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Objectives The aim of this study was to assess 1-year clinical outcomes among high-risk patients with failed surgical mitral bioprostheses who underwent transseptal mitral valve-in-valve (MViV) with the SAPIEN 3 aortic transcatheter heart valve (THV) in the MITRAL (Mitral Implantation of Transcatheter Valves) trial. Background The MITRAL trial is the first prospective study evaluating transseptal MViV with the SAPIEN 3 aortic THV in high-risk patients with failed surgical mitral bioprostheses. Methods High-risk patients with symptomatic moderate to severe or severe mitral regurgitation (MR) or severe mitral stenosis due to failed surgical mitral bioprostheses were prospectively enrolled. The primary safety endpoint was technical success. The primary THV performance endpoint was absence of MR grade ≥2+ or mean mitral valve gradient ≥10 mm Hg (30 days and 1 year). Secondary endpoints included procedural success and all-cause mortality (30 days and 1 year). Results Thirty patients were enrolled between July 2016 and October 2017 (median age 77.5 years [interquartile range (IQR): 70.3 to 82.8 years], 63.3% women, median Society of Thoracic Surgeons score 9.4% [IQR: 5.8% to 12.0%], 80% in New York Heart Association functional class III or IV). The technical success rate was 100%. The primary performance endpoint in survivors was achieved in 96.6% (28 of 29) at 30 days and 82.8% (24 of 29) at 1 year. Thirty-day all-cause mortality was 3.3% and was unchanged at 1 year. The only death was due to airway obstruction after swallowing several pills simultaneously 29 days post-MViV. At 1-year follow-up, 89.3% of patients were in New York Heart Association functional class I or II, the median mean mitral valve gradient was 6.6 mm Hg (interquartile range: 5.5 to 8.9 mm Hg), and all patients had MR grade ≤1+. Conclusions Transseptal MViV in high-risk patients was associated with 100% technical success, low procedural complication rates, and very low mortality at 1 year. The vast majority of patients experienced significant symptom alleviation, and THV performance remained stable at 1 year.

As the prevalence of asymptomatic COVID-19 continues to increase, there is an increasing possibility that patients with COVID-19 may presen with ST-segment elevation myocardial infarction (STEMI). With social distancing and restricted access to preventive healthcare and emergency services, the management of acute cardiac emergencies such as myocardial infarction has suffered collateral damage. Thus far, global trends suggest a decrease in STEMI activations with possible worse outcomes due to delayed presentation and management. In this review, we discuss the challenges to STEMI management in the COVID-19 era and provide potential solutions for adherence to evidence-based therapies as the pandemic progresses into the year 2021.

Objectives The aim of this study was to evaluate 1-year outcomes of valve–in–mitral annular calcification (ViMAC) in the MITRAL (Mitral Implantation of Transcatheter Valves) trial. Background The MITRAL trial is the first prospective study evaluating the feasibility of ViMAC using balloon-expandable aortic transcatheter heart valves. Methods A multicenter prospective study was conducted, enrolling high-risk surgical patients with severe mitral annular calcification and symptomatic severe mitral valve dysfunction at 13 U.S. sites. Results Between February 2015 and December 2017, 31 patients were enrolled (median age 74.5 years [interquartile range (IQR): 71.3 to 81.0 years], 71% women, median Society of Thoracic Surgeons score 6.3% [IQR: 5.0% to 8.8%], 87.1% in New York Heart Association functional class III or IV). Access was transatrial (48.4%), transseptal (48.4%), or transapical (3.2%). Technical success was 74.2%. Left ventricular outflow tract obstruction (LVOTO) with hemodynamic compromise occurred in 3 patients (transatrial, n = 1; transseptal, n = 1; transapical, n = 1). After LVOTO occurred in the first 2 patients, pre-emptive alcohol septal ablation was implemented to decrease risk in high-risk patients. No intraprocedural deaths or conversions to open heart surgery occurred during the index procedures. All-cause mortality at 30 days was 16.7% (transatrial, 21.4%; transseptal, 6.7%; transapical, 100% [n = 1]; p = 0.33) and at 1 year was 34.5% (transatrial, 38.5%; transseptal, 26.7%; p = 0.69). At 1-year follow-up, 83.3% of patients were in New York Heart Association functional class I or II, the median mean mitral valve gradient was 6.1 mm Hg (IQR: 5.6 to 7.1 mm Hg), and all patients had ≤1+ mitral regurgitation. Conclusions At 1 year, ViMAC was associated with symptom improvement and stable transcatheter heart valve performance. Pre-emptive alcohol septal ablation may prevent transcatheter mitral valve replacement–induced LVOTO in patients at risk. Thirty-day mortality of patients treated via transseptal access was lower than predicted by the Society of Thoracic Surgeons score. Further studies are needed to evaluate safety and efficacy of ViMAC.

