Primary or elective PCI should not be performed in hospitals without on-site cardiac surgery capabilities without a proven plan for rapid transport to a cardiac surgery operating room in a nearby hospital or without appropriate hemodynamic support capa- bility for transfer. (Level of Evidence: C) See Online Data Supplement 20 for additional data regarding hospitals without on-site surgical backup. Primary and elective PCI can be performed at hospitals without on-site cardiac surgical backup with a high success rate, low in-hospital mortality rate, and low rate for emer- gency CABG.351,353,354 The best outcomes for patients with STEMI are achieved at hospitals with 24/7 access to primary PCI.355 Criteria for the performance of PCI without on-site surgical backup have been proposed in an SCAI expert consensus document.352 Consideration of elective PCI with- out on-site cardiac surgical backup is thought to be appropri- ate only when performed by experienced operators with complication rates and outcomes equivalent or superior to national benchmarks. Accurate assessment of complication rates and patient outcomes via a regional or national data registry, so that outcomes can be compared with established benchmarks, is an important quality control component of any PCI program. Desires for personal or institutional finan- cial gain, prestige, market share, or other similar motives are not appropriate considerations for initiation of PCI programs without on-site cardiac surgery. It is only appropriate to consider initiation of a PCI program without on-site cardiac surgical backup if this program will clearly fill a void in the healthcare needs of the community. Competition with another PCI program in the same geographic area, particularly an established program with surgical backup, may not be in the best interests of the community. Tables 5 and 6 list the SCAI expert consensus document requirements for PCI programs without on-site surgical backup. 