We hope that you will find this information helpful and thought provoking.

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1 The Department of Thoracic and Cardiovascular Surgery is pleased to present our annual edition of Outcomes. This is the 9th published version of cardiothoracic surgical results of MetroHealth Medical Center that relate our outcomes to national standards established by The Society of Thoracic Surgeons. The outcomes reported here are the result of the collaborative efforts of cardiothoracic surgeons, cardiologists, cardiac anesthesiologists, vascular surgeons, and cardiovascular radiologists. In the future, treating patients with cardiovascular disease will become ever more complex and exciting as new surgical techniques and technologies emerge. Maintaining a high level of care for our patients will require maintaining a high level of collaboration between MetroHealth Medical Center, our Cleveland Clinic main campus and our cardiothoracic colleagues nationally and internationally. We hope that you will find this information helpful and thought provoking. Bruce W. Lytle, M.D. Chairman, Department of Thoracic and Cardiovascular Surgery

2 Table of Contents CLEVELAND CLINIC Founded in 1921, Cleveland Clinic is a not-for-profit academic medical center that integrates clinical and hospital care with research and education. Today, 1,7 Cleveland Clinic physicians and scientists practice in 12 medical specialties and subspecialties. Cleveland Clinic s main campus, with 41 buildings spanning 13 acres, includes a 1,-bed hospital, an outpatient clinic, subspecialty centers, and supporting laboratories and facilities. Cleveland Clinic also operates 13 family health centers, 8 community hospitals and 2 affiliate hospitals, and a medical facility in Weston, Florida. Cleveland Clinic is determined to exceed the expectations of patients, families and referring physicians. In light of this goal, we are committed to providing accurate and timely information about our patient care. Through participation in national initiatives, Cleveland Clinic supports transparent public reporting of healthcare quality data. Cleveland Clinic participates in the following public reporting initiatives: Joint Commission Performance Measurement Initiative (qualitycheck.org) Centers for Medicare and Medicaid Services (CMS) Hospital Compare (hospitalcompare.hhs.gov) The Leapfrog Group (leapfroggroup.org) Overview 4 Coronary Disease 8 Valve Disease 1 Great Vessels 11 General Thoracic 12 Innovation 16 Staff Biographies 2 Contact Information 23 Ohio Department of Health Service Reporting (odh.state.oh.us) In addition, this publication was produced to assist patients and referring physicians in making informed decisions. To that end, information about care and services is provided, with a focus on outcomes of care. For more information, please visit the Cleveland Clinic Quality web site at clevelandclinic.org/quality. #1 Heart Center in America For the 12th year in a row, the Cleveland Clinic Heart and Vascular Institute has been ranked America s number one heart program in U.S. News & World Report s prestigious Best Hospitals survey.

3 Overview Case Distribution 5% Thoracic 45% Cardiac 5% Pacemaker & Other Cardiac Case Distribution 26 Total Cases 195 Total Cardiac Cases Total Cases 38 Cardiac Cases 137 Coronary artery bypass grafting (CABG) operations accounted for 65% of cardiac procedures. Valve and other cardiac procedures, including aortic surgery, represented 35% of all cardiac cases. 65% CABG 7% Valve 5% CABG & Valve The Cleveland Clinic s Department of Thoracic and Cardiovascular Surgery and MetroHealth Medical Center have enjoyed a successful affiliation since The program continued to thrive in 26, performing more than 3 thoracic and cardiovascular procedures. Our surgeons specialize in a variety of thoracic and cardiovascular procedures, offering the most advanced techniques to address each patient s unique diagnosis. 23% Other volume In 26, Cleveland Clinic Thoracic and Cardiovascular surgeons at MetroHealth Medical Center performed a total of 38 procedures. Of these, 137 were cardiac, 155 were thoracic, and 16 were other procedures. Surgical Experience Isolated CABG Valve procedures Great vessels Thoracic Other # of cases Other Cardiac Thoracic

4 6 Overview 7 Status of cardiac cases In 26, 96% of cardiac cases at MetroHealth Medical Center were non-emergent procedures. % of cases Elective Urgent Emergent Emergent/ Salvage Risk Factors Although age and gender are known risk factors affecting patient outcomes, other factors may also have an adverse effect. Risk factors in our patients are shown below. Hypertension Smoking Diabetes Heart Failure Chronic Lung Dx PVD Cerebrovasc Dx gender In 26, 63% of our patients were male and 37% were female. Renal Failure % of Patients 63% Male 37% Female POSTOPERATIVE length of stay Length of stay following isolated revascularization surgery was 7.9 days in age & Mortality distribution MetroHealth Medical Center treats a large number of elderly patients. Advanced age and associated medical conditions are known risk factors that can adversely affect cardiac surgical outcomes. Days Patients (%) Mortality (%) epicardial lead placement 2 1 < Age (years) 7-79 > Cardiac resynchronization therapy (CRT) uses an implanted biventricular pacing system to treat patients with heart failure. The system delivers lowenergy electrical impulses to restore proper timing of the heart s contractions. This allows the heart to fill with blood and work more efficiently. At MetroHealth Medical Center, epicardial leads used for biventricular pacing are implanted by our cardiothoracic surgeons.

