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C M Y KPROJECT: Cardiovascular Report

TITLE: Christ_cardio rep_2011_fnl.indd

CLIENT: Christ

JOB#: CHRIST11058

DATE: 8-8-11

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© 2 0 1 1 Photonics graPhics

Cardiovascular Outcomes 2011B

Introduction

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Introduction

Cardiovascular Outcomes 2011 1

We are happy to share data relevant to The Christ Hospital Heart and Vascular Center. Our Center is dedicated to personalized care, enhanced with cutting-edge clinical and research technology. Continuous evaluation and modification of our processes are necessary for ongoing quality improvement, and we are proud to deliver world class medicine to our Tristate region.

For more information or to speak with one of our Heart and Vascular physicians, please call 513-585-1613.

The Christ Hospital and The Carl and Edyth Lindner Center for Research and Education recently launched a new web site for physicians.

The site includes information about current clinical trials, a listing of publications, abstracts and much more.

www.cardiovascularresearch.net

Cover image provided by Edwards Lifesciences.

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Cardiovascular Outcomes 20112

Three innovative technologies at The Christ Hospital are noteworthy for their potential impact on patient outcomes: transcatheter aortic valve replacement for aortic stenosis, advanced catheter ablation for atrial fibrillation and ventricular tachycardia and ventricular assist devices for advanced heart failure.

Transcatheter Aortic Valve ReplacementFor patients with severe symptomatic aortic stenosis deemed to be at high risk for surgery, transcatheter aortic valve replacement (TAVR)—currently investigational in the U.S.—is a new therapeutic option. The Christ Hospital is participating in the PARTNER II Trial, in which TAVR is performed with a bovine pericardial tissue heart valve mounted within a balloon-expandable frame (Edwards SAPIEN XT valve system). Currently, this is performed via femoral access, although a transapical approach will be available in the near future. The PARTNER Trial demonstrated a 20 percentage point higher one-year survival in inoperable patients who received the transcatheter valve, as compared to those that were treated with standard therapy. It promises to be an effective therapy in those ineligible for surgery.

Future studies will expand on the comparison between TAVR and standard surgery as well. Data presented at the 2011 American College of Cardiology Scientific Sessions demonstrates that TAVR is equivalent to open surgery for high-risk but operable patients, although with different adverse event profiles.

Advanced Technologies

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Advanced Technologies


Catheter Ablation Procedures For atrial fibrillation (AF) and ventricular tachycardia (VT) that fails to respond adequately to rate- or rhythm-control medications, The Christ Hospital Heart and Vascular Center offers radiofrequency ablation and cryoablation.

Radiofrequency ablation Patients with AF refractory to medical therapy can benefit from pulmonary vein isolation (PVI) using high-frequency, low-voltage energy. PVI restores normal sinus rhythm in approximately 70 percent of patients with paroxysmal AF after one procedure, and in nearly 50 percent of patients with persistent AF. Many patients may be able to remain free of anti-arrhythmic and anticoagulation medications. Radiofrequency ablation may also be appropriate for atrial flutter.

Cryoablation An alternative ablation procedure uses the Arctic Front® Cardiac Cryoablation Catheter. A balloon positioned at the ostium of each pulmonary vein, and inflated with coolant, freezes and fully ablates the surrounding tissue. In a major trial, nearly 70 percent of 245 patients treated with cryoablation remained symptom free at one year, compared with just 7.3 percent of patients treated with medications alone. Cryoablation was also associated with a decrease in the need for drug therapy and substantial improvements in physical and mental quality-of-life indicators.

Ventricular tachycardia ablation For those with ventricular tachycardia (VT) resistant to drug therapies (or in younger patients in whom long-term amiodarone therapy is not desirable), ablation offers real potential for a better quality of life. Catheter ablation of

VT involves the use of a 3-dimensional imaging system, sophisticated mapping techniques, a programmable stimulator and modern, irrigated-tip ablation catheters. Following successful catheter ablation of VT, patients can often be taken off of amiodarone and other anti-arrhythmic agents.

Ventricular Assist DeviceAt The Christ Hospital, the implantable ventricular assist device (VAD) is an option for end-stage heart failure patients. The VAD team at our accredited Carl H. and Edyth Lindner Heart Failure Treatment Center consists of board-certified surgeons, cardiologists, nurse practitioners, registered nurses, dieticians, exercise specialists, psychologists and social workers. Potential candidates for VAD therapy are patients with severe advanced systolic heart failure, typically dependent on continuous inotropic infusion. These patients will typically have a depressed ejection fraction, are frequently hospitalized for heart failure and remain unresponsive to optimal medical and device management.

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Operating within The Christ Hospital Heart and Vascular Center’s environment of specialized acute interventions is a team of physicians and mid-level healthcare professionals who provide inpatient clinical care. Six attending physicians rotate in dedicated one-week periods, with no other clinical or administrative duties, to provide focused patient management. The active team onsite typically consists of an attending physician, four nurse practitioners and a medical resident. In support of the clinical service, imaging with echocardiography, computerized tomography, magnetic resonance imaging and stress testing are available seven days a week.

Teaching and Multidisciplinary Team InteractionWe believe patient care is optimized when providers have the opportunity to discuss cases in multidisciplinary settings, with a spectrum of available expertise. At Wednesday morning reviews, interesting and difficult cases are discussed. On Friday mornings each week, a teaching conference for medical residents takes place. In addition, morbidity and mortality conferences occur monthly.

Clinical Service

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Clinical Service


6,000

4,000

3,000

2,000

1,000

02008 2009 2010

5,000

Cardiac Acute Care Admissions by Year

Pat

ient

Cou

nt

Year

5.00

2.00

1.00

0.00

Cardiac Acute Care Average Length of Stay (LOS) by Year

4.00

3.00

2008 2009 2010

Avg

LO

S (d

ays)

Year

eICU ServiceUsing advanced telemedicine technology, which incorporates visual, audio and full capability monitoring features, The Christ Hospital provides attending eICU coverage for heart and vascular patients during “off hours” (7 p.m. to 7 a.m.). Availability of timely assessment of critically ill patients by an intensive care physician has been shown to significantly improve outcomes.

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The Christ Hospital has long been recognized, nationally and internationally, for its work with leading-edge technologies for treatment of acute coronary syndrome (ACS). In that role, The Christ Hospital continues to introduce state-of-the-art ACS interventions to the Cincinnati region. We expect to be named the lead center for the imminent pivotal trial for FDA approval of the first bioresorbable coronary stent, in which no permanent mechanical presence in the artery will exist after the early period of support and drug delivery. We implanted the first cobalt-chromium stent worldwide, and continue to offer multiple clinical trials through which cutting edge technology is made available. We have consistently been one of the top enrollers in clinical trials in this arena.

