The Department of Thoracic and Cardiovascular Surgery ispleasedtopresentour2005editionof Surgical Outcomes.Thisisthe2nd abridged version of cardiothoracic surgical results of FairviewHospital,relatingouroutcomestonationalstandardsestablishedbyTheSocietyofThoracicSurgeons.

Theoutcomesreportedherearetheresultofthecollabora-tive efforts of cardiothoracic surgeons, cardiologists, cardiac anes-thesiologists,vascularsurgeons,andcardiovascularradiologists.Inthefuture,treatingpatientswithcardiovasculardiseasewillbecomeevermorecomplexandexcitingasnewsurgicaltechniquesandtech-nologiesemerge.Maintainingahighlevelofcareforourpatientswillrequire maintaining a high level of collaboration between FairviewHospital,ourClevelandClinicmaincampusandourcardiothoraciccolleaguesnationallyandinternationally.

We hope that you will find this information helpful andthoughtprovoking.

BruceW.Lytle,M.D.Chairman,DepartmentofThoracicandCardiovascularSurgery

CLEVELAND CLINIC

Cleveland Clinic, located in Cleveland, Ohio, is a not-for-profit, academic medical center that integrates clinical and hospital care with research and education. The Clinic was founded in 1921 by four renowned physicians with a vision of providing out-standing patient care based upon the principles of cooperation, compassion, and innovation. Today, more than 1,700 Cleveland Clinic physicians and scientists practice in 120 medical special-ties and subspecialties.

The Cleveland Clinic’s main campus, with 37 buildings, in-cludes a 1,000-bed hospital, outpatient clinic, children’s hos-pital, cancer center, eye institute, and supporting laboratories and facilities. As part of the Cleveland Clinic Health System, the Clinic also operates 12 family health centers, 9 community hos-pitals and 3 affiliate hospitals, and a medical facility in Florida. The health system employs more than 33,000 people.

Table of Contents

Overview 4

CoronaryDisease 8

GeneralThoracic 10

Innovation 12

StaffBiographies 16

ContactInformation 18

� Overview

41% CABG

37% Thoracic

1% Valve

7% Pacemaker

2005 CASE DiStribution

14% Other

Fairview Hospital has now completed its second full year of affiliation with the Cleveland Clinic Department of Thoracic and Cardiovascular Surgery. Year two was a successful one, with consistently high surgical volumes as well as outstanding outcomes. This affiliation continues to provide access to new technology and pro-cedures tested and validated at Cleveland Clinic and to enhance the cardiovascular care of the patients whom we serve.

2005 Total Cases �32

Cardiac Cases 233

�

CArDiAC CASES

In 200�, Cleveland Clinic thoracic and cardiovascular surgeons performed a total of �32 procedures at Fairview Hospital. Of these, 233 were cardiac procedures, 160 were thoracic procedures, and 39 were other procedures.

75% CABG

2% Valve

8% CABG & Valve

15% All Other

Coronary artery bypass grafting (CABG) operations accounted for 7�% of the cardiac procedures. Valves and other cardiac proce-dures, including aortic surgery, represented 2�% of all cardiac cases.

In 200�, the mean age of patients under-going isolated CABG at Fairview Hospital was 6� years. �0% of the patients were septuagenarians or octogenarians.

500500

400400

300300

200200

100100

00

2004

#of Patients

2005

OtherThoracicCardiac

4040

3030

2020

1010

00

<50 50-59 ≥8060-69 70-79

#of Patients

2004 The year Fairview Hospital became a Cleveland Clinic thoracic and cardiovascular surgery affiliate program site.

6 Overview

49% Elective

44% Urgent

6% Emergent

1% Salvage

0%

0%

0%

3.4%

4.2%

2.3%

1.9%

1.6%

HospitalMortality

% of Patients

00 2020 4040 6060 8080 100100

Hypertension

Smoking

Diabetes

Heart Failure

Chronic Lung Dx

PVD

Cerebrovasc Dx

Renal Failure

SurgiCAl ExpEriEnCE

Thoracic case volume in 200� increased 21% compared with 200�.

