lowing PCI among hospitals , including the use of vascular ultrasound during the procedure when using the femoral artery as the access point , along with using protocols to stop bleeding .” Additionally , improved data collection could help explain bleeding variations across sites and circulate best practices from high-performing centers .

Vora AN , Peterson ED , McCoy LA , et al . J Am Coll Cardiol Intv . 2016 ; 9 ( 8 ): 771-9 .

Women undergoing complex percutaneous coronary intervention ( PCI ) are at a higher risk of adverse events , but according to a recent study in JACC : Cardiovascular Interventions , new-generation drug-eluting stents ( DES ) may be significantly more safe and effective compared with early-generation DES .

Gennaro Giustino , MD , and colleagues pooled female patients from 26 randomized clinical trials evaluating DES . A total of 10,241 women were included and 4,629 ( 45 %) underwent complex PCI . A significantly higher crude rate of major adverse cardiovascular events ( MACE ) was seen in women with complex PCI compared to those without . Women who underwent complex PCI also had higher rates of all-cause mortality , cardiac mortality , myocardial infarction ( MI ) and target lesion revascularization . In these women , the use of newgeneration DES was associated with a significantly lower risk of MACE and all-cause mortality at 3 years compared to those with earlier-generation DES . Improvements were seen with new-generation stents in women with and without complex PCI . The benefits on MACE , composite death , MI and stent thrombosis were more apparent between 1 and 3 years than within the first year . There were no difference in very-late stent thrombosis rates between complex PCI and non-complex PCI patients with new-generation DES .

“ By improving drug release kinetics , polymer biocompatibility , and endothelial patterns , new-generation DES significantly overcame the limitations observed with early-generation DES ,” the authors write . Because their findings suggest that procedural complexity does not affect the thrombotic

safety of new-generation DES , women with advanced coronary artery disease undergoing complex percutaneous revascularization may not need prolonged dual antiplatelet therapy .

“ The present findings have to be viewed in light of the recently published studies comparing newgeneration DES with coronary artery bypass graft surgery in patients with multivessel CAD , in which surgery was associated with reduced risk of MI and need for revascularization alongside an increased risk of early stroke ,” the authors add . “ Although new-generation DES seem to narrow the disparities versus surgery in terms of effectiveness , they still do not totally fill the gap . The decision-making process for revascularization of advanced CAD is complex and must take into account the early hazard of surgery and the late complications associated with PCI . However , knowing that newgeneration DES provide consistent benefits even in challenging coronary anatomies is reassuring and may support the use of PCI in this clinical setting in women with advanced CAD for whom coronary revascularization with surgery is not an option .”

“ Although this study adds to our knowledge base , there is much that we still do not understand ,” write Cindy L . Grines , MD , and Theodore Schreiber , MD , in an accompanying editorial . They suggest further research into the interplay between young women , risk factors , lack of recognition , and poor prognosis . “ Defining the molecular and vascular biology for different risk factors for atherosclerosis in women and the unique pathophysiological mechanisms for myocardial infarction in women need further investigation ,” they also note . “ We need to clarify the mechanisms of an increased incidence of angina and heart failure despite less epicardial coronary disease and preserved left ventricular function in women […] Better understanding of the patient and health care provider rationale for delays in presentation , treatment , withholding or refusing treatment as well as effective interventions to improve delays are necessary . Although we have come a long way in understanding heart disease in women , substantial gaps in our knowledge remain .”

Giustino G , Baber U , Aquino M , et al . J Am Coll Cardiol Intv . 2016 ; 9 ( 7 ): 674-84 .

A statement published May 2 in JACC : Cardiovascular Interventions outlines an algorithm to guide interventional cardiologists in clinical decisionmaking around the use of mechanical circulatory support ( MCS ) devices in patients undergoing percutaneous coronary ( PCI ) intervention with highrisk features or cardiogenic shock . The statement , authored by members of the ACC ’ s Interventional Scientific Council , aims to define a practical approach to determining when to use MCS , how to select a device type , and practical points to consider when using these devices .

MCS is used primarily in 3 populations — high-risk PCI , cardiogenic shock , and cardiac arrest — representing a wide spectrum of disease that requires tailored treatment . According to the statement , physicians must first identify patients with cardiogenic shock or high-risk features for PCI . Next , a multidisciplinary heart team approach , including interventional cardiology , cardiothoracic surgery , critical care , and advanced heart failure physicians should be initiated . The next step is to identify disease severity from a PCI and / or shock perspective to determine the most appropriate level of support .

Several technical requirements must also be considered prior to choosing a device for MCS , including identifying indications , contraindications , access site , and operator experience . The learning curve that exists with these devices must also be considered . The authors discuss the device types that should be considered in different settings , including intra-aortic balloon pump , venoarterial extracorporeal membrane oxygenation , Impella or TandemHeart . Post-procedure device management when transferring patients to an intensive care unit ( ICU ) is also an important aspect of MCS and each institution should establish appropriate training and protocols .

“ With multiple MCS devices available , each institution must develop a strategy for the preferred MCS device for patients with adequate training of cardiac catheterization and ICU staff ,” the authors , led by Tamara M . Atkinson , MD , write . “ A critical aspect of device management involves unification of cardiac catheterization staff , coronary care intensivists and nurses , interventional cardiologists , advanced heart failure cardiologists , and cardiothoracic surgeons to create an operational strategy for each institution . This facilitates protocols that can be used and executed in a timely manner and assist in especially for troubleshooting issues or complications . Ideally , this team should also review the outcomes for all patients treated with left ventricular support devices to tabulate and evaluate complications as well as identify process improvement areas .” ■

Atkinson TM , Ohman EM , O ’ Neill WW , et al . J Am Coll Cardiol Intv . 2016 ; 9 ( 9 ): 871-83 .