The Christ Hospital has initiated a Chest Pain Network throughout the Greater Cincinnati region, enabling participating hospitals and emergency medical service providers to implement a standardized protocol for managing ACS patients. The Christ Hospital’s Level III Chest Pain Unit and all of the participating hospitals are accredited by the Society of Chest Pain Centers. The Christ Hospital serves as the tertiary center for myocardial infarction (MI) care for this network of hospitals in the Tristate region and over the past year, MI referrals to The Christ Hospital from regional facilities have increased by 20 percent. A complementary initiative is the American Heart Association’s Mission: Lifeline—chaired in Ohio by Dean Kereiakes, M.D.,—a program seeking to streamline cardiovascular treatment protocols in all communities, thereby reducing mortality and morbidity for MI patients and improving their quality of care.

1400

8001000

400600

2000

2008 2009

Percutaneous Coronary Intervention (PCI) Annual VolumesData Source: The Christ Hospital internal reporting software.

1200

2010

Pro

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Year

Acute Coronary Syndrome

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Acute Coronary Syndrom

e


2.50

2.00

1.00

1.50

0.50

0.002008 2009

Percutaneous Coronary Intervention Average Length of Stay (LOS) Data Source: The Christ Hospital internal reporting software.

2010

LOS

Year

100.0%

80.0%

40.0%

60.0%

20.0%

0.0%20092008

Acute Myocardial Infarction Core Measure All or None Bundle Compliance

Data Source: Centers for Medicare and Medicaid Services Acute Myocardial Infarction Core Measure

2010

Per

cent

Com

plia

nce

Year

120

60

30

0

ST-Segment Elevated Myocardial Infarction Average Door to Balloon Time (D2B)

Data Source: Centers for Medicare and Medicaid Services Acute Myocardial Infarction Core Measure

90

2008 2009 2010

Tim

e (m

inut

es)

The Christ Hospital Average D2B 90 Min GoalYear

1.6%

0.8%

0.4%

0.0%

American College of Cardiology (ACC) CathPCI Registry Percutaneous Coronary Intervention Mortality Rates

Data Source: ACC CathPCI Registry from October 2009 - September 2010.

1.2%

The Christ Hospital All Participating Hospitals

Expected Observed

Mor

talit

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Hospitals

4,000

3,200

1,600

2,400

800

02008 2009

Overall Diagnostic Catheterization Left Heart (LH), Right Heart (RH) and LH/RH Volumes

Data Source: The Christ Hospital internal reporting software.

2010

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Year

500

400

200

300

100

02008 2009

Non-ST Elevated Myocardial Infarction Volumes Data Source: The Christ Hospital internal reporting software.

2010

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e

Year

350

250

100150

500

2008 2009

Transfer (to The Christ Hospital) Acute Myocardial Infarction Volumes

Data Source: The Christ Hospital internal reporting software.

300

200

2010

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Year

25

20

10

15

5

02008 2009

Valvuloplasty Volumes Data Source: The Christ Hospital internal reporting software.

2010

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Year

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The Carl H. and Edyth Lindner Heart Failure Treatment Center is accredited by both the Joint Commission and the Healthcare Accreditation Colloquium for heart failure care. Five advanced heart failure sub-specialty physicians rotate in full-week assignments to provide consistent inpatient care for heart failure patients. This inpatient service parallels the inpatient clinical service. (See Clinical Service). Rounding out the multidisciplinary treatment team are subspecialty mid-level providers, specialized registered nurses, pharmacists, dieticians and physical therapists, who work collaboratively with the physicians to implement current guidelines and the best clinical evidence available.

Specialized TreatmentsAs part of its comprehensive management program, the Center offers two highly specialized treatments: ultrafiltration and ventricular assist device implantation (See Advanced Technologies for the latter). Ultrafiltration may effectively reduce fluid volume in patients for whom other treatment options have proved insufficient. The Center manages one of the largest ultrafiltration registries in existence, helping to refine treatment strategies and tailor ultrafiltration use to individual patients.

Heart Link ProgramWhen inpatients are ready to return home, the transition is enabled by the Center’s Heart Link program. Specially trained nurses follow up with patients after discharge to review diet, exercise, medication and how to monitor for changes in health. This program was recognized at the 2008 Innovative Solution Awards, presented by the Greater Cincinnati Health Council.

ResearchClinical research has been an important part of the Center’s work. The panel of studies available through collaboration with The Carl and Edyth Lindner Center for Research and Education spans a wide range, from multi-center studies to evaluate new drugs or implantable devices to single center studies of hypothesis generating ideas.

Heart Failure

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Heart Failure


25.00%

20.00%

15.00%

10.00%

5.00%

0.00%2008 2009 2010

The Christ Hospital 30 Day Re-admit Percent

25thPercentile

50thPercentile

75thPercentile

Rea

dmis

sion

Per

cent

ages

Year

Primary Heart Failure 30 Day All CauseReadmission Percent by Year

4,000

3,200

1,600

2,400

800

02008 2009 2010

Secondary Heart Failure (HF) Admissions by Year

Pat

ient

Adm

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Year

1,200

800

600

400

200

02008 2009 2010

1,000

The Christ Hospital Heart Failure Principle Volume

25thPercentile

50thPercentile

75thPercentile

Pat

ient

Adm

issi

ons

Year

Primary Heart Failure Admissions by Year

3.00%

2.40%

1.80%

1.20%

0.60%

0.00%2008 2009 2010

The Christ Hospital Mortality 25thPercentile

50thPercentile

75thPercentile

Mor

talit

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erce

nt

Year

Primary Heart Failure Mortality Percent by Year

8.00

6.00

4.00

2.00

0.0020092008 2010

ALO

S (d

ays)

The Christ Hospital Average LOS

25thPercentile

50thPercentile

75thPercentile

Year

Primary Heart Failure Average Length of Stay (LOS) by Year

Source: Unless otherwise noted, graph data for this page is from The Christ Hospital internal reporting. Percentile rankings are from the Midas Comparative Database based on hospitals with a similar bedsize >= 400 beds.