200200

150150

5050

100100

00

#of Patients

IsolatedCABG

OtherValveProcedures

Pacemakers ThoracicProcedures

20042005

In 200�, 93% of all cardiac cases were non-emergent.

73% of our patients were male and 27% female.

27% Female

73% Male

riSk fACtorS

Although age and gender are known risk factors affecting outcomes, other factors may have an adverse effect as well.

7

VAlVE SurgEry

In 200�, the number of valve procedures remained consistent with 200�. There were no valve mortalities for the second consecutive year.

VAlVE DEViCES

33 valves were repaired or replaced in 200� at Fairview Hospital. The majority were bioprosthetic implants.

1515

1010

55

00

#of Patients

AVReplacement

MVReplacement

AVReplacement

& CABG

MVReplacement

& CABG

20042005

82% Bioprosthesis

9% Annuloplasty

9% Mechanical

A 43-year-old American missionary working in Romania, Richard Millhouse knew since he was 17 that someday he would need a new heart valve. Home for Christ-mas for the first time in 11 years, he consulted cardiologist Ashoka Nautiyal, M.D., at Cleveland Clinic’s Westlake Family Health Center. “If you were a member of my family, I’d suggest you have the valve replaced now,” said Dr. Nautiayal. Before seeing Cleveland Clinic surgeon Baldev Sekhon M.D., Mr. Millhouse researched heart valves on the internet, determining to ask for a Edwards Pericardial Tissue Valve, because it would not require lifelong use of the drug coumadin (possibly unavailable back in Ro-mania). It turned out to be the valve Dr. Sekhon himself would have chosen. During surgery, Dr. Sekhon made his initial cut higher up on the aorta than usual, and dis-covered a slight abnormality – a discovery, that enabled him to perform a less-com-plicated repair than might otherwise have been needed if the abnormality had been found later. “I don’t know why I made the cut higher,” Dr. Sekhon told Mr. Millhouse’s wife after the surgery. The devout Mrs. Millhouse saw a larger force at work, “guiding the hands of a skilled, experienced heart surgeon.” But for Cleveland Clinic heart surgeons, medical miracles are a daily occurance.

Medical Miracle?

� Coronary Disease

98% Arterial

2% Vein Only

Arterial grafts, with their excellent long-term patency, remain the conduits of choice for coronary revascularization. In 200�, 9�% of all patients received at least one arterial graft.

ArtEriAl grAftS

In 200�, 9�% of all CABG patients received at least one internal thoracic artery graft, 3% received two, and 10% received a radial artery graft.

poStopErAtiVE morbiDity

In 200�, 6 patients required prolonged ventilation and 3 developed new-onset renal failure following isolated CABG. There were no other major complications.

100100

8080

6060

4040

2020

00ITA Double

ITARadial

%of Patients

55

44

33

22

11

00

ReopBleeding

CVA RenalFailure

PeriopMI

VentProlonged

SternalInfection

%of Patients

9

The number of years Fairview has participated in the STS Adult Cardiac Nation-al Database.

2

mortAlity

In-hospital mortality for isolated CABG was 1.1%, well below the Society of Thoracic Surgeons’ national benchmark of 2.2%.

lEngth of StAy

The average postoperative length of stay for isolated CABG was �.1 days in 200�, 0.� days less than in 200�. The national average reported by the Society of Thoracic Surgeons is 6.9 days.

SEVErity SCorE

The Cleveland Clinic Higgins Severity Score is a tool that utilizes risk factors to predict outcomes. In 200�, most patients had a severity score of less than �.

2.52.5

2.02.0

1.51.5

1.01.0

.5.5

002004 2005 STS

%

88

66

44

22

002004 2005 STS

Days

00

5050

4040

0 1 2 3 4 5 6 7 8 9 10 >10

2020

3030

1010

Patients (#)Patients (#)

Severity Score

0

50

Mortality (%)

40

20

10

30

10 General Thoracic

77% Open

23% Minimally Invasive

24% Mediastinum

31% Pulmonary

19% Pleura

13% Pericardium

7% Chest Wall

3% Airway3% Esophagogastric

In 200�, Cleveland Clinic thoracic and cardiovascular surgeons per-formed 160 thoracic procedures at Fairview Hospital. This represents a 20% increase from 200�.

