal blood pressure with traditional therapy. Renal denervation is a one-time interventional treatment similar
to a cardiac catheterization. A small catheter is inserted through the groin and guided to the renal arteries. A low-energy
radiofrequency is transmitted to the arteries, which burns the nerves inside the arteries. Once the nerves are burned, the
brain receives feedback that translates into a significant reduction in blood pressure. The reduction can be as great as 30
to 40 mm Hg. The treatment has the potential to become the standard of care for patients with resistant hypertension and
may benefit patients with other conditions, such as heart failure, metabolic syndrome and insulin resistance. In addition to
the therapeutic benefit of renal denervation, the treatment offers significant cost savings to patients.
Vagus Nerve Stimulator
An imbalance between the parasympathetic and sympathetic nervous systems contributes to the progression of chronic
heart failure. Contemporary treatment options only partially address this factor. Cleveland Clinic researchers are
participating in an international multicenter trial to test the efficacy and safety of the vagus nerve stimulator. The device
is similar to a pacemaker in shape and size and has two leads. It is implanted in the upper right side of the chest, and
the leads are attached to the vagus nerve on the right side of the neck and the right ventricle. Patients who receive the
device are already receiving optimal medical therapy. The device helps correct autonomic imbalance through intermittent
stimulation of the vagus nerve. The stimulation is timed to QRS complexes sensed by the right ventricular lead. Cleveland
Clinic was the first in Ohio to implant this device.
97Sydell and Arnold Miller Family Heart & Vascular Institute
∆Chair Holders
Outcomes 201298
Staff Listing
Institute Leadership
Bruce W. Lytle, MD∆, Chairman, Sydell and Arnold Miller Family Heart & Vascular Institute
Daniel Clair, MD∆, Chairman, Vascular Surgery
Steven E. Nissen, MD∆, Chairman, Robert and Suzanne Tomsich Department of Cardiovascular Medicine
Joseph F. Sabik III, MD∆, Chairman, Thoracic and Cardiovascular Surgery
Quality Review Officers
Nicholas G. Smedira, MD∆, Sydell and Arnold Miller Family Heart & Vascular Institute
Sunita Srivastava, MD, Vascular Surgery
Lars G. Svensson, MD, PhD, Thoracic and Cardiovascular Surgery
Institute Patient Experience Officer
A. Marc Gillinov, MD∆
Thoracic and Cardiovascular Surgery
Joseph F. Sabik III, MD∆, Chairman
Gösta B. Pettersson, MD, PhD∆, Vice Chairman
Cardiovascular Surgery
A. Marc Gillinov, MD∆
Douglas R. Johnston, MD
Bruce W. Lytle, MD∆
Kenneth R. McCurry, MD
Stephanie Mick, MD
Tomislav Mihaljevic, MD∆
Nader Moazami, MD
José L. Navia, MD
Gösta B. Pettersson, MD, PhD∆
Eric E. Roselli, MD
Joseph F. Sabik III, MD∆
Nicholas G. Smedira, MD∆
Edward G. Soltesz, MD
Lars G. Svensson, MD, PhD
Thoracic Surgery
Thomas W. Rice, MD∆, Section Head
David P. Mason, MD
Sudish C. Murthy, MD, PhD
Siva Raja, MD, PhD
Daniel Raymond, MD
Pediatric and Adult Congenital Heart Surgery
Gösta B. Pettersson, MD, PhD∆, Section Head
Robert D. Stewart, MD, Surgical Director of Congenital Heart Transplantation
Vascular Surgery
Daniel Clair, MD∆, Chairman
Linda Graham, MD, Vice Chair
Timur Sarac, MD, Vice Chair
Matthew Eagleton, MD
Roy K. Greenberg, MD
Jeanwan Kang, MD
Rebecca Kelso, MD
Levester Kirksey, MD
Sean Lyden, MD
∆Chair Holders
99Sydell and Arnold Miller Family Heart & Vascular Institute
Institute Overview
Tara Mastracci, MD
Patrick O’Hara, MD
Michael Park, MD
Christopher Smolock, MD
Sunita Srivastava, MD
Robert and Suzanne Tomsich Department of Cardiovascular Medicine
Steven E. Nissen, MD, Chairman
A. Michael Lincoff, MD, Vice Chairman