Objectives The authors report 1-year outcomes of high-risk patients with failed surgical annuloplasty rings undergoing transseptal mitral valve–in–ring (MViR) with the SAPIEN 3 aortic transcatheter heart valve (THV). Background The MITRAL (Mitral Implantation of Transcatheter Valves) trial is the first prospective study evaluating transseptal MViR with the SAPIEN 3 aortic THV in high-risk patients with failed surgical annuloplasty rings. Methods Prospective enrollment of high-risk patients with symptomatic moderate to severe or severe mitral regurgitation (MR) or severe mitral stenosis and failed annuloplasty rings at 13 U.S. sites. The primary safety endpoint was technical success. The primary THV performance endpoint was absence of MR grade ≥2+ or mean mitral valve gradient ≥10 mm Hg (30 days and 1 year). Secondary endpoints included procedural success and all-cause mortality (30 days and 1 year). Results Thirty patients were enrolled between January 2016 and October 2017 (median age 71.5 years [interquartile range: 67.0 to 76.8 years], 36.7% women, median Society of Thoracic Surgeons score 7.6% [interquartile range: 5.1% to 11.8%], 76.7% in New York Heart Association functional class III or IV). Technical success was 66.7% (driven primarily by need for a second valve in 6 patients). There was no intraprocedural mortality or conversion to surgery. The primary performance endpoint was achieved in 85.7% of survivors at 30 days (24 of 28) and 89.5% of patients alive at 1 year with echocardiographic data available (17 of 19). All-cause mortality at 30 days was 6.7% and at 1 year was 23.3%. Among survivors at 1-year follow-up, 84.2% were in New York Heart Association functional class I or II, the median mean mitral valve gradient was 6.0 mm Hg (interquartile range: 4.7 to 7.3 mm Hg), and all had ≤1+ MR. Conclusions Transseptal MViR was associated with a 30-day mortality rate lower than predicted by the Society of Thoracic Surgeons score. At 1 year, transseptal MViR was associated with symptom improvement and stable THV performance.

This multisocietal Expert Consensus Systems of Care document was commissioned by the American Association for Thoracic Surgery (AATS), the American College of Cardiology (ACC), the Society for Cardiovascular Angiography and Interventions (SCAI), and the Society of Thoracic Surgeons (STS). Expert

To reduce emergency department (ED) chest pain observation and admission rates, a multidisciplinary task force designed and implemented a triage protocol using quantitative symptom scoring (HEART score) and biomarkers for myocardial damage. High-sensitivity troponin-T (hs-TnT) has been shown to be an effective tool in diagnosing patients with suspected acute coronary syndrome (ACS) in the ED.1 2 The protocol risk stratified patients by HEART score and hs-TnT into low risk (HEART score 0–3 and normal hs-TnT in two separate measurements in 2-hour intervals), intermediate risk (HEART score 4–6 and hs-TnT

There does not appear to be a difference in patient outcomes of percutaneous coronary intervention for unprotected left main coronary artery stenosis whether using first- or second-generation drug elutting stent. This is despite increase in patients having more adjunctive procedures such as intravascular imaging and newer generation antiplatelet agents. This single-center study provokes questions as to why there has not been improvement in outcomes.