SurgiCAl ApproACh

77% of these operations were open procedures, including lobectomies, pneumonecto-mies, and limited resections. 23% were performed using a minimally invasive approach.

DiStribution of proCEDurES

00

200200

150150

100100

5050

2004

#of Patients

2005

11

57% Wedge

37% Lobectomy

4% Pneumonectomy2% Segmentectomy

41% Mediastinoscopy

20% Other

9% Biopsy

4% Chest Wall

26% Mediastinal Resection

35% Pericardial Window-Resection

20% Decortication

7% Pleural Drainage

2% Other36% Air Leak Control

Wedge resections represented �7% of all pulmonary procedures performed in 200�.

Mediastinoscopies and mediastinal resections accounted for 67% of all mediastinal and chest wall cases.

Pericardial procedures and air leak control procedures represented 71% of all procedures performed on the pleura and pericardium.

12 Innovation

PERCUTANEOUS FUNCTIONAL TRICUSPID VALVE

Cleveland Clinic performed the first percutaneous tricuspid valve replacement, using a device developed at our institu-tion. The patient had severe radiation heart disease, had undergone previous pericardectomy, and was plagued by recurring ascites due to severe tricuspid regurgitation. At one-year follow-up, her new valve remains competent, and her quality of life is improved.

LEFT ATRIALAPPENDAGE LIGATION

Physicians and researchers at Cleveland Clinic have de-

veloped a ligation device for clipping and isolating the left

atrial appendage. Clinical trials of this device will begin in

mid-2006.

TRANSCATHETER AND GUIDE WIRE VALVE REPLACEMENTS

A

a) Transapical valve being placed

b) Balloon catheter with valve

c) Ballooninflationtosecurethevalve

bC

ClevelandClinicisoneofonlythreesitesintheUnitedStatesapprovedforpercutaneousaorticvalvereplacement.Thisnewtechnologyhasthepotentialtoredefinevalvesurgery.

This three-dimensional reconstruction CTA depicts the implanted valve within the inferior vena cava (white arrow) immediately inferior to the right atrium. Note the absence of contrast inferior to the valve (orange arrow). This demonstrates competence of the valve.

13

E-VALVE

ClevelandClinicphysiciansarenowinactivetrialswith

E-Valve,atechnologythattreatspatientsexperiencing

mitralregurgitationwithacliponthemitralvalveleaflets.

3D CT IMAGEAORTIC ROOT TRANSAPICAL

Cleveland Clinic has

created an innovative

online tool to improve

collaboration with

referring physicians.

Called Dr.Connect,

it allows referring

physicians to track their patients’ Cleveland Clinic

care in real time. Requiring no special software, the

fully secure, internet-based service can be integrated

into physicians’ office practices. Features include

daily e-mail updates of additions to patients’ medi-

cal records, a direct link to the Dr.Connect website,

new encounter updates, and searchable records. To

establish a Dr.Connect account, call 877.224.7367,

email drconnect@ccf.org, or register online at www.

eclevelandclinic.org.

New Tool for Referring Physicians

A b

For planning percutaneous valve and transapical aortic valve replacement, high-reso-lution CT scans are used to assess the aortic valve. The valve leaflets and central blood flows are clearly seen in this image.

a) E-Valvepercutaneousvalveclipbeingpositionedonmitralvalveleaflets

b) After mitral valve clip implant

inVEStigAtionAl DEViCE - limitED by uS fEDErAl lAw to inVEStigAtionAl uSE.

1� Innovation

bilEAflEt VAlVE

bilEAflEt VAlVE with flAp-ChorDAE

ENDOSCOPIC RADIAL ARTERY HARVESTING

In2005,weexpandedourminimallyinvasive

offeringtoincludeharvestingofradial

arteries.Ourexperiencewithendoscopic

saphenousveinharvestingprovideda

solidtechnicalskillbase.Patientsare

pleasedwiththeaesthetics,recovery,and

comfortofthislessinvasiveapproach.