Randall C. Starling, MD, Vice Chairman
E. Murat Tuzcu, MD, Vice Chairman
Cardiac Electrophysiology and Pacing
Bruce D. Lindsay, MD, Section Head
Peter Aziz, MD
Bryan Baranowski, MD
Mandeep Bhargava, MD
Thomas Callahan IV, MD
Daniel Cantillon, MD
Lon W. Castle, MD
Mina K. Chung, MD
Thomas Dresing, MD
Fetnat Fouad-Tarazi, MD
Fredrick J. Jaeger, DO
Mohamed Kanj, MD
David O. Martin, MD
Mark Niebauer, MD
Walid I. Saliba, MD
Richard Sterba, MD
Khaldoun Tarakji, MD
Patrick J. Tchou, MD
Donald A. Underwood, MD
Niraj Varma, MD
Oussama Wazni, MD
Bruce L. Wilkoff, MD
Cardiac Electrophysiology and Pacing — Syncope Clinic
Fetnat Fouad-Tarazi, MD
Frederick J. Jaeger, DO
Cardiovascular Imaging
Manuel Cerqueira, MD
Milind Desai, MD
Scott Flamm, MD
Brian P. Griffin, MD∆
Richard A. Grimm, DO
Rory Hachamovitch, MD
Wael Jaber, MD
Avrum Jacobs, MD
Vidyasagar Kalahasti, MD
Allan L. Klein, MD
Deborah Kwon, MD
Harry M. Lever, MD
Chiara Liguori, MD
Venugopal Menon, MD
Juan Carlos Plana, MD
Zoran Popovic, MD
L. Leonardo Rodriguez, MD
∆Chair Holders
Outcomes 2012100
Staff Listing
Ellen Mayer-Sabik, MD
Paul Schoenhagen, MD
William James Stewart, MD
Balaji Tamarappoo, MD
Maran Thamilarasan, MD
James Thomas, MD
Abdul Wattar, MD
Clinical Cardiology
Ben Barzilai, MD, Section Head
Ajay Bhargava, MD
Caroline Casserly, MD
Michael Faulx, MD
Adam Grasso, MD, PhD
Donald F. Hammer, MD
Joel B. Holland, MD
Julie Huang, MD
Carlos Hubbard, MD, PhD
Fuad Y. Jubran, MD∆
Umesh Khot, MD
Richard Krasuski, MD
David Majdalany, MD
Steven E. Nissen, MD
Mehdi Razavi, MD∆
Curtis Rimmerman, MD∆
Michael B. Rocco, MD
Michael B. Rollins, MD
Terrence G. Tulisiak, MD
Donald A. Underwood, MD
Heart Failure and Cardiac Transplant Medicine
Randall C. Starling, MD, Section Head
Corinne Bott-Silverman, MD
Eiran Gorodeski, MD
Mazen A. Hanna, MD
Robert E. Hobbs, MD
Eileen Hsich, MD
Carlos Hubbard, MD, PhD
Karen B. James, MD
Sangjin Lee, MD
Christine Moravec, PhD
Maria Mountis, DO
W.H. Wilson Tang, MD
David O. Taylor, MD
James B. Young, MD∆
Invasive Cardiology
Stephen Ellis, MD, Section Head
Christopher Bajzer, MD
Corinne Bott-Silverman, MD
Joseph G. Cacchione, MD
Leslie Cho, MD
Khosrow Dorosti, MD
Michael Faulx, MD
Perry L. Fleisher, MD
Irving Franco, MD
Frederick A. Heupler Jr., MD
Robert E. Hobbs, MD
Martin Joseph, MD
∆Chair Holders
101Sydell and Arnold Miller Family Heart & Vascular Institute
Institute Overview
Samir Kapadia, MD
Richard Krasuski, MD
Amar Krishnaswamy, MD
A. Michael Lincoff, MD
Ravi N. Nair, MD
Russell E. Raymond, DO
Jonathan Scharfstein, MD
Mehdi Shishehbor, DO
Conrad C. Simpfendorfer, MD
John Stephens, MD
E. Murat Tuzcu, MD
Vladimir Vekstein, MD
Patrick L. Whitlow, MD
Preventive Cardiology and Rehabilitation
Leslie Cho, MD, Section Head
Stanley L. Hazen, MD, PhD, Section Head
Michael B. Rocco, MD, Medical Director, Cardiac Rehabilitation
Gordon Blackburn, PhD, Program Director, Cardiac Rehabilitation
David J. Frid, MD Department of Cardiovascular Medicine
Betul Hatipoglu, MD Department of Endocrinology
Julie Huang, MD Department of Cardiovascular Medicine
Leopoldo Pozuelo, MD Program Director, Cardiovascular Behavioral Health Clinic
Paul Schoenhagen, MD Department of Diagnostic Radiology
Pediatric Preventive Cardiology and Metabolic Clinic
Naim Alkhouri, MD Department of Pediatric Gastroenterology
Richard Lorber, MD Department of Pediatric Cardiology
Douglas Rogers, MD Section Head, Pediatric Endocrinology
Vascular Medicine
John R. Bartholomew, MD, Section Head
Christopher Bajzer, MD
Robert Bauman, MD
Natalie Evans, MD
Carmen Fonseca, MD
Leslie Gilbert, MD
Marcelo Gomes, MD
Heather L. Gornik, MD
Douglas Joseph, DO
Samir Kapadia, MD
Soo Hyun (Esther) Kim, MD
Natalia Fendrikova Mahlay, MD
Michael Maier, DPM