25.00%

20.00%

10.00%

5.00%

0.00%

The Christ Hospital’s Crude Mortality Rates Compared to ADHERE Study Using Classification and Regression Tree

Analysis (CART)

15.00%

Low Risk** Intermediate Risk 3

Intermediate Risk 2**

Intermediate Risk 1

High Risk

The Christ Hospital Heart Failure Population (n=2,129)*

ADHERE Heart Failure Population (n=33,046)*

Mor

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erce

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Risk Categories

*The Christ Hospital population equates to acute decompensated HF patients discharged between July 2008 and December 2010. ADHERE patient population equates acute decompensated HF patients discharged from 263 different hospitals between October 2001 and February 2003.**Using Chi-Square analysis, the difference in mortality percentage (The Christ Hospital vs. ADHERE) is statistically significant (p-value < 0.05)Comparison Source: “Risk Stratification for In-Hospital Mortality in Acutely Decompensated Heart Failure: Classification and Regression Tree Analysis.” The Journal of the American Medical Association; February 2, 2005; Issue: No. 5; Volume: 293; Pages 572-580.Copyright ©2005 American Medical Association. All rights reserved.

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The Christ Hospital provides state-of-the-art electrophysiology services, including pacemaker and defibrillator implants, lead extractions and advanced ablation procedures for rhythm disturbances such as atrial fibrillation, atrial flutter and ventricular tachycardia. Available technologies include:• Low-radiation fluoroscopy, which minimizes patient

and clinician exposure to ionizing radiation during ablation procedures.

• Carto 3 and Ensite imaging systems, which use magnetic and electrical current-enabled processes to provide precise visualization of cardiac anatomy, generating 3-D mapping to guide catheter placement during complex arrhythmia ablations (See Advanced Technologies.)

• Cryoablation, used to treat atrial fibrillation, employing a catheter-mounted balloon inflated with a coolant, thereby freezing and ablating the full thickness of adjacent tissue (See Advanced Technologies.)

• MRI compatible pacemakers through clinical trial participation.

Electrophysiology

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Electrophysiology


500

400

200

300

100

02008 2009 2011*

Implantable Cardiac Defibrillator (ICD) VolumeData Source: Reported from The Christ Hospital internal data collection.

*2011 volume annualized from Jan.-Mar. 2011 data included to reflect the expansion in the number of providers during fourth quarter 2010.**Volumes include ICD initial implants, replacements, lead changes/extractions and upgrades.

2010

Pro

cedu

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Year

500

400

200

300

100

02008 2009 2011*

Pacemaker VolumeData Source: Reported from The Christ Hospital internal data collection.

*2011 volume annualized from Jan.-Mar. 2011 data included to reflect the expansion in the number of providers as of fourth quarter 2010.

2010

Pro

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Year

200

100

150

50

02008 2009 2011*

Atrial Fibrillation Ablation VolumeData Source: Reported from The Christ Hospital internal data collection.

*2011 volume annualized from Jan.-Mar. 2011 data included to reflect the expansion in the number of providers during fourth quarter 2010.

2010

Pro

cedu

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Year

15

6

9

12

3

02008 2009 2011*

Ventricular Tachycardia Ablation VolumeData Source: Reported from The Christ Hospital internal data collection.

*2011 volume annualized from Jan.-Mar. 2011 data included to reflect the expansion in the number of providers during fourth quarter 2010.

2010

Pro

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300

200

250

100

150

50

02008 2009 2011*

Cardiac Resynchronization Therapy (CRT) VolumeData Source: Reported from The Christ Hospital internal data collection.

**2011 volume annualized from Jan-Mar 2011 data included to reflect the expansion in the number of providers during fourth quarter 2010.**Volumes show CRT of defibrillators and pacemakers including initial implants, replacements, lead changes/extractions and upgrades.

2010

Pro

cedu

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olum

e

Year

125

50

75

100

25

02008 2009 2011*

Other Ablation Volumes Superventricular Tachycardia, Atrioventricular Nodal and

Atrial TachycardiaData Source: Reported from The Christ Hospital internal data collection.

*2011 volume annualized from Jan-Mar 2011 data included to reflect the expansion in the number of providers Fourth Quarter 2010.

2010

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dysfunction who are undergoing a procedure involving the use of contrast dye. The goal is to prevent contrast induced nephropathy (CIN).

Acute Coronary SyndromeSOLID TrialPatients presenting with acute coronary syndrome (ACS) are treated with a plaque stabilizing agent in order to decrease recurrent cardiac events.

ATLAS TrialThis trial studies a new direct thrombin inhibitor to reduce recurrent cardiac events post-ACS.

CANTOS This trial is testing the use of an agent to decrease the inflammatory process in patients with high C-reactive protein (CRP) values with the intent of reducing future cardiovascular events.

Peripheral Vascular DiseaseLevant II Coming soon, this trial tests a drug coated balloon for peripheral vascular disease blockages in the lower extremities.

Heart Failure (HF)REVEAL XTThis trial studies a cardiac monitoring device for diastolic heart failure seeking to provide diagnostic information to enhance understanding of HF processes.

OPTIMUM HFThis physician-directed trial addresses if the fluid indicator of implantable cardiac defibrillators (ICD) or

The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital has participated in more than 1,200 clinical research trials (130 active trials) and has introduced most of the new techniques in cardiovascular medicine over the past 20 years. These studies have included first-in-man as well as first-in-the-U.S. experiences with leading-edge techniques.

Current Coronary and Peripheral Vascular Trials of Significance

Coronary InterventionsDAPT (Dual Antiplatelet Therapy)Dean Kereiakes, M.D. is national Co-Principal Investigator of the trial, which answers one of the most significant questions on how long antiplatelet (Plavix) therapy is required post intervention. This is in the follow-up phase.

PARTNER II: Transcatheter Aortic Valve ReplacementThis randomized trial tests replacement of the valve (aortic) non-surgically to treat severe symptomatic aortic stenosis. A surgical candidate arm is expected to launch in the coming months.

EXCELLeft main coronary artery lesions usually treated surgically will be randomized to the Xience stent or surgery. This trial is pending FDA approval.

TRYTONThe bifurication stent to treat CAD lesions trial is enrolling now.

BOSS This study compares the administration of sodium bicarbonate infusion to saline in patients with renal

Research

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Research


cardiac resynchronization therapy (CRT) can be used to help physicians treat HF patients more effectively with ultrafiltration.

Close The GapAn observational trial that will try to determine adherence to guidelines directing CRT/ICD device evaluation/implantation.

LAPTOPThe placement of a left atrial pressure lead along with an interactive patient ambulatory monitoring device looks to determine if the combination enhances treatment and improves outcomes in HF.

ParadigmParadigm introduces a new agent to prevent the progression of HF.

EchoCRTThis evaluation of narrow QRS (wave) presentation qualifies patients for CRT, therefore improving patient outcomes.

ASTRONAUT and Relax HFBoth trials offer new agents to treat patients hospitalized with decompensated HF.