5 8 Coronary Disease 9 Complications after isolated CABG with mortality Isolated Revascularization Major complications after isolated revascularization include reoperation for bleeding, renal failure, prolonged ventilation, leg infection, deep sternal wound infection, and septicemia. In 26, there were no mortalities among patients who developed these complications. Prolonged Vent Hospital Mortality % In 26, 92% of patients received at least one internal mammary artery graft, 17% received bilateral grafts, and 16% received a radial artery graft. % Renal Failure CVA Reop Bleed Leg INF Septicemia Deep Sternal Periop MI % % % % % % % SEVERITY IMA Bilateral IMA Radial In 26, the average severity score was 2.5 for isolated revascularization procedures. There were no in-hospital mortalities at The MetroHealth Medical Center % of patients 4 MORTALITY Severity Score In-hospital mortality for isolated revascularization was % for the 3rd consecutive year. This is well below The Society of Thoracic Surgeon s (STS) benchmark. % % % % Mortality % Mortality % STS predicted risk of mortality The STS predicted risk of mortality algorithm counts in-hospital deaths and deaths occuring after discharge but within 3 days. The STS risk-adjusted ratio for mortality remained well below 1 for the 9th consecutive year. % % % % % Percent mortality mortality for isolated CABG for three consecutive years Observed/ Expected

6 1 Valve Disease Great Vessels 11 Valve Surgery There were 17 valves repaired or replaced in 26 at MetroHealth Medical Center. 66% Bioprosthesis 17% Annuloplasty great vessel surgery In 26, 27% of great vessel procedures were traumatic cases. 73% Non-traumatic 27% Traumatic Valve volume 17% Mechanical valve Great vessel volume Great vessel surgery represents 11% of total cardiac surgical volume. These operations are some of the most complicated procedures undertaken. In 26, there were no great vessel mortalities. In 26, the number of valve procedures at MetroHealth Medical Center remained consistent with prior years. There has been only 1 valve mortality for 114 valve cases over the past 6 years AVR MVR CABG+AVR CABG+MVR # # MITRAL VALVE REPAIR WITH ANNULOPLASTY RING Cleveland Clinic research has shown that mitral valve repair is durable and has a long-term survival advantage compared with valve replacement. Aneurysms that involve some or all of the visceral arteries represent the most challenging cases. Various etiologies, including degenerative aneurysms and acute aortic dissections, are seen at MetroHealth Medical Center.

7 12 Thoracic 13 thoracic Cases In, 26, there were 155 thoracic procedures performed at MetroHealth Medical Center. Pericardial Procedures Pericardial windows accounted for 95% of pericardial procedures. 25 # % Pericardial Windows % Resection for Malignancy distribution of procedures 25% Mediastinum 31% Pleura 8% Esophagogastric 11% Pericardium 2% Other 23% Pulmonary minimally invasive lobectomies In 26, a minimally invasive anatomic lung resection program began at MetroHealth Medical Center. 15 minimally invasive lobectomies were performed. 6 4 Surgical Approach In 26, 75% of thoracic procedures were performed through a minimally invasive approach versus traditional open thoracotomy. 75% Closed # 2 Right Upper Lobe Right Middle Lobe Right Lower Lobe Left Upper Lobe Left Lower Lobe 25% Open Video-assisted thorascopic surgery (VATS) has been shown to reduce pain, shorten length of hospital stay, and offer a quicker recovery than traditional open surgery. This illustration shows the placement of operating ports for the VATS technique.