William Ruschhaupt, MD
Mehdi Shishehbor, DO
Patrick L. Whitlow, MD
Women’s Cardiovascular Center
Leslie Cho, MD, Director
Julie Huang, MD
Soo Hyun (Esther) Kim, MD
Ellen Mayer-Sabik, MD
Pediatric and Adult Congenital Heart Surgery Research
Marshall Jacobs, MD, Director Clinical Research
Cardiothoracic Anesthesiology
Michael S. O’Connor, DO, Chairman
Colleen Koch, MD, Vice Chair
Michael Licina, MD, Vice Chair
John Apostolakis, MD, Quality Review Officer
Ahmad Adi, MD
Andrej Alfirevic, MD
C. Allen Bashour, MD
M. Gregory Bourdakos, MD
Sergio Bustamante, MD
Michelle Capdeville, MD
Gohar Dar, MD
Pierre DeVilliers, MD
Andra Duncan, MD
Brian Fitzsimons, MD
Marius Gota, MD
Michael Hauser, MD
Steven Insler, DO
Brian Johnson, MD
Erik Kraenzler, MD
Tory McGrath, MD
Anand Mehta, MD
Michael S. O’Connor, DO
Grzegorz Pitas, MD
Dominique Prud’Homme, MD
Shiva Sale, MD
∆Chair Holders
Outcomes 2012102
Staff Listing
Research
Clinical Investigations
Eugene H. Blackstone, MD∆, Director
Vascular Surgery Research
Roy K. Greenberg, MD, Director of Endovascular Research
Cardiovascular Research and C5Research (Cleveland Clinic Coordinating Center for Clinical Research)
A. Michael Lincoff, MD∆, Director
Stephen J. Nicholls, MD, PhD, Cardiovascular Director
Associate Directors of C5Research
Heather L. Gornik, MD
Roy K. Greenberg, MD
Wael A. Jaber, MD
David O. Martin, MD
Stephen J. Nicholls, MD, PhD
W.H. Wilson Tang, MD
Patrick L. Whitlow, MD
C5Research Core Laboratory Directors
Roy K. Greenberg, MD
Stanley L. Hazen, MD, PhD
Wael A. Jaber, MD
Soo Hyun (Esther) Kim, MD
Venugopal Menon, MD
Mehdi H. Shishehbor, DO
Robert M. Savage, MD
Joyce Shin, MD
Norman J. Starr, MD
Carlos Trombetta, MD
Lee Wallace, MD
Jean-Pierre Yared, MD
Cardiovascular Intensive Care Units Anesthesiology
Jean-Pierre Yared, MD, Medical Director, Cardiovascular ICU Director, Center for Critical Care Medicine
David Anthony, MD
C. Allen Bashour, MD
Gregory Bourdakos, MD
Gohar Dar, MD
Andra Duncan, MD
Marius Gota, MD
Steven Insler, DO
Eric Kaiser, MD
Donn Marciniak, MD
Michael S. O’Connor, DO
Robert Savage, MD
Vascular Surgery Anesthesiology
Theodore Marks, MD, Section Head
Maged Argalious, MD
Harendra Arora, MD
Jacek Cywinski, MD
Tracy Dovich, MD
Brian Fitzsimons, MD
Alexandru Gottlieb, MD
Robert Helfand, MD
Samuel Irefin, MD
Jia Lin, MD
Brian Parker, MD
Mangalakaraipudur Ramachandran, MD
Regional Medical Practice
Avon (Richard E. Jacobs) Health Center
Mark Angel, MD, Cardiovascular Medicine
James Bekeny, MD, Vascular Surgery
Thomas Callahan IV, MD, Cardiovascular Medicine
Lon W. Castle, MD, Cardiovascular Medicine
Albert Chan, MD, Cardiovascular Medicine
Basem Droubi, MD, Vascular Surgery
Lawrence Jacobs, MD, Cardiovascular Medicine
Jeanwan Kang, MD, Vascular Surgery
Soo Hyun (Esther) Kim, MD, Vascular Medicine
Chiara Liguori, MD, Cardiovascular Medicine
Robert D. Mosteller, MD, Cardiovascular Medicine
Ashoka Nautiyal, MD, Cardiovascular Medicine
Christopher Smolock, MD, Vascular Surgery
Christine Tanaka-Esposito, MD, Cardiovascular Medicine
Beachwood Family Health and Surgery Center
Joseph Cacchione, MD, Cardiovascular Medicine
Leslie Gilbert, MD, Vascular Medicine
Joel B. Holland, MD, Cardiovascular Medicine
Carlos Hubbard, MD, Cardiovascular Medicine
David Naar, MD, Vascular Surgery
103Sydell and Arnold Miller Family Heart & Vascular Institute
Institute Overview
Michael B. Rocco, MD, Cardiovascular Medicine
Sunita Srivastava, MD, Vascular Surgery
Patrick Tchou, MD, Cardiovascular Medicine
Brunswick Family Health Center
Joel Godard, MD, Cardiovascular Medicine
Chagrin Falls Family Health Center
Jason Confino, MD, Cardiovascular Medicine
Leslie Gilbert, MD, Vascular Medicine
Joseph Martin, MD, Cardiovascular Medicine