MiscellaneousGore PFO This device is used to reduce and close the patent foramen ovale (PFO) to prevent misdirected blood flow and high risk to cardiac adverse events.

ElectrophysiologyADVISA MRI This trial studies an MRI-compatible device looking for labeling indicating full body clearance.

Acuity LeadA new post market lead is studied.

Protecta Protecta evaluates a new ICD with new algorithm programming to prevent inappropriate shocks.

Pulmonary Arterial Hypertension (PAH)Many trials are underway with various agents that seek to reduce the symptoms of PAH and prevent disease progression. Acute Myocardial Infarction (MI)Osiris AMIThis stem cell therapy post-MI study, which aimed to reduce loss of heart function, just completed. We were the second highest enrolling site.

TOTALThe interventional strategy post-MI during PCI for thrombus-aspirations vs medical therapy is evaluated.

PROMPTThe post-MI placement of CRT to pace at the site of injury, reducing adverse remodeling, is reviewed.

Atrial FibrillationPREVAILThe left atrial appendage sealer (Watchman) is compared to coumadin therapy to prevent complications of AF.

More information is available on these trials at www.cardiovascularresearch.net.

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At The Christ Hospital, physicians who perform echocardiography, computed tomography (CT) and magnetic resonance imaging (MRI) are Level III certified in accordance with the American College of Cardiology guidelines and recommendations.

Training for Cardiac CT Angiography (CTA) The Cardiac CTA program (www.cardiac-cta.com) conducts a certification course for physicians interested in reading CT coronary angiography. Cardiologists, fellows, cardiovascular surgeons and radiologists undergo a four-day hands-on immersion course involving live patient cases, augmented by individual review of an extensive library of pathology images.

Pivotal Role in Research The transesophageal program, with extensive experience in 3-D imaging, provides support of advanced procedures such as percutaneous aortic valve replacement, left atrial appendage exclusion and ablation. In conjunction with the Cleveland Clinic, The Ohio State University and Case Western Reserve University, The Christ Hospital is participating in the EXIMER trial, comparing exercise MRI and exercise nuclear studies in the evaluation of chest pain.

Technologic Advances An example of newer technologies employed at The Christ Hospital is the Vital Enterprise Solution that allows rapid access to images from any location, enabling direct online consultation between physicians and expedited reporting of image findings.

Cardiac Imaging

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Cardiac Imaging


The Christ Hospital’s team of cardiologist Wojciech Mazur, M.D., and Jennifer Schaaf, B.S, R.D.C.S., echo lab technical director, joined the Cincinnati Zoo in administering an echocardiogram to the zoo’s 19-year-old silverback, western lowland gorilla “Jomo.”

Real time 3-D imaging of a mechanical mitral valve with a paravalvular dehiscence.

Using one of the most advanced computed tomography scanners, 256 slice, allows us to reduce radiation exposure to 1/20 the amount.

500

400

200

300

100

02008 2009 2010

Cardiac Computed Tomography Volume by Year Source: The Christ Hospital internal reporting tool

Test

Vol

ume

Year

200

160

80

120

40

02008 2009 2010

Cardiac Magnetic Resonance Imaging Volume by Year Source: The Christ Hospital internal reporting tool

Test

Vol

ume

Year

16,000

8,000

12,000

4,000

0Echo – Calendar Year 2010 Nuclear – Calendar Year 2010

Overall Echocardiogram and Nuclear Diagnostic Testing(Main Hospital and All Outside Testing Centers)

Source: The Christ Hospital internal reporting

Test

Vol

ume

Year

7,500

6,000

3,000

4,500

1,500

02008 2009 2010

Transthoracic (TTE) and Transesophageal (TEE) Echocardiography Volume by Year

Source: The Christ Hospital internal reporting tool

Test

Vol

ume

Year

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The Christ Hospital’s high-volume Vascular Center program consists of a multidisciplinary team of interventional radiologists and cardiologists, as well as vascular surgeons and cardiothoracic surgeons employing leading-edge techniques.

Interventional Trial Participation The Christ Hospital Vascular Center participates in multiple clinical trials. Currently, we’re enrolling patients for the CHOICE study, a post-marketing trial to assess clinical outcomes with carotid artery stenting and embolic protection systems. The Centers for Medicare & Medicaid Services will evaluate study findings in determining whether to extend its coverage of these devices to a wider patient population. We’re also recruiting patients for the EASE study that’s evaluating the safety and effectiveness of a minimally invasive atherectomy catheter used to cut and retrieve peripheral arterial plaques in the legs.

Educating Visiting Physicians Eight times a year, our specialists lead on-site proctorships in peripheral vascular techniques, directed to cardiologists and vascular physicians. The sessions typically accommodate four visiting physicians to ensure highly personalized training.

Venous Procedures Treatment of venous diseases has become increasingly important. Percutaneous catheter-directed venous procedures include thermal ablation, stripping for symptomatic varicose veins, stenting for superior vena cava stenosis and lysis of deep vein thromboses.

Vascular

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Vascular


100

80

40

60

20

02008 2009

Open and Endovascular Abdominal Aortic Aneurysm (AAA) Repair Volume by Year

Data Source: The Christ Hospital internal data reporting

2010

Open AAA Repair Endovascular AAA Repair

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60

30

45

15

02008 2009

Open and Endovascular Thoracic Aortic Aneurysm (TAA) Repair Volume by Year


2010

Open TAA Endo TAA

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Vascular Surgery Lower Extremity Bypass Volume by Year Data Source: The Christ Hospital internal data reporting

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02008 2009

Overall Carotid Artery Procedure (Endarterectomy + Stent)Volume by Year


2010

Carotid Artery Stent Carotid Artery Endarterectomy

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2,000

3,000

1,000

02008 2009 2010

Carotid Duplex Volume by Year Data Source: The Christ Hospital internal data reporting

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1,200

1,000

600

800

400

200

02008 2009 2010

Overall Peripheral Vascular Intervention Volume by YearData Source: The Christ Hospital internal data reporting

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50

30

40

20

10

02008 2009 2010

Vein Clinic Visit Volume by Year Data Source: The Christ Hospital internal data reporting

Pat

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Pulmonary hypertension is a debilitating disease, once largely overlooked because of the lack of effective treatments. With the advent of medications in the last few years that can change the course of the disease, it is now imperative to identify these patients whose unexplained dyspnea or hypoxia are often mistaken for heart failure, lung disease or as a consequence of obesity or being out of shape. The members of our multidisciplinary pulmonary hypertension clinic—Peter Engel, M.D., medical director; Robert Baughman, M.D., pulmonologist; Greg Egnaczyk, M.D., Ph.D., cardiologist—work closely with primary care physicians to achieve optimal outcomes for patients.