Background: Transcatheter mitral valve replacement using aortic transcatheter heart valves has recently become an alternative for patients with degenerated mitral bioprostheses, failed surgical repairs with annuloplasty rings or severe mitral annular calcification who are poor surgical candidates. Outcomes of these procedures are collected in the Society of Thoracic Surgeons/American College of Cardiology/Transcatheter Valve Therapy Registry. A comprehensive analysis of mitral valve-in-valve (MViV), mitral valve-in-ring (MViR), and valve-in-mitral annular calcification (ViMAC) outcomes has not been performed. We sought to evaluate short-term outcomes of early experience with MViV, MViR, and ViMAC in the United States. Methods: Retrospective analysis of data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. Results: Nine hundred three high-risk patients (median Society of Thoracic Surgeons score 10%) underwent MViV (n=680), MViR (n=123), or ViMAC (n=100) between March 2013 and June 2017 at 172 hospitals. Median age was 75 years, 59.2% female. Technical and procedural success were higher in MViV. Left ventricular outflow tract obstruction occurred more frequently with ViMAC (ViMAC=10%, MViR=4.9%, MViV=0.7%; P P =0.004) and 30-day mortality (MViV=8.1%, MViR=11.5%, ViMAC=21.8%; P =0.003) were higher in ViMAC. At 30-day follow-up, median mean mitral valve gradient was 7 mm Hg, most patients (96.7%) had mitral regurgitation grade ≤1 (+) and were in New York Heart Association class I to II (81.7%). Conclusions: MViV using aortic balloon-expandable transcatheter heart valves is associated with a low complication rate, a 30-day mortality lower than predicted by the Society of Thoracic Surgeons score, and superior short-term outcomes than MViR and ViMAC. At 30 days, patients in all groups experienced improvement of symptoms, and valve performance remained stable. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02245763.

To ensure that guidelines reflect current knowledge, available treatment options, and optimum medical care, existing clinical practice guideline recommendations are modified and new recommendations are added in response to new data, medications or devices. To keep pace with evolving evidence, the American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Clinical Practice Guidelines (“Task Force”) has issued this focused update to revise guideline recommendations on the basis of recently published data. This update is not based on a complete literature review from the date of previous guideline publications, but it has been subject to rigorous, multilevel review and approval, similar to the full guidelines. For specific focused update criteria and additional methodological details, please see the ACC/AHA guideline methodology manual.1 ### Modernization In response to published reports from the Institute of Medicine2,3 and ACC/AHA mandates,4–7 processes have changed leading to adoption of a “knowledge byte” format. This entails delineation of recommendations addressing specific clinical questions, followed by concise text, with hyperlinks to supportive evidence. This approach better accommodates time constraints on busy clinicians, facilitates easier access to recommendations via electronic search engines and other evolving technology (eg, smart phone apps), and supports the evolution of guidelines as “living documents” that can be …

Jonathan L. Halperin, MD, FACC, FAHA, Chair Glenn N. Levine, MD, FACC, FAHA, Chair-Elect Jeffrey L. Anderson, MD, FACC, FAHA, Immediate Past Chair [∗∗][1] Nancy M. Albert, PhD, RN, FAHA[∗∗][1] Sana M. Al-Khatib, MD, MHS, FACC, FAHA Kim K. Birtcher, PharmD, MS, AACC Biykem Bozkurt, MD

This multisocietal Expert Consensus Systems of Care document was commissioned by the American Association for Thoracic Surgery (AATS), the American College of Cardiology (ACC), the Society for Cardiovascular Angiography and Interventions (SCAI), and the Society of Thoracic Surgeons (STS). Expert