Anthony Rizzo, MD, Vascular Surgery
Elyria Family Health Center
David Joyce, MD, Cardiovascular Medicine
Cleveland Clinic Florida
Richard Adamick, MD, Cardiovascular Medicine
Marianela Areces, MD, Cardiovascular Medicine
Craig Asher, MD, Cardiovascular Medicine
Jose Baez-Escudero, MD, Cardiovascular Medicine
Andrew Boyle, MD, Cardiovascular Medicine
Nicolas Brozzi, MD, Cardiothoracic Surgery
Howard S. Bush, MD, Cardiovascular Medicine
Carmel Celestin, MD, Vascular Medicine
Mehrdad Farid, MD, Vascular Medicine
Bernardo Fernandez, MD, Vascular Medicine
Kenneth Fromkin, MD, Cardiovascular Medicine
Mark Grove, MD, Vascular Surgery
Marcelo Eduardo Helguera, MD, Cardiovascular Medicine
Terry King, MD, Vascular Surgery
Darryl Miller, MD, Vascular Surgery
Viviana Navas, MD, Cardiovascular Medicine
Gian Novaro, MD, Cardiovascular Medicine
Sergio Pinski, MD, Cardiovascular Medicine
Edward Savage, MD, Cardiothoracic Surgery
Michael Shen, MD, Cardiovascular Medicine
David Wolinsky, MD, Cardiovascular Medicine
Independence Family Health Center
Caroline Casserly, MD, MBA, Cardiovascular Medicine
Joel Godard, MD, Cardiovascular Medicine
Lawrence Jacobs, MD, Cardiovascular Medicine
Rebecca Kelso, MD, Vascular Surgery
Michael Maier, DPM, Vascular Medicine
Sudish Murthy, MD, Thoracic Surgery
Michael B. Rollins, MD, Cardiovascular Medicine
Lorain Family Health and Surgery Center
David Joyce, MD, Cardiovascular Medicine
Michael Langer, DO, Cardiovascular Medicine
Theodore Pacheco, MD, Cardiovascular Medicine
Richard Sterba, MD, Pediatric Cardiology
Mentor Medical Office Building
Abdul Wattar, MD, Cardiovascular Medicine
Strongsville Family Health and Surgery Center
John R. Bartholomew, MD, Vascular Medicine
Joel Godard, MD, Cardiovascular Medicine
Outcomes 2012104
Staff Listing
Matthew Kaminski, MD, Cardiovascular Medicine
Natalia Fendrikova Mahlay, MD, Vascular Medicine
Tara Mastracci, MD, Vascular Surgery
Robert Mosteller, MD, Cardiovascular Medicine
Daniel Raymond, MD, Thoracic Surgery
Terrence G. Tulisiak, MD, Cardiovascular Medicine
Twinsburg Family Health Center
George Anton, MD, Vascular Surgery
Daniel Cantillon, MD, Cardiovascular Medicine
Jason Confino, MD, Cardiovascular Medicine
Joseph Martin, MD, Cardiovascular Medicine
Mark Pace, DO, Cardiovascular Medicine
Willoughby Hills Family Health Center
Mohamed A. Atassi, MD, Cardiovascular Medicine
Leslie Gilbert, MD, Vascular Medicine
Kamal Riad, MD, Cardiovascular Medicine
Lincoln Roland, MD, Vascular Surgery
Abdul Wattar, MD, Cardiovascular Medicine
Niraj Varma, MD, PhD, Cardiovascular Medicine
Wooster Family Health Center
Kenneth E. Shafer, MD, Cardiovascular Medicine
Richard Sterba, MD, Pediatric Cardiology
Bennett Werner, MD, Cardiovascular Medicine
Cleveland Clinic Hospitals
Ashtabula Medical Center
Perry L. Fleisher, MD, Cardiovascular Medicine
John Stephens, MD, Cardiovascular Medicine
Euclid Hospital
J. Michael Koch, MD, Cardiovascular Medicine
Fairview Hospital
Albert Chan, MD, Cardiovascular Medicine
Basem Droubi, MD, Vascular 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
Hillcrest Hospital
Rami Akhrass, MD, Thoracic and Cardiovascular Surgery
George Anton, MD, Vascular Surgery
Mark J. Botham, MD, Thoracic and Cardiovascular Surgery
Avrum Jacobs, MD, Cardiovascular Medicine
David Naar, MD, Vascular Surgery
Anthony Rizzo, MD, Vascular Surgery
Lincoln Roland, MD, Vascular Surgery
Thomas G. Santoscoy, MD, Thoracic and Cardiovascular Surgery
T. Mark Sequeira, MD, Cardiovascular Medicine
105Sydell and Arnold Miller Family Heart & Vascular Institute
Institute Overview
Jonathan Scharfstein, MD, Cardiovascular Medicine
Vladimir Vekstein, MD, Cardiovascular Medicine
Donna J. Waite, MD, Thoracic and Cardiovascular Surgery
