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 [email protected], 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