8 14 Thoracic 15 Pleural Procedures Evacuation of empyema and decortication 58% Talc sclerosis Mediastinal Case Distribution The majority of mediastinal procedures were mediastinoscopies other includes (radical thymectomy, other tumor, thoracic duct ligation, etc). airway and Esophageal cases Airway or esophageal obstructions represent complex clinical problems. Stents provide patients with a minimally invasive solution to shortness of breath or difficulty swallowing. 5% Minor (dilation, stenting) 21% Decortications 55% Bronchoscopy 9% Drainage for Hemothorax, Empyema, Loculated Effusion 12% Other (pleurectomy,enbloc resections,biopsy) 64% Mediastinoscopy or thorascopic node biopsy 14% Other 22% Mediastinal dissections 2% EGD Ambassadors of Quality Care When a serious medical problem is identified, patients and their families are confronted with difficult medical decisions. Often a patient or family member will try to decipher complex options by asking, If this was your family member, what would you do? The answer best comes from someone who has been through the experience. People who have experienced the physical aspects of illness and surgery, including discomfort, hospitalization, recovery and return to normal activities, are the best ambassadors of quality care. They also can speak to the patient experience; what it was like to be cared for by particular doctors and nurses in a particular hospital. The entire Timothy Smedley experience is best assessed and related by people who have experienced it. If a recommendation comes from a family member, then it carries even more weight. When Timothy Smedley required thoracic surgery, he put his faith in Cleveland Clinic surgeons at MetroHealth Medical Center. He underwent a successful minimally invasive operation with an uncomplicated recovery. One year later, his father, Mr. Maddox was referred for thoracic surgery. Based on his own experience, Mr. Smedley was able to enthusiastically recommend Cleveland Clinic at MetroHealth to his father. Mr. Maddox Richard Dietz had a similar experience. When a nodule was discovered in his lung, he trusted the dedication and skill of Cleveland Clinic surgeons at MetroHealth. Like hundreds of patients at MetroHealth each year, he underwent successful thoracic surgery and an uncomplicated recovery. Five years later, when his adult daughter needed a thoracic operation, Mr. Dietz recommended Cleveland Clinic surgeons at MetroHealth to his daughter without hesitation. The Dietz Family A gratifying and successful thoracic surgical experience allows our patients to wholeheartedly recommend Cleveland Clinic at MetroHealth to others, including their own family members. 5% Major (complete or partial resections, fistula repair, exploration and drainage) 25% Mediastinoscopy

9 16 Innovation 17 The partnerships between the Cleveland Clinic Department of Thoracic and Cardiovascular Surgery and their affiliate sites enhance opportunities to provide new treatments and therapies to patients as well as accelerate mutual accomplishments in cardiac care. Below is an overview of the latest innovations being investigated at Cleveland Clinic. Robotically Assisted Valve Surgery Robotically assisted mitral valve repair represents a novel, minimally invasive approach in treatment of mitral regurgitation (leaky mitral valve). This approach allows performance of complex mitral valve repairs with the least amount of trauma to the patient. The operation is performed through a small incision on the right side of the chest, without the need for division of the breast bone. This operation is suitable for all patients with mitral valve regurgitation. Next-Generation Heart Assist Devices Cleveland Clinic continues to offer the newest technology available for mechanical circulatory support. We are currently participating in clinical trials for second- and third-generation mechanical circulatory support devices for patients with a failing left ventricle. These devices are compact, easier to implant, and may be used in smaller patients who previously may not have been candidates for this type of support. The devices include Thoratec Corporation s Heartmate II Left Ventricular Assist System; the MicroMed DeBakey Ventricular Assist Device (VAD), and VentrAssist by Ventracor. HeartMate II DeBakey VentrAssist Combined Minimally Invasive Valve Surgery and Ablation In 26, Cleveland Clinic surgeons developed a new minimally invasive technique that enables combined mitral valve surgery and ablation of atrial fibrillation through a small chest wall incision. The left and right atrial lesion sets are depicted. Tomislav Mihaljevic, M.D., operating the robotic arms Correcting Mitral Regurgitation Cleveland Clinic is participating in a large multi-center trial evaluating the Myocor Coapsys device. This novel instrument is used to correct mitral regurgitation in patients with advanced coronary artery disease and associated functional mitral regurgitation. Mitral regurgitation that is caused by enlargement of the left ventricle is corrected by reduction in the diameter of the left ventricle after placement of the device.