Pulmonary Hypertension

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Pulmonary

Hypertension


Right heart catheterizations are the cornerstone of pulmonary hypertension diagnosis. Hemodynamics are the focus during clinics for both initial evaluation and follow-up.

2,000

1,600

800

1,200

400

02008 2009 2010

Pulmonary Hypertension Clinic Visits Annual VolumesData Source: The Christ Hospital internal reporting software.

Pat

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02008 2009 2010

Right Heart Catheterization VolumesData Source: The Christ Hospital internal reporting software.

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The Christ Hospital’s pulmonary hypertension clinic conducts a thorough hemodynamic evaluation of every patient who may have pulmonary hypertension, including nitric oxide challenge and exercise evaluation at time of right heart catheterization.

Commitment to Care The Christ Hospital cares for one of the largest populations of continuous infusion-therapy patients. Most treatments for pulmonary hypertension are exceedingly expensive and our experienced social work network is necessary in securing approval for their use.

Continuous Improvement The Christ Hospital hosts an annual symposium on pulmonary hypertension, organized by Dr. Engel, featuring nationally recognized experts and attended by approximately 100 clinicians.

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The Christ Hospital’s cardiac surgery program draws referrals from a wide regional base of 14 counties surrounding the Greater Cincinnati area. The following highlights are representative of our commitment to achieve best possible outcomes.

• With the recruitment of Robert Gallegos, M.D., Ph.D., cardiothoracic surgeon, The Christ Hospital will significantly expand its ventricular assist device services (see Advanced Technologies).

• For coronary artery bypass grafting, our venous harvest team collects saphenous veins endoscopically through a small incision in the leg, sparing patients an ankle-to-thigh scar and aiding long-term graft survival by reducing trauma to the vein.

• Our 16-bed cardiovascular intensive care unit (ICU) is staffed by personnel experienced specifically in the care of cardiac surgery patients. In addition, we are currently recruiting three mid-level providers dedicated to helping the physicians caring for these patients as well as providing continuing education of the ICU nurses.

• For those families in need of lodging, a private hospital suite may be provided free of charge upon availability.

Cardiac Surgery

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CLIENT: Christ

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Cardiac Surgery


400

320

160

240

80

02008 2009 2010

Overall Coronary Artery Bypass (CAB) Procedure Volumes*Data Source: Society of Thoracic Surgeons (STS) National Database

*Procedure volumes include isolated CAB, aortic valve replacement + CAB, mitral valve (MV) replacement + CAB, and MV repair + CAB.

Pro

cedu

re V

olum

e

Year

10.0

8.0

4.0

2.0

0.0

Isolated Coronary Artery Bypass Overall Mean Length of StayThe Christ Hospital (TCH) vs. Overall Society of Thoracic

Surgeons (STS) Benchmarks Data Source: Society of Thoracic Surgeons (STS) National Database

6.0

2008 2009 2010

Mea

n LO

S (d

ays)

STS Benchmark TCH

Year

3.0%

2.0%

1.0%

0.5%

0.0%

Coronary Artery Bypass Risk Adjusted Operative* Mortality Rates The Christ Hospital vs. Overall Society of

Thoracic Surgery (STS) Benchmarks Data Source: Society of Thoracic Surgeons (STS) National Database

*Operative mortality is defined as death during the same hospitalization as surgery or after discharge but within 30 days of the procedure

2.5%

1.5%

2008 2009 2010

STS Benchmark TCH

Mor

talit

y P

erce

nt

Year

300

200

100

50

0

National Quality Forum Measure 2010 Calendar Year VolumesThe Christ Hospital (TCH) vs. Society of Thoracic Surgeons (STS)

Data Source: Society of Thoracic Surgeons (STS) National Database

*Any mitral, aortic, tricuspid, or pulmonary valve surgery without a conconmi-

tant coronary artery bypass (CAB) procedure.**Any mitral, aortic, tricuspid, or pulmonary valve surgery with a conconmitant CAB procedure

250

150

CAB Valve* CAB + Valve**

STS Average TCH

Pro

cedu

re V

olum

e

Surgery Type

150

120

60

90

30

02008 2009 2010

Overall Valve Procedure Volumes*Data Source: Society of Thoracic Surgeons (STS) National Database

*Procedure volumes include aortic valve (AV) replacement, AV replacement + coronary artery bypass (CAB), mitral valve (MV) replacement, MV replacement + CAB, MV repair and MV repair + CAB.

Pro

cedu

re V

olum

e

Year

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To increase patient satisfaction, we have implemented several new systems and services.• Complimentary valet parking eases hospital arrivals and

departures.• A waiting area receptionist conveys information in a timely

manner to patients and families.• Single occupancy hospital rooms—now 75 percent of all

rooms—provide privacy for patients and their families.• Nurses make hourly rounds to check on patients’ medical

status and comfort.• Patients can now order room service and select foods

from an expanded menu.• Following discharge from the hospital, patients receive

phone calls as needed to check on their well-being or to ensure clarity of post-procedure instructions.

In surveys regarding patient satisfaction with emergency department (ED) experiences, scores for The Christ Hospital have risen steadily from the 35th to the 83rd percentile. A major attributive factor is the initiation of “LEAN,” a structured business management approach using critical thinking skills to improve the efficiency of processes and business operations. To date, the LEAN methodology has yielded substantial improvements in ED supply logistics and in patient length of stay.

20.0%

15.0%

0.0%

Most Preferred Hospital For Quality Source: National Research Corporation Preference Results 2010

Christ #2 Hospital #3 Hospital #4 Hospital #5 Hospital

10.0%

5.0%

Sept. 2009 – Aug. 2010 Sept. 2008 – Aug. 2009 May – Aug. 2008

Per

cent

Pre

fere

nce

Hospital

The National Research Corporation (www.nationalresearch.com) surveys the region’s consumers regarding hospital preferences. Data is based on the following: The market is the Cincinnati-Middletown-OH-KY-IN CBSA (Core-Based Statistical Area) counties of: Indiana: Dearborn, Franklin and Ohio; Kentucky: Boone, Bracken, Campbell, Gallatin, Grant, Kenton and Pendleton; Ohio: Brown, Butler, Clermont, Hamilton and Warren. The sample size is 1,516 households. Range of error: ±2.2% at the 95% confidence level.