Martin Wiseman, MD, Cardiovascular Medicine
Lakewood Hospital
Rami Akhrass, MD, Thoracic and Cardiovascular Surgery
Mark Angel, MD, Cardiovascular Medicine
James Bekeny, MD, Vascular Surgery
Albert Chan, MD, Cardiovascular Medicine
Basem Droubi, MD, Vascular Surgery
Khodanpur Guruprasad, MD, Cardiovascular Medicine
A. George Hawwa, MD, Cardiovascular Medicine
Wael Khoury, MD, Cardiovascular Medicine
Douglas Joseph, DO, Cardiovascular Medicine
Thomas Santoscoy, MD, Thoracic and Cardiovascular Surgery
Amir Taraben, MD, Cardiovascular Medicine
R. Thomas Temes, MD, Thoracic and Cardiovascular Surgery
Marymount Hospital
Javier Alvarez-Tostado, MD, Vascular Surgery
Khodanpur Guruprasad, MD, Cardiovascular Medicine
A. George Hawwa, MD, Cardiovascular Medicine
Wael Khoury, MD, Cardiovascular Medicine
John Patzakis, DO, Vascular Surgery
Sotero Peralta, MD, Vascular Surgery
James Poliquin, MD, Vascular Surgery
Amir Taraben, MD, Cardiovascular Medicine
Donna J. Waite, MD, Thoracic and Cardiovascular Surgery
Medina Hospital
Michael Amalfitano, DO, Cardiovascular Medicine
Kathleen Boyle, MD, Vascular Surgery
Natalia Fendrikova Mahlay, MD, Cardiovascular Medicine
Siva Raja, MD, Thoracic Surgery
Matthew Kaminski, MD, Cardiovascular Medicine
South Pointe Hospital
Monica Khot, MD, Cardiovascular Medicine
Michael Koch, MD, Cardiovascular Medicine
Abdul Wattar, MD, Cardiovascular Medicine
Some physicians may practice in multiple locations.
For a complete list including staff photos, please visit
clevelandclinic.org/staff
Outcomes 2012106
Staff Listing
107Sydell and Arnold Miller Family Heart & Vascular Institute
Contact Information
Sydell and Arnold Miller Family Heart & Vascular Institute
General Information and Appointments800.659.7822
Thoracic and Cardiovascular Surgery EvaluationNurse practice managers will expedite patient record review with a Cleveland Clinic surgeon and address questions.216.444.3500 or 877.8HEART1 (877.843.2781)
Cardiovascular Medicine Appointments/Referrals216.444.6697 or 800.223.2273, ext. 46697
Vascular Medicine Appointments/Referrals216.444.4420 or 800.223.2273, ext. 44420
Vascular Surgery Appointments/Referrals 216.444.4508 or 800.223.2273, ext. 44508
Sydell and Arnold Miller Family Heart & Vascular Institute Resource CenterNurses are available Monday through Friday, 8:30 a.m. to 4:00 p.m., Eastern time, to answer patient questions and concerns about heart and blood vessel disease or to schedule a second opinion.216.445.9288 or 866.289.6911 or email heartcenter@ccf.org
On the Web at clevelandclinic.org/heart
Additional Contact Information
General Information 216.444.2200
Hospital Transfers24/7 hospital transfers or physician consults 800.553.5056
Referring Physician Center and HotlineCleveland Clinic’s Referring Physician Center has established a 24/7 hotline — 855.REFER.123 (855.733.3712) — to streamline access to our array of medical services. Contact the Referring Physician Hotline for information on our clinical specialties and services, to schedule and confirm patient appointments, for assistance in resolving service-related issues, and to connect with Cleveland Clinic specialists.
Medical Concierge for Out-of-State PatientsComplimentary assistance for out-of-state patients and families 800.223.2273, ext. 55580 or email medicalconcierge@ccf.org
Global Patient Services/International CenterComplimentary assistance for international patients and families001.216.444.8184 or visit clevelandclinic.org/gps
For address corrections or changes, please call800.890.2467
Outcomes 2012108
The Sydell and Arnold Miller Family Heart & Vascular Institute physicians see patients at the locations below. Please inquire about the availability of specific services at each location when calling.