With the evolution of transcatheter valve replacement, an important opportunity has arisen for cardiologists and surgeons to collaborate in identifying the criteria for performing these procedures. Therefore, The Society for Cardiovascular Angiography and Interventions (SCAI), American Association for Thoracic Surgery (AATS), American College of Cardiology (ACC), and The Society of Thoracic Surgeons (STS) have partnered to provide recommendations for institutions to assess their potential for instituting and/or maintaining a transcatheter valve program. This article concerns transcatheter pulmonic valve replacement (tPVR). tPVR procedures are in their infancy with few reports available on which to base an expert consensus statement. Therefore, many of these recommendations are based on expert consensus and the few reports available. As the procedures evolve, technology advances, experience grows, and more data accumulate, there will certainly be a need to update this consensus statement. The writing committee and participating societies believe that the recommendations in this report serve as appropriate requisites. In some ways, these recommendations apply to institutions more than to individuals. There is a strong consensus that these new valve therapies are best performed using a Heart Team approach; thus, these credentialing criteria should be applied at the institutional level. Partnering societies used the ACC's policy on relationships with industry (RWI) and other entities to author this document (http://www.acc.org/guidelines/about-guidelines-and-clinical-documents). To avoid actual, potential, or perceived conflicts of interest due to industry relationships or personal interests, all members of the writing committee, as well as peer reviewers of the document, were asked to disclose all current healthcare-related relationships including those existing 12 months before the initiation of the writing effort. A committee of interventional cardiologists and surgeons was formed to include a majority of members with no relevant RWI and to be led by an interventional cardiology cochair and a surgical cochair with no relevant RWI. Authors with relevant RWI were not permitted to draft or vote on text or recommendations pertaining to their RWI. RWI were reviewed on all conference calls and updated as changes occurred. Author and peer reviewer RWI pertinent to this document are disclosed in the Appendices. In addition, to ensure complete transparency, authors' comprehensive disclosure information (including RWI not pertinent to this document) is available in Appendix AII. The work of the writing committee was supported exclusively by the partnering societies without commercial support. SCAI, AATS, ACC, and STS believe that adherence to these recommendations will maximize the chances that these therapies will become a successful part of the armamentarium for treating valvular heart disease in the United States. In addition, these recommendations will hopefully facilitate optimum quality during the delivery of this therapy, which will be important to the development and successful implementation of future, less invasive approaches to structural heart disease.

roved by the American College of Cardiology erican Association for Thoracic Surgery Council, ular Angiography and Interventions Foundation e Society ofThoracic Surgeons Board ofDirectors e purpose of transparency, disclosure information stees, the board of the convening organization of e at http://www.cardiosource.org/ACC/Aboutership/Officers-and-Trustees.aspx. of Cardiology requests that this document be PT, Calhoon JH, Moon MR, Tommaso CL. or mitral regurgitation: a professional society rican College of Cardiology, the American urgery, Society for Cardiovascular Angiography ation, and The Society of Thoracic Surgeons. 3:840–52. This a and Card vascular S Copie the Ame ican Ass for Card and The documen 3820, ePermi of this d America via the E to-re-use

Jeffrey L. Anderson, MD, FACC, FAHA, Chair; Alice K. Jacobs, MD, FACC, FAHA, Immediate Past Chair; Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect; Nancy M. Albert, PhD, CCNS, CCRN, FAHA; Ralph G. Brindis, MD, MPH, MACC; Mark A. Creager, MD, FACC, FAHA; David DeMets, PhD; Robert A. Guyton, MD

Jeffrey L. Anderson, MD, FACC, FAHA, Chair; Alice K. Jacobs, MD, FACC, FAHA, Immediate Past Chair; Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect; Nancy M. Albert, PhD, CCNS, CCRN, FAHA; Ralph G. Brindis, MD, MPH, MACC; Mark A. Creager, MD, FACC, FAHA; David DeMets, PhD; Robert A. Guyton, MD

Current guidelines indicate that routine aspiration thrombectomy (AT) has a level III indication and AT is only indicated for "bail-out" indications. "Bail-out" situations are not well defined. The AT catheter may still be necessary and have other uses such as distal contrast or drug delivery.