This unique valve design is the invention of a Cleveland Clinic cardiac surgeon. Bioprosthetic valve design preserves the structural integrity of mitral annulus–pap-illary muscle continuity, which is essential for normal left ventricular function.

The native mitral valve provides a support-ing structure for the new bioprosthesis, and stentless design makes it hemodynam-ically efficient.

STENTLESS MITRAL VALVES

opEn

EnDoSCopiC

minimAlly inVASiVE lobECtomy

The images below illustrate an incision

from a traditional open thoracotomy

for lobectomy and a minimally invasive

lobectomy. Minimally invasive surgery

reduces blood loss, trauma, hospital

length of stay, and postoperative pain.

Increased surgical experience, advance-

ments in surgical technique, and revised

instrumentation have enabled many

thoracic operations to be performed

through a minimally invasive approach.

Open Minimally Invasive

1�

INNOVATIVE ARCH ANEURSYM REPAIR

Theimageatright,providedbyClevelandClinicvascular

surgeonRoyGreenberg,M.D.,demonstratesanarchaneu-

rysmrepairwithanaorticstentgraftbranchingintothe

leftcommoncarotidarteryandacarotid-subclavianartery

bypass.Ourcardiacsurgeonsfrequentlyworkintandem

withvascularsurgeons,offeringateam-basedapproachto

treatingcomplexaorticdisease.

SELF-SUPPORTED ANNULOPLASTY

Thiscomplete,self-supported,andsemi-flexiblemitralandtricuspidannuloplastystent-ringisintroducedpercutaneous-lyanddeployedintothesupraannularvalvularpositionusingballoonexpandabletechnology.Purposesofthisprostheticringaretorestrictandsupportthenativeannulus,correctandpreventvalvularregurgitation,andreestablishthenormalshapeandcontourofthenativeannulus,allowingeffectivefunctioningofthevalve.ThissystemisbeingdevelopedbystaffsurgeonJoséL.Navia,M.D.

MINIMALLY INVASIVE APPROACH FOR BIVENTRICULAR LEAD PLACEMENT

Cardiacsurgeonsarenowabletoinsertbiventricularleadsusingroboticsandathora-scopicapproachtotreatpatientswithheartfailure.Thefirstillustrationshowsrobotictechnologyforplacingpacingleadsontheventricle.Thesecondshowsthorascopicleadplacement.

16 Staff Biographies

Medical Director, Thoracic and Cardiovascular Surgery, Fairview Hospital, a Cleveland Clinic Hospital and Cleveland Clinic Thoracic and Cardiovascular Surgery Affiliate Program

Staff Surgeon, Thoracic and Cardiovascular Surgery, Lakewood Hospital, a Cleveland Clinic Hospital

Staff Surgeon, Thoracic and Cardiovascular Surgery, MetroHealth Medical Center, a Cleveland Clinic Thoracic and Cardiovascular Surgery Affiliate Program

SPECIALTIES: Surgical treatment of adult acquired heart disease, reoperations, ascending aorta surgery, off-pump coronary artery bypass grafting, esophageal surgery, lung surgery

MEDICAL DEGREE: Dayanand Medical College and Hospital, Punjab, India

SPECIAL TRAINING: Medical College of Georgia, Augusta, Georgia; Fairview General Hospital, Cleveland, Ohio

BOARD CERTIFICATIONS: American Board of Thoracic Surgery

CLINIC APPOINTMENT: 2004

Dr. Sekhon was born in Punjab, India, and now resides on the west side of Cleveland with his wife and three children. He enjoys hiking, racquetball, bicycling, golf, and reading.

BaldevSekhon,M.D.

17

R.ThomasTemes,M.D.,MBA

InderjitS.Gill,M.D.