Cleveland Clinic Main Campus 9500 Euclid Ave. Cleveland, OH 44195 216.444.2200 or 800.223.2273
Cleveland Clinic Florida 2950 Cleveland Clinic Blvd. Weston, FL 33331954.659.5320 clevelandclinic.org/florida Cardiovascular medicine, vascular medicine, cardiothoracic surgery, thoracic surgery
Ashtabula County Medical Center2420 Lake Road Ashtabula, OH 44004440.994.7622 acmchealth.orgCardiovascular medicine
Beachwood Family Health and Surgery Center26900 Cedar Road Beachwood, OH 44122216.839.3000 or toll-free 866.318.2491 Cardiovascular medicine, vascular surgery
Brunswick Family Health Center3574 Center Road Brunswick, OH 44212330.225.8886Cardiovascular medicine
Elyria Family Health and Surgery Center303 Chestnut Commons Drive Elyria, OH 44035440.366.9444 or 440.204.7900Vascular surgery
Euclid Hospital18901 Lakeshore Blvd. Euclid, OH 44119216.531.9000 euclidhospital.orgCardiovascular medicine
Fairview HospitalFairview Physicians’ Center 18101 Lorain Ave. Cleveland, OH 44111216.476.7310 fairviewhospital.orgCardiovascular medicine, cardiothoracic surgery, vascular surgery
Hillcrest Hospital 6780 Mayfield Road Mayfield Heights, OH 44124440.449.9300 hillcresthospital.orgCardiovascular medicine, cardiothoracic surgery, vascular surgery
Independence Family Health CenterCrown Centre II 5001 Rockside Road Independence, OH 44131216.986.4000Cardiovascular medicine, vascular surgery, thoracic surgery
Institute Locations
Lorain Family Health and Surgery Center5700 Cooper Foster Park Road Lorain, OH 44053440.204.7400 or 800.272.2676 Pediatric cardiovascular medicine, vascular surgery
Marymount Hospital12300 McCracken Road Garfield Heights, OH 44125216.587.4280 marymount.orgVascular surgery, thoracic surgery
Medina Hospital1000 E. Washington St. Medina, OH 44256330.725.1000Cardiovascular medicine, vascular surgery, thoracic surgery
South Pointe Hospital20000 Harvard Road Warrensville Heights, OH 44122216.491.6000 southpointehospital.orgCardiovascular medicine, thoracic surgery
Strongsville Family Health and Surgery Center16761 SouthPark Center Strongsville, OH 44136440.878.2500 or 800.239.1098 Cardiovascular medicine, vascular medicine, vascular surgery, thoracic surgery
Twinsburg Medical Office8701 Darrow RoadTwinsburg, OH 44087330.888.4000 Cardiovascular medicine, vascular surgery
Westlake Family Health Center30033 Clemens Road Westlake, OH 44145440.899.5555 or 800.599.7771 Cardiovascular medicine, thoracic and cardiovascular surgery
Willoughby Hills Family Health Center2570 SOM Center Road Willoughby Hills, OH 44094440.943.2500 or 800.807.2888 Cardiovascular medicine, vascular medicine
Wooster Family Health and Surgery Center 1740 Cleveland Road Wooster, OH 44691330.287.4500 or 800.451.9870 Cardiovascular medicine
109Sydell and Arnold Miller Family Heart & Vascular Institute
Clinical and Research Alliance
MedStar Heart Institute5565 Sterrett Place Columbia, MD 21044877.772.6505
Heart & Vascular Institute Affiliates
The Bellevue Hospital1400 W. Main St.Bellevue, OH 44811419.483.4040 bellevuehospital.com
Cadence Health25 N. Winfield Road Winfield, IL 60190 cdh.org
Cleveland Clinic Florida2950 Cleveland Clinic Blvd.Weston, FL 33331954.659.5320
Fisher-Titus Medical Center272 Benedict Ave.Norwalk, OH 44857419.668.8101 fisher-titus.org
Forsyth Medical Center3333 Silas Creek ParkwayWinston-Salem, NC 27103336.718.5000 forsythmedicalcenter.org
Presbyterian Hospital200 Hawthorne LaneCharlotte, NC 28204704.384.4000 presbyterian.org
Saint Vincent232 W. 25th St.Erie, PA 16544814.452.5000 saintvincenthealth.com
Heart Surgery Affiliates
Cape Fear Valley Health System1638 Owen Drive Fayetteville, NC 28304 910.609.4000 www.capefearvalley.comCardiothoracic surgery
Chester County Hospital 701 E. Marshall St. West Chester, PA 19380610.738.2690 www.cchosp.com Cardiothoracic surgery
EMH Regional Medical CenterGates Medical Building, Suite 101 630 E. River St. Elyria, OH 44035440.284.1504 emh-healthcare.orgCardiothoracic surgery
Outcomes 2012110
Alliances and Affiliations
Fairview Hospital18101 Lorain Ave.Cleveland, OH 44111216.476.7310 fairviewhospital.orgCardiothoracic surgery, vascular surgery, cardiovascular medicine
Hillcrest Hospital6780 Mayfield Rd.Mayfield Heights, OH 44124440.449.9300Cardiothoracic surgery, vascular surgey, cardiovascular medicine
Lake Health WestLake West Medical Building, Suite 28036000 Euclid Ave. Willoughby, OH 44094440.918.4640 lakehealth.orgCardiothoracic surgery
MetroHealth Medical Center2500 MetroHealth Drive Cleveland, OH 44109216.778.4304 metrohealth.orgCardiothoracic surgery
Rochester General Hospital1425 Portland Ave. Rochester, NY 14621585.544.6550 rochestergeneralhospital.orgCardiothoracic surgery
111Sydell and Arnold Miller Family Heart & Vascular Institute
Overview
Cleveland Clinic is an academic medical center offering patient care services supported by research and education in a nonprofit group practice setting. More than 3,000 Cleveland Clinic staff physicians and scientists in 120 medical specialties care for more than 5 million patients across the system, performing more than 200,000 surgeries and conducting 450,000 Emergency Department visits. Patients come to Cleveland Clinic from all 50 states and more than 132 nations around the world.