Patient Satisfaction

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Patient Satisfaction


100

20

40

10

60

80

30

50

0Apr. – June 2010 July – Sept. 2010 Jan. – Mar. 2011

Emergency Department Patient SatisfactionSource: PressGaney patient satisfaction survey data

90

70

Oct. – Dec. 2010

Data depicted over timeframe of new emergency physician group orientation.

Emergency Department Overall Rating Percentile Ranking 40-50,000 Annual Visits

Per

cent

Sat

isfa

ctio

n

Timeframe

20.0%

16.0%

8.0%

4.0%

0.0%

18.0%

12.0%


10.0%

6.0%

2.0%

14.0%

Most Preferred Hospital Physicians By Consumers Source: National Research Corporation Preference Results 2010


Per

cent

Pre

fere

nce

Hospital

18.0%16.0%

8.0%

4.0%

0.0%

12.0%


10.0%

6.0%

2.0%

14.0%

Most Preferred Hospital Nurses By Consumers Source: National Research Corporation Preference Results 2010


Per

cent

Pre

fere

nce

Hospital

45.0%40.0%

20.0%

10.0%

0.0%

Most Preferred Hospital For Heart Care By ConsumersSource: National Research Corporation Preference Results 2010

30.0%

Christ #2Hospital

#3 Hospital

#4 Hospital

#5 Hospital

25.0%

15.0%

5.0%

35.0%

#6Hospital

#7 Hospital

#8Hospital


Per

cent

Pre

fere

nce

Hospital

20.0%

16.0%

8.0%

4.0%

0.0%

Most Preferred Hospital Inpatient Care By ConsumersSource: National Research Corporation Preference Results 2010

18.0%

12.0%


10.0%

6.0%

2.0%

14.0%

#6 Hospital


Per

cent

Pre

fere

nce

Hospital

18.0%16.0%

8.0%

4.0%

0.0%

Highest Patient Safety As Viewed By Consumers Source: National Research Corporation Preference Results 2010

12.0%


10.0%

6.0%

2.0%

14.0%


Per

cent

Pre

fere

nce

Hospital

95

91

93

87

89

86

92

94

88

90

85

Inpatient Cardiology Patient SatisfactionSource: PressGaney patient satisfaction survey data

Apr. – June 2010 July – Sept. 2010 Jan. – Mar. 2011Oct. – Dec. 2010

Cardiology Overall Rating Percentile Ranking Compared to Large HospitalsP

erce

nt S

atis

fact

ion

Timeframe

96

84

88

82

9294

86

90

80

Inpatient Cardiac Surgery Patient Satisfaction Source: PressGaney patient satisfaction survey data

Apr. – June 2010 July – Sept. 2010 Jan. – Mar. 2011Oct. – Dec. 2010

Cardiac Surgery Overall Rating Percentile Ranking Compared to Large Hospitals

Per

cent

Sat

isfa

ctio

n

Timeframe

18.0%16.0%

8.0%

4.0%

0.0%

Most Personalized Care Source: National Research Corporation Preference Results 2010

12.0%


10.0%

6.0%

2.0%

14.0%


Per

cent

Pre

fere

nce

Hospital

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Kereiakes DJ, Turco MA, Breall J, Farhat NZ, Feldman RL, McLaurin B, Popma JJ, Mauri L, Zimetbaum P, Massaro J, Cutlip DE. A Novel Filter-Based Distal Embolic Protection Device for Percutaneous Intervention of Saphenous Vein Graft Lesions: Results of the Amethyst Randomized Controlled Trial. J Am Coll Cardiol Intv 2008; 1:248-257.

Kereiakes DJ, Petersen JL, Batchelor WB, Fitzgerald PJ, Mehran R, Lansky A, Tsujino I, Schofer J. Dubois C, Verheye S, Cristea E, Garg J, Wijns W, Krucoff MW. Clinical and Angiographic Outcomes In Diabetic Patients Following Single or Multivessel Stenting In The COSTAR II Randomized Trial. J Invas Cardiol 2008; 20:335-341.

Chan PS, Kereiakes DJ, Bartone C, Chow T. Usefulness of microvolt T-wave alternans to predict outcomes in patients with ischemic cardiomyopathy beyond one year. Am J Cardiol 2008; 102:280-4.

Chow T, Kereiakes DJ, Onufer J, Woelfel A, Gursoy S, Peterson BJ, Brown ML, Pu W, Benditt DG on behalf of the MASTER Trial Investigators. Does Microvolt T-Wave Alternans Testing Predict Ventricular Tachyarrhythmias In Patients with Ischemic Cardiomyopathy and Prophylactic Defibrillators?: The MASTER Trial. J Am Coll Cardiol 2008; 52:1607-1615.

Holmes DR, Kereiakes DJ, Kleiman NS, Mauri L, Moliterno D, Harrington R, Giuseppe P, Grines C. Combining Antiplatelet and Anticoagulant Therapy: A note of caution. J Am Coll Cardiol 2009; 54:95-109.

Kereiakes DJ. Return to sender: Hospital readmission after percutaneous coronary intervention. (Editorial comment) J Am Coll Cardiol 2009; 54:908-910.

Coronary Artery DiseaseKereiakes DJ. Does clopidogrel each day keep thrombosis away? The evolving therapeutic algorithm for drug-eluting stents. J Am Med Assn 2007; 297:209-211.

Chow T, Kereiakes DJ, Bartone C, Booth T, Schloss EJ, Waller T, Chung E, Menon S, Nallamothu BK, Chan PS. Microvolt T-wave alternans identifies patients with ischemic cardiomyopathy who benefit from implantable cardioverter-defibrillator therapy. J Am Coll Cardiol 2007; 49:50-8.

Kereiakes DJ. The emperor’s new clothes: Another Cypher versus Taxus post-hoc meta-analysis. J Am Coll Cardiol 2007; 50:1381-1385.

Kereiakes DJ, Teirstein PS, Sarembock IJ, Holmes DR, Krucoff MW, O’Neill WW, Waksman R, Williams DO, Popma JJ, Buchbinder M, Mehran R, Meredith I, Moses JW, Stone GW. The truth and consequences of COURAGE. J Am Coll Cardiol 2007; 50:1598-603.

Kereiakes DJ, Gurbel P. Periprocedural platelet function and platelet inhibition in percutaneous coronary intervention. J Am Coll Cardiol Intv 2008; 1:111-121.