Robert A. Harrington, MD, FACC, Chair Eric R. Bates, MD, FACC[¶][1] Deepak L. Bhatt, MD, MPH, FACC Charles R. Bridges, MD, MPH, FACC[¶][1] Mark J. Eisenberg, MD, MPH, FACC[¶][1] Victor A. Ferrari, MD, FACC John D. Fisher, MD, FACC Timothy Gardner, MD, FACC Federico Gentile, MD, FACC

Determining the most appropriate revascularization strategy for patients presenting with unprotected left main coronary (UPLM) disease has been a topic of great recent interest. During this current decade, there have been multiple clinical trials and registries addressing this subject. Previously, UPLM disease has almost exclusively resulted in utilizing a surgical revascularization treatment strategy. However, recent improvements in percutaneous coronary intervention (PCI) techniques in parallel with the benefits of drug-eluting stents (DES) to reduce clinical restenosis have enabled further investigation in catheterization-based treatment strategies as possible alternative therapeutic options. These advances as well as an increased understanding of both the procedural and anatomical challenges involved with complex coronary interventions have allowed further advancements in the field. Better adjunctive antithrombotic pharmacological therapy in the PCI setting has favored such progress. American College of Cardiology/American Heart Association/Society for Coronary Angiography and Interventions guidelines do not currently endorse the performance of PCI as an appropriate alternative to surgical revascularization for patients with UPLM disease. This paper is a review of the current evidence on UPLM PCI and proposes future directions in this evolving field.

Doctor: “Ma'am you need an angioplasty” Patient: “Doctor, the newspaper says that medicine is as good as angioplasty” Doctor: “Ma'am you're having a heart attack” The COURAGE trial was published 1 year ago and received attention from the media, patients, and other medical specialties concerning the value of percutaneous coronary intervention. Now, 1 year later there has been time to reflect on COURAGE, and some newer data have emerged. The purpose of this article is to put into perspective the issues surrounding the COURAGE trial and suggest different approaches for future trials of stable coronary artery disease. © 2008 Wiley-Liss, Inc.

The learning curve for TAVR is determined based on technical (procedural) data from PARTNER-1 Trial The number of cases needed to reach a learning curve for TAVR in PARTNER-1 was 50 for original sites and fell to 25 for late entering sites Analyses such as this is important in developing guidelines for other emerging technologies.

The granting of clinical staff privileges to physicians is a primary mechanism used by institutions to uphold the quality of care. The Joint Commission on Accreditation of Healthcare Organization (JCAHO) requires that the granting of continuing medical staff privileges be based on assessments of applicants against professional criteria specified in the medical staff bylaws. Physicians themselves are thus charged with …

The learning curve for TAVR is determined based on technical (procedural) data from PARTNER-1 Trial The number of cases needed to reach a learning curve for TAVR in PARTNER-1 was 50 for original sites and fell to 25 for late entering sites Analyses such as this is important in developing guidelines for other emerging technologies.

The interventional cardiologist makes a provisional diagnosis of the no-reflow phenomenon in the presence of an acute reduction in coronary flow despite a widely patent epicardial vessel during percutaneous coronary intervention (PCI). Its occurrence is recognized as a column of contrast arising distal to the original target stenosis that does not rapidly clear [1–3]. The precise pathophysiologic mechanisms are uncertain, although flow-limiting spasm of the distal microvasculature, distal thromboembolism, and microembolization of atherosclerotic debris are believed to be operative, in some combination, in most cases [4,5]. No-reflow as a cardiac phenomenon was originally identified in experimental models of acute myocardial infarction and described as the failure to restore normal myocardial blood flow despite subsequent removal of the coronary arterial obstruction, attributable to microvascular damage related to irreversible ischemic changes and local edema. It has been recognized for over a decade clinically [6,7] as an uncommon (0.6–2.0%) complication of PCI [1,2,6]. It occurs frequently following thrombolytic or mechanical reperfusion for acute myocardial infarction and in the setting of unstable angina [3,7,8]. It is most common during use of rotational atherectomy [9,10] and during PCI in saphenous vein grafts [2]. The purpose of this review is to define the angiographic appearance and clinical outcomes of no-reflow and to summarize the various treatment and prevention options currently available to the interventional cardiologist.

The use of mechanical thrombectomy in STEMI with large amount of jeopardized myocardium may preserve regional wall motion When appropriate and done with proper removal technique, there does not appear to be any increased incidence of neurologic complications The guideline recommendation that mechanical thrombectomy should not be done routinely is supported by these authors.