Cleveland Clinic is an integrated healthcare delivery system with local, national, and international reach. The main campus in midtown Cleveland, Ohio, has a 1,450-bed hospital, outpatient clinic, specialty institutes, labs, classrooms, and research facilities in 46 buildings on 167 acres. Cleveland Clinic patients represent the highest CMS case-mix index in the nation. Cleveland Clinic encompasses 75 northern Ohio outpatient locations, including 16 full-service family health centers, eight community hospitals, an affiliate hospital, and a rehabilitation hospital for children. Cleveland Clinic also includes Cleveland Clinic Florida, Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas, Cleveland Clinic Canada, and Sheikh Khalifa Medical City (management contract). Cleveland Clinic Abu Dhabi is a full-service hospital and outpatient center in the United Arab Emirates scheduled to begin offering services in 2014. Cleveland Clinic is the second-largest employer in Ohio with nearly 44,000 employees. It generates $10.5 billion of economic activity a year.
The Cleveland Clinic Model
Cleveland Clinic was founded in 1921 by four physicians who had served in World War I and hoped to replicate the organizational efficiency of military medicine. The organization has grown through the years by adhering to the model set forth by the founders. All Cleveland Clinic staff physicians receive a straight salary with no bonuses or other financial incentives. The hospital and physicians share a financial interest in controlling costs, and profits are reinvested in research and education.
The Cleveland Clinic system began to grow in 1987 with the founding of Cleveland Clinic Florida and expanded in the 1990s with the development of 16 family health centers across Northeast Ohio. Fairview Hospital, Hillcrest Hospital, and six other community hospitals joined Cleveland Clinic over the past decade and a half, offering Cleveland Clinic institute services in heart and neurological care, physical rehabilitation, and more. Clinical and support services were reorganized into 27 patient-centered institutes beginning in 2007. Institutes combine medical and surgical specialists around specific diseases or body systems under single leadership and in a shared location to provide optimal team care for every patient. Institutes work with the Office of Patient Experience to give every patient the best outcome and experience.
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About Cleveland Clinic
Cleveland Clinic Lerner Research Institute At the Lerner Research Institute, hundreds of principal investigators, project scientists, research associates, and postdoctoral fellows are involved in laboratory-based translational and clinical research. Total research expenditures from external and internal sources exceeded $265 million in 2012. Research programs include cardiovascular, oncology, neurology, musculoskeletal, allergy and immunology, ophthalmology, metabolism, and infectious diseases.
Cleveland Clinic Lerner College of Medicine Lerner College of Medicine of Case Western Reserve University, which celebrated its 10th anniversary in 2012, is known for its small class size, unique curriculum, and full-tuition scholarships for all students. The program is open to 32 students who are preparing to be physician investigators.
Graduate Medical Education In 2012, nearly 1,800 residents and fellows trained at Cleveland Clinic and Cleveland Clinic Florida, which is part of a continuing upward trend.
U.S. News & World Report Ranking Cleveland Clinic is consistently ranked among the top hospitals in America by U.S. News & World Report, and our heart and heart surgery program has been ranked No. 1 in the nation since 1995. In 2012, Cleveland Clinic’s urology and nephrology programs were both ranked No. 1 in the nation.
For more information about Cleveland Clinic, please visit clevelandclinic.org.
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Referring Physician Center and Hotline
24/7 hotline to streamline access to our array of medical services and schedule patient appointments, call 855.REFER.123 (855.733.3712), email refdr@ccf.org, or visit clevelandclinic.org/refer123.
Remote Consults
Online medical second opinions from Cleveland Clinic’s MyConsult® are particularly valuable for patients who wish to avoid the time and expense of travel. Cleveland Clinic offers online medical second opinions for more than 1,200 life-threatening and life-altering diagnoses. For more information, visit clevelandclinic.org/myconsult, email eclevelandclinic@ccf.org, or call 800.223.2273, ext. 43223.
Request Medical Records
216.444.2640 or 800.223.2273, ext. 42640
Track Your Patients’ Care Online
DrConnect® offers referring physicians secure access to their patients’ treatment progress while at Cleveland Clinic. To establish a DrConnect account, visit clevelandclinic.org/drconnect or email drconnect@ccf.org.
Medical Records Online
Cleveland Clinic continues to expand and improve electronic medical records (EMRs) to provide faster, more efficient, and more accurate care by sharing patient data through a highly secure network. Patients using MyChart® can renew prescriptions and review test results and medications from their personal computers. MyChart provides a link to Microsoft HealthVault, a free online
service that helps patients securely gather and store health information. It connects to Cleveland Clinic’s social media and Internet site, currently the most visited hospital website in America. For more information, visit clevelandclinic.org/mychart.
Critical Care Transport Worldwide
Cleveland Clinic’s critical care transport team and fleet of mobile ICU vehicles, helicopters, and fixed-wing aircraft serve critically ill and highly complex patients across the globe.
To arrange a transfer for STEMI (ST elevated myocardial infarction), acute stroke, ICH (intracerebral hemorrhage), SAH (subarachnoid hemorrhage), or aortic syndrome, call 877.379.CODE (2633).