Krucoff WM, Kereiakes DJ, Petersen JL, Mehran R, Hasselblad V, Lansky AJ, Fitzgerald PJ, Garg J, Turco MA, Simonton CA, Verheye S, Dubois CL, Gammmon R, Batchelor WB, O’Shaughnessy CD, Hermiller JB, Schofer J. Buchbinder M, Wijns W for the COSTAR II investigators group. Novel bioresorbable polymer paclitaxel eluting stent for the treatment of single and multivessel coronary disease: primary results of the Cobalt Chromium Stent with Antiproliferative for restenosis II (COSTAR II) study. J Am Coll Cardiol 2008; 51:1543-52.

Publications

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Publications


Stone GW, Rizvi A, Newman W, Mastali K, Wang JC, Caputo R, Doostzadeh J, Cao S, Simonton CA, Sudhir K, Lansky AJ, Cutlip DE, Kereiakes DJ for the SPIRIT IV investigators. Everolimus-eluting versus paclitaxel-eluting stents in coronary artery disease. New Engl J Med 2010; 362:1663-74.

Kereiakes DJ. Cultivating prognosis following percutaneous coronary intervention: The ACC/NCDR Risk Score. J Am Coll Cardiol 2010; 55:1933-5.

Kereiakes DJ, Cannon LA, Feldman RL, Popma JJ, Magorien R, Whitbourn R, Dauber IM, Rabinowitz AC, Ball MW, Bertolet B, Kabour A, Foster MC, Wang JC, Underwood P, Dawkins KD. Clinical and angiographic outcomes following treatment of de novo coronary stenoses with a novel platinum-chromium thin strut stent: primary results of the PERSEUS (a Prospective Evaluation in a Randomized trial of the Safety and Efficacy of the Use of the TAXUS Element paclitaxel-eluting coronary Stent system). J Am Coll Cardiol 2010; 56:264-71.

Gurbel PA, Tantry US, Shuldiner AR, Kereiakes DJ. Genotyping: One piece of the puzzle to personalize antiplatelet therapy. J Am Coll Cardiol 2010; 56:264-71. (Editorial comment for Damani/Topol paper)

Tantry U, Kereiakes DJ, Gurbel P. Clopidogrel and proton pump inhibitors: Influence of pharmacologic interactions on clinical outcomes and mechanistic explanations. J Am Coll Cardiol Interventions 2011; 4:365-380.

Stone GW, Rizvi A, Sudhir K, Newman W, Applegate RJ, Cannon LA, Maddux JT, Cutlip DE, Simonton CA, Sood P, Kereiakes DJ for the SPIRIT IV investigators. Randomized comparison of everolimus- and paclitaxel-eluting stents: Two-year follow-up from the SPIRIT IV (Clinical evaluation of the XIENCE V everolimus eluting coronary stent system) trial. J Am Coll. Cardiol. 2011; 58:19-25.

Kereiakes DJ, Smits PC, Kedhi E, Parise H, Fahy M, Serruys PW, Stone GW. Predictors of death or myocardial infarction, ischaemic-driven revascularisation, and major adverse cardiovascular events following everolimus-eluting or paclitaxel-eluting stent deployment: Pooled analysis from the SPIRIT II, III, IV and COMPARE trials. EuroIntervention 2011; 7:74-83.

Kereiakes DJ, Cannon LA, Ormiston JA, Turco MA, Wang H, Underwood P, Dawkins KD. Propensity-matched patient level comparison of the TAXUS Liberté and TAXUS Element (ION) paclitaxel-eluting stents. Am J Cardiol (in press- scheduled to publish September 2011).

Heart FailureChung ES, Menon SG, Weiss R, Schloss EJ, Chow T, Kereiakes DJ, Pastore J. Attenuation of Cardiac Remodeling after Recent Myocardial Infarction through Biventricular Pacing. Congestive Heart Failure 2007, Jan-Feb. 13(1):9-15.

Curtis AB, Adamson PB, Chung ES, St. John Sutton M, Tang F, Worley S. Biventricular vs. Right Ventricular Pacing in Heart Failure Patients with AV Block (BLOCK HF): Clinical study design and rationale. J Cardiovasc Electrophysiol. 2007 Sep; 18(9):965-71. Epub 2007 Jul 27.

Chung ES, Guo L, Casey Jr DE, Bartone C, Menon SG, Saghir S, Mital A, Kereiakes DJ. Relationship of a Quality Measure Composite to Clinical Outcomes for Patients with Heart Failure. Am J Med Qual. 2008 May-Jun; 23(3):168-75.

Chung ES, Leon AR, Tavazzi L, Sun JP, Nihoyannopoulos P, Merlino J, Abraham WT, Ghio S, Leclercq C, Bax JJ, Yu CM, Gorcsan J 3rd, St. John Sutton M, De Sutter J, Murillo J. Results of the Predictors of Response to CRT (PROSPECT) Trial: Circulation. 2008 May 20; 117(20):2608-16.

Mazur W. and Chung ES. The role of electrocardiography in cardiac resynchronization therapy. Curr Heart Fail Rep 2009; 1:37-43.

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Van Bommel RJ, Bax JJ, Abraham WT, Chung ES, Pires LA, Tavazzi L, Zimetbaum PJ, Gerritse B, Kristiansen N, Ghio S. Characteristics of heart failure patients associated with good and poor response to cardiac resynchronization therapy: a PROSPECT (Predictors of Response to CRT) sub analysis. Eur Heart J. 2009; 30:2470-7.

Chung ES, Katra RP, Ghio S, Bax JJ, Gerritse B, Hilpisch K, Peterson BJ, Feldman DS, Abraham WT. Cardiac Resynchronization Therapy May Benefit Patients with Left Ventricular Ejection Fraction > 35%: a PROSPECT Trial Substudy. Eur J Heart Fail. 2010; 12:581-7.

Chung ES, Dan D, Solomon SD, Bank AJ, Pastore J, Iyer A, Berger RD, Franklin J, Jones G, Machado C, Stolen CM. Effect of Peri-Infarct Pacing Early after Myocardial Infarction: Results of the Prevention of Myocardial Enlargement and Dilatation Post Myocardial Infarction (MENDMI) Study. Circ Heart Fail. 2010; 1:650-8.

Chung ES, Mazur W. Echocardiographic assessment of dyssynchrony: moving forward. Editorial. Circ Heart Fail. 2010 Sep 1; 3(5):561-4.

Cardiac ImagingHor KN, Wansapura J, Markham LW, Mazur W, Cripe LH, Fleck R, Benson DW, Gottliebson WM. Circumferential strain analysis identifies strata of cardiomyopathy in Duchenne muscular dystrophy: a cardiac magnetic resonance tagging study. J Am Coll Cardiol 2009; 53:1204-10.