With the evolution of transcatheter valve replacement, an important opportunity has arisen for cardiologists and surgeons to collaborate in identifying the criteria for performing these procedures. Therefore, The Society for Cardiovascular Angiography and Interventions (SCAI), American Association for Thoracic Surgery (AATS), American College of Cardiology (ACC), and The Society of Thoracic Surgeons (STS) have partnered to provide recommendations for institutions to assess their potential for instituting and/or maintaining a transcatheter valve program. This article concerns transcatheter pulmonic valve replacement (tPVR). tPVR procedures are in their infancy with few reports available on which to base an expert consensus statement. Therefore, many of these recommendations are based on expert consensus and the few reports available. As the procedures evolve, technology advances, experience grows, and more data accumulate, there will certainly be a need to update this consensus statement. The writing committee and participating societies believe that the recommendations in this report serve as appropriate requisites. In some ways, these recommendations apply to institutions more than to individuals. There is a strong consensus that these new valve therapies are best performed using a Heart Team approach; thus, these credentialing criteria should be applied at the institutional level. Partnering societies used the ACC's policy on relationships with industry (RWI) and other entities to author this document (http://www.acc.org/guidelines/about-guidelines-and-clinical-documents). To avoid actual, potential, or perceived conflicts of interest due to industry relationships or personal interests, all members of the writing committee, as well as peer reviewers of the document, were asked to disclose all current healthcare-related relationships including those existing 12 months before the initiation of the writing effort. A committee of interventional cardiologists and surgeons was formed to include a majority of members with no relevant RWI and to be led by an interventional cardiology cochair and a surgical cochair with no relevant RWI. Authors with relevant RWI were not permitted to draft or vote on text or recommendations pertaining to their RWI. RWI were reviewed on all conference calls and updated as changes occurred. Author and peer reviewer RWI pertinent to this document are disclosed in the Appendices. In addition, to ensure complete transparency, authors' comprehensive disclosure information (including RWI not pertinent to this document) is available in Appendix AII. The work of the writing committee was supported exclusively by the partnering societies without commercial support. SCAI, AATS, ACC, and STS believe that adherence to these recommendations will maximize the chances that these therapies will become a successful part of the armamentarium for treating valvular heart disease in the United States. In addition, these recommendations will hopefully facilitate optimum quality during the delivery of this therapy, which will be important to the development and successful implementation of future, less invasive approaches to structural heart disease.

roved by the American College of Cardiology erican Association for Thoracic Surgery Council, ular Angiography and Interventions Foundation e Society ofThoracic Surgeons Board ofDirectors e purpose of transparency, disclosure information stees, the board of the convening organization of e at http://www.cardiosource.org/ACC/Aboutership/Officers-and-Trustees.aspx. of Cardiology requests that this document be PT, Calhoon JH, Moon MR, Tommaso CL. or mitral regurgitation: a professional society rican College of Cardiology, the American urgery, Society for Cardiovascular Angiography ation, and The Society of Thoracic Surgeons. 3:840–52. This a and Card vascular S Copie the Ame ican Ass for Card and The documen 3820, ePermi of this d America via the E to-re-use

