Valve Surgery Volume. 29.5% Isolated Primary Valve Surgeries (N = 831) 42.5% Combined Primary Valve Surgeries (N = 1,199)

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1 Valve Disease Valve Surgery , 2, 1, In 211, Cleveland Clinic surgeons performed 2,816 valve surgeries. This includes 2,3 primary operations and 786 reoperations. Cleveland Clinic continues to be the leader in the number of valve surgeries performed in the United States. Distribution of Isolated and Combined Valve Operations (N = 2,816) % Isolated Primary Valve Surgeries (N = 831) 1% 42.5% Combined Primary Valve Surgeries (N = 1,199) 11.3% Isolated Valve Reoperations (N = 317) 16.7% Combined Valve Reoperations (N = 469) 28% The majority of valve operations performed at Cleveland Clinic in 211 were combined primary procedures. However, reoperations accounted for 28 percent of all valve surgeries. These procedures are typically more complex and challenging than primary procedures. 26 Outcomes 211

2 Aortic Valve (AV) Surgery (N = 1,739) , 1,5 AV-Sparing AV Repair AV Replacement 1, Cleveland Clinic performs the largest number of aortic valve operations in the nation. In 211, we performed 1,739 aortic valve operations. Ninety-one percent were valve replacements (N = 1,553), 5 percent were valve repairs (N = 11) and 4 percent were valve-sparing operations (N = 85). Isolated Aortic Valve Replacement Mortality (N = 1,553) STS Expected Isolated Combined Primary Reoperation The hospital mortality rate at Cleveland Clinic for patients who had an isolated aortic valve replacement in 211 was.6 percent. This is significantly lower than The Society of Thoracic Surgeons (STS) benchmark of 3.5 percent. Hospital mortality rates for all other aortic valve replacement procedures were also lower than the STS benchmark. Source: Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database, 211. 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 January 29 through December 211. Sydell and Arnold Miller Family Heart & Vascular Institute 27

3 Valve Disease (continued) Isolated Aortic Valve Replacement Complications Observed STS Expected Deep Sternal Wound Infection Post-Op Stroke Post-Op Renal Failure Source: Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database, 211. Patients who had isolated aortic valve replacement surgery at Cleveland Clinic in 211 had fewer complications than expected, according to The Society of Thoracic Surgeons (STS) benchmarks. Mitral Valve Surgery (N = 1,286) 211 1, Replace Repair Post-Op Reoperation (any) Cleveland Clinic is the nation s leader in mitral valve surgery volume. Our surgeons performed 1,286 mitral valve surgeries in 211. A total of 87 (68%) were repairs and 416 (32%) were replacements. 28 Outcomes 211

4 Mitral Valve Surgery Repair vs. Replacement Repair Replacement Cleveland Clinic surgeons performed mitral valve repairs before it was 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), and there is no need for anticoagulation therapy. The majority of mitral valve repairs at Cleveland Clinic are performed using a minimally invasive approach. Primary Isolated Mitral Valve Surgery Hospital Mortality* Cleveland Clinic STS Expected 2 Replace % Repair *Isolated mitral valve repair based on STS data from Oct. 1, 21 to Sept. 31, 211 In 211, Cleveland Clinic had the country s lowest mortality rate (%) for primary isolated mitral valve repair. The mortality rate for patients who had a primary isolated mitral valve replacement was also well below The Society of Thoracic Surgeons (STS) benchmark. Sydell and Arnold Miller Family Heart & Vascular Institute 29

5 Valve Disease (continued) Valve Replacement Prostheses and Type , 1,5 Bioprostheses 1, 5 Mechanical Allografts The majority (92.7%) of valve replacement procedures at Cleveland Clinic in 211 involved bioprostheses (biologic tissue valves). Bioprostheses are preferred for most aortic and mitral valve procedures because they are durable and help most patients avoid lifelong anticoagulant therapy after surgery. Surgical Treatment of Infective Endocarditis Infective endocarditis is a life-threatening disease. It causes bacterial or fungal growths on the heart valves that can lead to perforation, rupture and subsequent valve regurgitation. Prompt diagnosis and treatment are critical. Cleveland Clinic surgeons treat a variety of patients with infective endocarditis, including those with advanced disease and prosthetic valve endocardititis. and Hospital Mortality (N = 128) Mortality (%) Reoperation Primary In 211, we performed 128 surgical procedures to treat infective endocarditis and maintained low mortality rates Outcomes 211

6 Percutaneous Mitral Valvuloplasty and Hospital Mortality Mortality (%) Many Cleveland Clinic patients with mitral valve stenosis are treated with percutaneous mitral valvuloplasty. The mortality rate is consistently percent with this procedure, and patients experience a shorter recovery than those who have traditional surgery. 2 1 % Hospital Mortality The hospital mortality rate for robotically assisted valve surgeries was percent in Robotically Assisted Valve Surgery (N = 16) 211. Cleveland Clinic performs more robotically assisted mitral valve surgeries than any major academic hospital in the United States. Robotically Assisted Mitral Valve Repair Cleveland Clinic surgeons performed 16 robotically assisted mitral valve repairs in Sydell and Arnold Miller Family Heart & Vascular Institute 31

7 Valve Disease (continued) Valve Surgery Mortality Observed Expected 5 Isolated AVR AVR + CABG Isolated MVR MVR + CABG % % Isolated MV Repair MV Repair + CABG Cleveland Clinic is the nation s leader in valve surgery volume and quality. Compared with comparable hospitals, mortality rates for valve surgery are far lower. Source: University HealthSystem Consortium (UHC) Comparative Database, January through November 211 discharges. Abbreviations: AVR, aortic valve replacement; CABG, coronary artery bypass grafting; MV, mitral valve; MVR, mitral valve replacement. Septal Myectomy Percutaneous Valve Treatments Cleveland Clinic remains dedicated to developing and using the best possible percutaneous methods to treat patients with valve disease. We are a national leader in these types of procedures. Transcatheter Aortic Valve Replacement and 3-Day Mortality In 211, Cleveland Clinic performed Expected Mortality (%) Mortality (%) 15 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. 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. 211;17: 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. 28;86: 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. 21;363: Smith CR, Leon MB, Mack MJ, et al. Transcatheter versus Surgical Aortic-Valve Replacement in HIgh-Risk Patients. N Engl J Med. 211;364: Outcomes 211

8 Percutaneous Aortic Valvuloplasty and Hospital Mortality Cleveland Clinic is a national leader in the development and use of percutaneous valve treatments. Expected Mortality (%) Mortality (%) 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. Sydell and Arnold Miller Family Heart & Vascular Institute 33