For all other critical care transfers, call 216.444.8302 or 800.553.5056.
CME Opportunities: Live and Online
Cleveland Clinic’s Center for Continuing Education operates one of the largest and most successful CME programs in the country. The center’s website (ccfcme.org) is an educational resource for healthcare providers and the public. Available 24/7, it houses programs that cover topics in 30 areas. Among other resources, the website contains a virtual textbook of medicine (Disease Management Project) and myCME, a system for physicians to manage their CME portfolios. Live courses, however, remain the backbone of the center’s CME operation. Most live courses are held in Cleveland, but outreach plans are underway.
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Resources
Clinical Trials
Since its establishment in 1921, Cleveland Clinic has been an innovator in medical breakthroughs, with a mission of unlocking basic science and pursuing clinical research. Today, Cleveland Clinic is running more than 2,000 clinical trials of various types. Our researchers are focusing on an array of conditions, including breast and liver cancer, coronary artery disease, heart failure, epilepsy, Parkinson disease, chronic obstructive pulmonary disease, asthma, high blood pressure, diabetes, depression, and eating disorders. To learn more, go to clevelandclinic.org/research.
Healthcare Executive Education
Cleveland Clinic’s dynamic executive education program provides real-world insights into the highly competitive business of healthcare. The Executive Visitors’ Program is an intensive three-day program that provides a behind-the-scenes view of our organization for the busy executive. The Samson Global Leadership Academy is a two-week immersion into the challenges of leadership, management, and innovation. The curriculum includes coaching and a personalized three-year leadership development plan. Learn more at clevelandclinic.org/execed.
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Treating the Whole Patient
The Heart & Vascular Institute works together with the Office of Patient Experience, Spiritual Care Department, Healing Services, and the Arts & Medicine Institute to provide a full range of complimentary services to patients and their families.
Services include light massage therapy, reiki and Healing TouchTM therapies, art and music therapy, and a guided imagery program to help patients relax and prepare for surgery or other procedures.
The chapel and Muslim prayer room are available to everyone throughout their time at Cleveland Clinic.
Art programs include art therapy, guided tours, and the Cleveland Museum of Art Distance Learning Program — an interactive experience that allows participants to take a virtual tour through some of the world’s best galleries via high-definition videoconferencing.
Each day, there are scheduled activities on the rooftop plaza. The space provides a spectacular view of the city. Guests can enjoy yoga, chair massages, labyrinth walk meditation, reiki, live cooking demonstrations, concerts, and tea.
In addition, the Sydell and Arnold Miller Family Pavilion hosts many musical and other performances and events throughout the year.
Patient and Family Health and Education Center
800.223.2273, ext. 43771 healthl@ccf.org
The Patient and Family Health and Education Center has provided resources to patients and visitors since October 2008. The center serves as a library of health and education materials. In addition, patients and guests have access to complimentary computers with Internet access, audio and video education programs, and health education classes and screenings. There were 11,436 visitors to the center in 2012.
Heart & Vascular Institute Resource Nurses866.289.6911 heartcenter@ccf.org
A team of dedicated, experienced nurses staffs the Resource Center. They answer thoracic- and cardiovascular-related questions by phone, email and online chat. This service is open to everyone and is especially helpful to those who do not have immediate access to a Cleveland Clinic cardiologist or surgeon. In 2012, there were 24,009 total contacts. This includes 11,226 phone calls; 5,636 online chats; 5,065 webmails; and 2,082 email, mail, in-person and other contacts.
The nurses also staff a 24/7 toll-free inbound call line for all patients discharged from the institute who have questions or concerns after they leave the hospital. In 2012, they answered 19,013 calls. The effort to improve the patient experience also includes a follow-up phone call from a registered nurse to every patient. Patients are asked about symptoms, complications, or concerns they may have once they are home.
Staying in Touch
The Heart & Vascular Institute has a variety of ways for patients and others to contact the institute and learn more about topics related to heart and vascular health. The institute’s Twitter account (twitter.com/ClevClinicHeart) has more than 1,500 followers and was recently named one of Good Housekeeping’s 14 Most Trusted Health Sites. In 2012, the institute hosted 41 live webchats with experts who answered questions about specific thoracic and cardiovascular topics. Transcripts are posted at clevelandclinic.org/heart/webchat. In 2012, the institute’s website (clevelandclinic.org/heart) and blog (health.clevelandclinic.org/heart) received more than 7 million visits combined. TheYouTube channel (youtube.com/clevelandclinic) receives more than 2 million views a year.
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Institute Resources
© The Cleveland Clinic Foundation 2013
This project would not have been possible without the commitment and expertise of a team led by Dr. Umesh Khot, Pam Goepfarth, Sandra Hays, and Vi Huynh. Graphic design and photography were provided by Brian Kohlbacher, Robin Bova, and Cleveland Clinic’s Center for Medical Art and Photography.
9500 Euclid Avenue, Cleveland, OH 44195 ClevelandClinic.org
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