Journal of the American College of Cardiology Ó 2014 by the American College of Cardiology Foundation, American Heart Association, Inc., American Medical Association, and National Committee for Quality Assurance Published by Elsevier Inc. Vol. 63, No. 7, 2014 ISSN 0735-1097/$36.00 http://dx.doi.org/10.1016/j.jacc.2013.12.003 PERFORMANCE MEASURES ACC/AHA/SCAI/AMA–Convened PCPI/NCQA 2013 Performance Measures for Adults Undergoing Percutaneous Coronary Intervention A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures, the Society for Cardiovascular Angiography and Interventions, the American Medical Association–Convened Physician Consortium for Performance Improvement, and the National Committee for Quality Assurance Developed in Collaboration With the American Association of Cardiovascular and Pulmonary Rehabilitation and Mended Hearts Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and Mended Hearts WRITING COMMITTEE MEMBERS Brahmajee K. Nallamothu, MD, MPH, FACC, FAHA, Co-Chair*; Carl L. Tommaso, MD, FACC, FAHA, FSCAI, Co-Chairy; H. Vernon Anderson, MD, FACC, FAHA, FSCAI*; Jeffrey L. Anderson, MD, FACC, FAHA, MACP*; Joseph C. Cleveland, J R , MDz; R. Adams Dudley, MD, MBA; Peter Louis Duffy, MD, MMM, FACC, FSCAIy; David P. Faxon, MD, FACC, FAHA*; Hitinder S. Gurm, MD, FACC; Lawrence A. Hamilton, Neil C. Jensen, MHA, MBA; Richard A. Josephson, MD, MS, FACC, FAHA, FAACVPRx; David J. Malenka, MD, FACC, FAHA*; Calin V. Maniu, MD, FACC, FAHA, FSCAIy; Kevin W. McCabe, MD; James D. Mortimer, Manesh R. Patel, MD, FACC*; Stephen D. Persell, MD, MPH; John S. Rumsfeld, MD, PhD, FACC, FAHAjj; Kendrick A. Shunk, MD, PhD, FACC, FAHA, FSCAI*; Sidney C. Smith, J R , MD, FACC, FAHA, FACP{; Stephen J. Stanko, MBA, BA, AA#; Brook Watts, MD, MS *ACC/AHA Representative. ySociety of Cardiovascular Angiography and Interventions Representative. zSociety of Thoracic Surgeons Representative. xAmerican Association of Cardiovascular and Pulmonary Rehabilitation Representative. kACC/AHA Task Force on Performance Measures Liaison. {National Heart Lung and Blood Institute Representative. #Mended Hearts Representative. The measure specifications were approved by the American College of Cardiology Board of Trustees, American Heart Association Science Advisory and Coordinating Committee, in January 2013 and the American Medical Association–Physician Consortium for Performance Improvement in February 2013. This document was approved by the American College of Cardiology Board of Trustees and the American Heart Association Science Advisory and Coordinating Committee in October 2013, and the Society of Cardiovascular Angiography and Interventions in December 2013. The American College of Cardiology requests that this document be cited as follows: Nallamothu BK, Tommaso CL, Anderson HV, Anderson JL, Cleveland JC, Dudley RA, Duffy PL, Faxon DP, Gurm HS, Hamilton LA, Jensen NC, Josephson RA, Malenka DJ, Maniu CV, McCabe KW, Mortimer JD, Patel MR, Persell SD, Rumsfeld JS, Shunk KA, Smith SC, Stanko SJ, Watts B. ACC/AHA/SCAI/AMA–Convened PCPI/NCQA 2013 perfor- mance measures for adults undergoing percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures, the Society for Cardiovascular Angiography and Interventions, the American Medical Association–Convened Physician Consortium for Performance Improvement, and the National Committee for Quality Assurance. J Am Coll Cardiol 2014;63:722–45. This article has been copublished in Circulation. Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.cardiosource.org) and the American Heart Asso- ciation (http://my.americanheart.org). For copies of this document, please contact Elsevier Inc. Reprint Department, fax (212) 633-3820, e-mail reprints@elsevier.com. Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American College of Cardiology. Requests may be completed online via the Elsevier site (http://www.elsevier.com/authors/obtaining- permission-to-re-use-elsevier-material). This Physician Performance Measurement Set (PPMS) and related data specifications were developed by the Physician Consortium for Performance Improvement (the Consortium), including the American College of Cardiology (ACC), the American Heart Association (AHA), and the American Medical Association (AMA), to facilitate quality-improvement activities by physicians. The performance measures contained in this PPMS are not clinical guidelines, do not establish a standard of medical care, and have not been tested for all potential applications. Although copyrighted, they can be reproduced and distributed, without modification, for noncommercial purposesdfor example, use by health care prov

To determine what differences exist in angiographic parameters between men and women undergoing revascularization therapy for coronary heart disease that may indicate a gender difference, a retrospective review of patients admitted to one hospital for diagnosis of cardiac ischemic syndrome, and undergoing coronary arteriography, percutaneous interventional procedure, or coronary bypass surgery, was performed. Demographic, clinical, and angiographic parameters were evaluated in men and women, including body surface area, distribution of coronary lesions, size of target coronary vessels, and results of interventional procedures. Men and women undergoing percutaneous revascularization did not differ in regard to distribution or size of vessels or outcome. Previous data support the contention that women may undergo coronary arteriography and coronary artery bypass surgery less frequently than men. No evidence of differences existed in selecting patients for percutaneous intervention from those patients who underwent coronary arteriography. Men and women who underwent percutaneous intervention had similar baseline angiographic characteristics, yet men were more likely to receive a new device.