Medical Director, Thoracic and Cardiovascular Surgery, MetroHealth Medical Center, a Cleveland Clinic Thoracic and Cardiovascular Surgery Affiliate Program

Staff Surgeon, Thoracic and Cardiovascular Surgery, Fairview Hospital, a Cleveland Clinic Hospital and Cleveland Clinic Thoracic and Cardiovascular Surgery Affiliate Program

Staff Surgeon, Thoracic and Cardiovascular Surgery, Lake West Hospital, a Cleveland Clinic Thoracic and Cardiovascular Surgery Affiliate Program

Staff Surgeon, Thoracic and Cardiovascular Surgery, Lakewood Hospital, a Cleveland Clinic Hospital

SPECIALTIES: Surgical treatment of adult acquired heart dis-ease, minimally invasive surgery, off-pump coronary artery by-pass surgery, surgery of the aorta, surgical treatment of atrial fibrillation, heart failure, and robotic cardiac surgery

MEDICAL DEGREE: Christian Medical College & Brown Memorial Hospital, Ludhiana, Punjab, India

SPECIAL TRAINING: University of Ottawa Heart Institute, Ottawa, Ontario, Canada; Cleveland Clinic, Cleveland, Ohio

BOARD CERTIFICATIONS: Cardiothoracic Surgery, Royal College of Physicians and Surgeons, Canada CLINIC APPOINTMENT: 1999

Dr. Gill is married and enjoys his three children, sailing, reading, and traveling.

Staff Surgeon, Thoracic and Cardiovascular Surgery, MetroHealth Medical Center, a Cleveland Clinic Thoracic and Cardiovascular Surgery Affiliate Program

Staff Surgeon, Thoracic and Cardiovascular Surgery, Fairview Hospital, a Cleveland Clinic Hospital and Cleveland Clinic Thoracic and Cardiovascular Surgery Affiliate Program

Staff Surgeon, Thoracic and Cardiovascular Surgery, Lakewood Hospital, a Cleveland Clinic Hospital

SPECIALTIES: Lung, esophageal, mediastinal, pleural, and other thoracic surgeries; minimally invasive surgery (lapa-roscopic and thorascopic); general thoracic surgery

MEDICAL DEGREE: Johns Hopkins University School of Medicine, Baltimore, Maryland

SPECIAL TRAINING: University of California-Davis Medical Center, Sacramento, California; Washington University School of Medicine/Barnes-Jewish Hospital, St. Louis, Missouri, MBA, Cleveland State University, Cleveland, Ohio

BOARD CERTIFICATIONS: American Board of Thoracic Surgery and American Board of General Surgery

CLINIC APPOINTMENT: 1999

Dr. Temes enjoys automobile mechanics, sailing, hiking, skiing, and other outdoor activities.

1� Contact Information

Fairview Hospital BaldevSekhon,M.D. InderjitS.Gill,M.D. R.ThomasTemes,M.D.

Main Campus BruceW.Lytle,M.D.,Chairman MichaelK.Banbury,M.D. EugeneH.Blackstone,M.D. DelosM.Cosgrove,M.D.,PresidentandCEO A.MarcGillinov,M.D. DavidP.Mason,M.D. TomislavMihaljevic,M.D. SudishC.Murthy,M.D.,Ph.D. JóseL.Navia,M.D. B.GöstaPettersson,M.D.,Ph.D. ThomasW.Rice,M.D. EricE.Roselli,M.D. JosephF.SabikIII,M.D. NicholasG.Smedira,M.D. LarsG.Svensson,M.D.,Ph.D.

DEpArtmEnt of thorACiC AnD CArDiothorACiC SurgEry

19

Evaluation for Cardiac Surgery (216)476-7310 Surgical clinicians and office supportpersonnelexpeditetherequestforconsult,organizethepatient’sscheduleandaddressquestions.

Hospital Transfer (216)476-7310 The cardiothoracic surgery office willfacilitatethetransferofapatientfromanyhospitaltoFairviewHospital.

Direct to Surgeon (216)476-7310 This is the cardiothoracic surgery office.Yourcallwillbedirectedtothestatedsurgeon. Emergencies (216)476-7000 Acardiothoracicsurgeonisavailable24hourseveryday.Theon-callsurgeoncanbereachedthroughtheFairviewHospitaloperator.

Location (216)476-7310 The cardiothoracic surgery office is locatedintheFairviewPhysicians’CenteratFairviewHospital.

www.clevelandclinic.org/heartcenterwww.fairviewhospital.org