10 18 Innovation 19 Percutaneous Valve Surgery Cleveland Clinic is one of three centers nationwide designated by the U.S. FDA as a study site for the percutaneous aortic valve technique. The procedure is performed in the cardiac catheterization laboratory under general anesthesia; no chest incision is required, nor is cardiopulmonary bypass. It requires close collaboration among the cardiac surgeon, interventional cardiologist, echocardiologist, and anesthesiologist. Heart Valve Tissue Graft Cleveland Clinic cardiac surgeons are working with CryoLife Inc., an Atlanta-based biomedical and medical device company, to develop a heart valve tissue graft for patients with serious heart infections. Our multidisciplinary Cleveland Clinic team has pioneered several refinements and improvements of the percutaneous aortic valve procedure, including being the first site to: Utilize the iliac artery Firsts Treat bicuspid valves Currently, the majority of patients receive synthetic implants, which are more prone to infection. This new technology may potentially provide a more infection-resistant treatment option. Patents covering the tissue preparation methods and implantation techniques have been filed by Cleveland Clinic, as active research and investigation continue. Place a valve within another valve - transcatheter approach Use 3-D imaging of aortic root to evaluate patients before and after the procedure Total Artificial Heart As a bridge to a heart transplant, the CardioWest total artificial heart by SynCardia Systems remains an option for patients suffering from biventricular failure and those with persistent ventricular arrhythmias. It is a pneumatic, biventricular, implantable system that completely replaces the failing heart. Left Atrial Appendage Ligation Physicians and researchers at Cleveland Clinic have developed a ligation device for clipping and isolating the left atrial appendage. Clinical trials of this device are under way. Dr. Delos Cosgrove, M.D., and Dr. A. Marc Gillinov, M.D., developed this device in collaboration with medical industry. Self-Supported Annuloplasty This complete, self-supported, and semi-flexible mitral and tricuspid annuloplasty stent-ring is introduced percutaneously and deployed using balloon technology. This prosthetic ring allows effective functioning of the valve and reestablishes normal shape and contour of the native annulus. Developed by staff surgeon José L. Navia, M.D., the system will be licensed to a medical device company in Spring 27.

11 2 Staff Biographies 21 Inderjit S. Gill, M.D. R. Thomas Temes, M.D., MBA 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, 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 disease, minimally invasive surgery, off-pump coronary artery bypass surgery, and 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 academics: Dr. Gills curriculum vitae currently include 118 educational videos, presentations, book chapters, abstracts, and publications. 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 (laparoscopic 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 academics: Dr. Temes curriculum vitae currently include 68 articles, book chapters, editorials and letters including recent publications in the Annals of Thoracic Surgery and the New England Journal of Medicine. Clinic Appointment: 1999 Dr. Temes enjoys automobile mechanics, sailing, hiking, skiing, and other outdoor activities. He is married and has two children.

12 22 Staff Biographies Contact Information 23 Rami Akhrass, M.D. Department of Thoracic and Cardiothoracic Surgery Medical Director, Thoracic and Cardiovascular Surgery, Lake Hospital System, a Cleveland Clinic Thoracic and Cardiovascular Surgery Affiliate Program 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 and lung disease Medical Degree: School of Medicine, Damascus University, Damascus, Syria Special Training: University Hospitals, Cleveland, Ohio; Cleveland Clinic, Cleveland, Ohio Board Certifications: American Board of Thoracic Surgery and American Board of General Surgery Clinic Appointment: 1997 Dr. Akhrass is a native of California with roots in Syria. He is married and has two children. MetroHealth Medical Center Main Campus Inderjit S. Gill, M.D. Rami Akhrass, M.D. R. Thomas Temes, M.D. Bruce W. Lytle, M.D., Chairman Michael K. Banbury, M.D. Eugene H. Blackstone, M.D. Delos M. Cosgrove, M.D., President and CEO A. Marc Gillinov, M.D. David P. Mason, M.D. Tomislav Mihaljevic, M.D. Sudish C. Murthy, M.D., Ph.D. Jóse L. Navia, M.D. B. Gösta Pettersson, M.D., Ph.D. Thomas W. Rice, M.D. Eric E. Roselli, M.D. Joseph F. Sabik III, M.D. Nicholas G. Smedira, M.D. Lars G. Svensson, M.D., Ph.D.

13 24 Contact Information Evaluation for Cardiac Surgery (216) Evaluation for Thoracic Surgery (216) Surgical clinicians and office support personnel expedite the request for consult, organize the patient s schedule and address questions. Hospital Transfer (216) The cardiothoracic surgery office will facilitate the transfer of a patient from any hospital to MetroHealth Medical Center. Direct to Surgeon (216) This is the cardiothoracic surgery office. Your call will be directed to the stated surgeon. Emergencies (216) A cardiothoracic surgeon is available 24 hours every day. The on-call surgeon can be reached through the MetroHealth Medical Center operator. Location (216) The cardiothoracic surgery office is located in the Heart and Vascular Center at MetroHealth Medical Center.