Background Women undergo evaluation and treatment for cardiac diseases less frequently than men with similar symptoms. The purpose of this study was to determine what differences exist in clinical evaluation and treatment between men and women presenting with coronary heart disease that may indicate a gender bias. Methods A single hospital retrospective review of patients admitted with the diagnosis of cardiac ischemic syndrome, undergoing stress testing, coronary arteriography, percutaneous interventional procedure, or coronary bypass surgery was performed, including an evaluation by gender of the demographic, clinical, and angiographic parameters of 1 year of patients undergoing hospital admission, evaluation, or revascularization therapy for coronary heart disease in a single university hospital. Results Women admitted to the coronary care unit with a coronary diagnosis were less likely to undergo coronary arteriography than men. Women having a positive stress test result were as likely to undergo coronary arteriography as men with similar findings. Women undergoing coronary arteriography were as likely as men to undergo percutaneous transluminal coronary angioplasty, but less likely to undergo coronary artery bypass surgery. Conclusions A gender-based selection bias exists in choosing patients to undergo coronary arteriography and coronary artery bypass grafting.

PREAMBLE The granting of staff privileges to physicians is an important mechanism to ensure quality care. The Joint Commission on Accreditation of Healthcare Organizations requires that medical staff privileges be based on professional criteria specified in medical staff bylaws. Physicians are charged with defining the criteria that constitute professional competence and with evaluating their peers accordingly. With the evolution of transcatheter aortic valve replacement (TAVR), an important opportunity arises for both cardiologists and surgeons to come together to identify the criteria for performing these procedures. The Society for Cardiovascular Angiography and Interventions (SCAI), American Association for Thoracic Surgery (AATS), American College of Cardiology Foundation (ACCF), and the Society of Thoracic Surgeons (STS) have, therefore, joined together to provide recommendations for institutions to assess their potential for instituting and/or maintaining a transcatheter valve program. This article concerns TAVR. As TAVR is in its infancy, there are few data on which to base this consensus statement. Therefore, many of these recommendations are based on expert consensus. As the procedures

The National Registry of Supported Angioplasty was formed in 1988 to collect data on patients undergoing supported angioplasty. The Registry was expanded to include patients also undergoing standby supported angioplasty. In 3 years the Registry collected data on 801 patients undergoing supported or standby supported angioplasty. The data indicate that in patients with low ejection fractions and/oror = 50% of jeopardized myocardium at risk can have an interventional procedure performed with a 6.9% risk of mortality with prophylactic or standby support, but patients withor = 20% ejection fraction do better with prophylactic support. In addition, patients with LMCA stenosis and ageor = 70 years are at higher risk. The Registry also demonstrates good long-term results for patients who have undergone the procedure.

Determining the most appropriate revascularization strategy for patients presenting with unprotected left main coronary (UPLM) disease has been a topic of great recent interest. During this current decade, there have been multiple clinical trials and registries addressing this subject. Previously, UPLM disease has almost exclusively resulted in utilizing a surgical revascularization treatment strategy. However, recent improvements in percutaneous coronary intervention (PCI) techniques in parallel with the benefits of drug-eluting stents (DES) to reduce clinical restenosis have enabled further investigation in catheterization-based treatment strategies as possible alternative therapeutic options. These advances as well as an increased understanding of both the procedural and anatomical challenges involved with complex coronary interventions have allowed further advancements in the field. Better adjunctive antithrombotic pharmacological therapy in the PCI setting has favored such progress. American College of Cardiology/American Heart Association/Society for Coronary Angiography and Interventions guidelines do not currently endorse the performance of PCI as an appropriate alternative to surgical revascularization for patients with UPLM disease. This paper is a review of the current evidence on UPLM PCI and proposes future directions in this evolving field.