Hagenbuch SC, Gottliebson WM, Wansapura J, Mazur W, Fleck R, Benson DW, Hor KN. Detection of progressive cardiac dysfunction by serial evaluation of circumferential strain in patients with Duchenne muscular dystrophy. Am J Cardiol 2010; 10:1451-5.

Pelberg RA, Mazur W, Clarke G, Szawaluk J. The what and why of cardiac CT angiography: data interpretation and

clinical practice integration. Rev Cardiovasc Med 2009; 10:152-63.

Wanaspura JP, Hor KN, Mazur W, Fleck R, Hagenbuch S, Benson DW, Gottliebson WM. Left ventricular T2 distribution in Duchenne muscular dystrophy. J Cardiovasc Magn Reson 2010; 12:14.

Mazur W, Hor KN, Germann JT, Fleck RJ, Al-Khalidi HR, Wansapura JP, Chung ES, Taylor MD, Jefferies JL, Woodrow Benson D, Gottliebson WM. Patterns of left ventricular remodeling in patients with Duchenne Muscular Dystrophy: a cardiac MRI study of ventricular geometry, global function, and strain. Int J Cardiovasc Imaging 2011 Jan. 8.

Kan N Hor, Janaka P Wansapura, Husseinn R Al-Khalidi, William Gottliebson, Michael Taylor, Richard Czosek, Shefif Nagueh, Nandakishore Akula, Eugene S Chung, D. Woodrow Benson, Wojciech Mazur, Presence of Mechanical Dyssynchrony in Duchenne Muscular Dystrophy, J Cardiovasc Magn Reson. 2011 Feb. 2; 13 (1):12.

Tomasz Miszalski-Jamka, Piotr Klimeczek, Robert Banys, Maciej Krupinski, Malgorzata Irzyk, Krzysztof Nycz, Krzystztof Bury, Michal Lada, Wojciech Mazur. Plaque composition and extend enhance CTCA prognostication. Int J Cardiovas Imaging. 2011, Mar 3 (Epub ahead of print).

Miszalski-Jamka T, Szczeklik W, Sokolowska B, Miszalski-Jamka K, Karwat K, Grzadziel G, Mazur W, Kereiakes DJ, Musial K. Cardiac involvement in Wegener’s granulomatosis resistant to induction therapy. European Journal of Radiology, in print 2011.

S. Sanjay Srivatsa, Michael D Taylor, Kan Hor, David A. Collins, Melissa King-Strunk, Robert A. Pelberg, Wojciech Mazur, Liquefaction Necrosis of Mitral Annular Calcification (LNMAC): Review of Pathology, Prevalence, Imaging

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and Management. International Journal of Cardiovascular Imaging, in print 2011.

Melissa King-Strunk, Wojciech Mazur, Amy Tipton, Sanjay S Srivatsa. MRI image sequencing of calcified myocardial masses: liquefaction necrosis of mitral annular calcification (LNMAC) Presented at the 2011 SCMR/Euro Joint Scientific Sessions Nice, France. 3-6 February 2011.

Janaka Wansapura, Kan Hor, Wojciech Mazur, Robert Fleck, Michael Taylor, Woodrow Benson, William Gottliebson. Serial assessment of myocardial T2 in Duchenne muscular dystrophy. Presented at the 2011 SCMR/Euro Joint Scientific Sessions, Nice, France. 3-6 February 2011.

Michael Taylor, Jordan R. Hill, Wojciech Mazur, William M. Gottliebson, D. Woodrow Benson, Kan N. Hor. Right ventricular strain in patients with tetralogy of Fallot. Presented at the 2011 SCMR/Euro Joint Scientific Sessions. Nice, France. 3-6 February 2011.

Kan N. Hor, Wojciech Mazur, Michael D. Taylor, Hussein R. Al-Khalidi, Linda H. Cripe, John L. Jefferies, Eugene S. Chung, Kathi Kinnett, Katelyn Williams, William M. Gottliebson, Woodrow Benson. Effects of Steroids and Angiotensin Converting Enzyme Inhibition on Circumferential Strain in Boys with Duchenne Muscular Dystrophy: A Cross-Sectional and Longitudinal Study Utilizing Cardiac Magnetic Resonance Imaging. Presented at the 2011 SCMR/Euro Scientific Sessions. Nice, France. 3-6 February 2011.

Hor KN, Baumann R, Pedrizzetti G, Tonti G, Gottliebson WM, Taylor M, Benson W, Mazur W. Magnetic resonance derived myocardial strain assessment using feature tracking. J Vis Exp. 2011 Feb. 12; (48). Pii 2356. doi 10.3791/2356. Hor KN, Gottliebson WM, Carson C, Wash E, Cnota J, Fleck R, Wansapura J, Klimeczek P, Al-Khalidi HR, Chung ES, Benson DW, Mazur W. Comparison of magnetic resonance

feature tracking for strain calculation with harmonic phase imaging analysis. JACC Cardiovasc Imaging. 2010 Feb; 3 (2): 144-51. Pulmonary HypertensionBaughman RP, Engel PJ, Meyer CA, Barrett AB, Lower EE. Pulmonary Hypertension in Sarcoidosis. Sarc Vasc Diff Lung Dis 2006:108-116.

Engel PJ, Baughman RP, Menon SG, et al. Pulmonary hypertension in neurofibromatosis. Am J Cardio 2007; 99:1177-8.

Simonueau G, Rubin, LJ, Galie N, Barst RJ, Fleming TR, Frost AE, Engel PJ, et al. Addition of Sildenafil to Long-Term Intravenous Epoprostenol Therapy in Patients with Pulmonary Arterial Hypertension: A randomized clinical trial. Ann Inter Med, 2008; 149:521-30; Erratum in: Ann Intern Med 2009; 150:63; Ann Intern Med 2009; 151:435.

Engel PJ, Baughman RP. Treatment of right ventricular dysfunction in pulmonary arterial hypertension: theoretical considerations. Med Hypothesis 2009; 73:448-52.

Baughman RP, Judson MA, Lower EE, Highland K, Kwon S, Craft N, Engel PJ. Inhaled iloprost for sarcoidosis associated pulmonary hypertension. Sarcoidosis Vasc Diffuse Lung Dis. 2009; 26:110-20.

Robert P. Baughman, Peter J. Engel, Lisa Taylor and Elyse E. Lower. Survival in sarcoidosis associated pulmonary hypertension: the importance of hemodynamic evaluation. Chest 2010; 138:1078-85.

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12 in

2139 Auburn AvenueCincinnati, Ohio 45219513-585-1613www.thechristhospital.com

NON-PROFIT ORGUS POSTAGE

PAIDCINCINNATI OHPERMIT #5489

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