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OBJECTIVE: To safely and effectively train the exercise capacity of post-COVID-19 patients it is important to test for cardiopulmonary risk factors and to assess exercise limitations. The goal of this study was to describe the exercise capacity and underlying exercise limitations of mechanically ventilated post-COVID-19 patients in clinical rehabilitation. DESIGN: A retrospective cohort study. METHOD: Twenty-four post-COVID-19patients that were mechanically ventilated at ICU and thereafter admitted for clinical rehabilitation performed a symptom-limited cardiopulmonary exercise test (CPET) with breath-by-breath gas-exchange monitoring, ECG-registration, blood pressure- and saturation monitoring. In absence of a primary cardiac or ventilatory exercise limitation patients were considered to be limited primarily by decreased peripheral muscle mass. RESULTS: Twenty-three patients could perform a maximal exercise test and no adverse events occurred. Cardiorespiratory fitness was very poor with a median peak oxygen uptake of 15.0 [10.1-21.4] mlO2/kg/min (57% of predicted values). However, we observed large differences within the group in both exercise capacity and exercise limitations. While 7/23 patients were primarily limited by ventilatory function, the majority (70%) was limited primarily by the decreased peripheral muscle mass. CONCLUSION: Cardiorespiratory fitness of post-COVID-19 patients in clinical rehabilitation is strongly deteriorated. The majority of patients seemed primarily limited for exercise by the decreased peripheral muscle mass.

OBJECTIVE: To safely and effectively train the exercise capacity of post-COVID-19 patients it is important to test for cardiopulmonary risk factors and to assess exercise limitations. The goal of this study was to describe the exercise capacity and underlying exercise limitations of mechanically ventilated post-COVID-19 patients in clinical rehabilitation.DESIGN: A retrospective cohort study.METHOD: Twenty-four post-COVID-19patients that were mechanically ventilated at ICU and thereafter admitted for clinical rehabilitation performed a symptom-limited cardiopulmonary exercise test (CPET) with breath-by-breath gas-exchange monitoring, ECG-registration, blood pressure- and saturation monitoring. In absence of a primary cardiac or ventilatory exercise limitation patients were considered to be limited primarily by decreased peripheral muscle mass.RESULTS: Twenty-three patients could perform a maximal exercise test and no adverse events occurred. Cardiorespiratory fitness was very poor with a median peak oxygen uptake of 15.0 [10.1-21.4] mlO2/kg/min (57% of predicted values). However, we observed large differences within the group in both exercise capacity and exercise limitations. While 7/23 patients were primarily limited by ventilatory function, the majority (70%) was limited primarily by the decreased peripheral muscle mass.CONCLUSION: Cardiorespiratory fitness of post-COVID-19 patients in clinical rehabilitation is strongly deteriorated. The majority of patients seemed primarily limited for exercise by the decreased peripheral muscle mass.

Elsewhere in this journal an important question is raised: 'Are randomized trials (RCTs) necessary to demonstrate the superiority of radiation treatment, more specifically proton therapy?' We recognize that RCTs are considered to be the highest degree of certainty (evidence) to substantiate differences, as they allow to demonstrate or reject causality between an intervention and an outcome. However, in this comment we also raise some concerns about RCTs, and explain why especially in technological innovations, RCTs are not always the best approach. We explain why we consider the model-based approach as currently applied in The Netherlands for proton therapy, as complementary to RCTs, just as epidemiological or real-life 'big data' are, each with their advantages and disadvantages. We compare this approach with the FDA's Fast Track program, since proton therapy is a treatment that 'reasonably likely' causes less serious side effects with the same tumour effects.

Elsewhere in this journal an important question is raised: 'Are randomized trials (RCTs) necessary to demonstrate the superiority of radiation treatment, more specifically proton therapy?' We recognize that RCTs are considered to be the highest degree of certainty (evidence) to substantiate differences, as they allow to demonstrate or reject causality between an intervention and an outcome. However, in this comment we also raise some concerns about RCTs, and explain why especially in technological innovations, RCTs are not always the best approach. We explain why we consider the model-based approach as currently applied in The Netherlands for proton therapy, as complementary to RCTs, just as epidemiological or real-life 'big data' are, each with their advantages and disadvantages. We compare this approach with the FDA's Fast Track program, since proton therapy is a treatment that 'reasonably likely' causes less serious side effects with the same tumour effects.

Elsewhere in this journal an important question is raised: 'Are randomized trials (RCTs) necessary to demonstrate the superiority of radiation treatment, more specifically proton therapy?' We recognize that RCTs are considered to be the highest degree of certainty (evidence) to substantiate differences, as they allow to demonstrate or reject causality between an intervention and an outcome. However, in this comment we also raise some concerns about RCTs, and explain why especially in technological innovations, RCTs are not always the best approach. We explain why we consider the model-based approach as currently applied in The Netherlands for proton therapy, as complementary to RCTs, just as epidemiological or real-life 'big data' are, each with their advantages and disadvantages. We compare this approach with the FDA's Fast Track program, since proton therapy is a treatment that 'reasonably likely' causes less serious side effects with the same tumour effects.

Extracorporeal CO2 removal is a low-flow technique in which a pump, a membrane lung and sweepgas, remove CO2 from a patient. This facilitates protective, invasive ventilation in patients with severe hypercapnia, for example in ARDS. Although the physiological concept has been proven many times, the indication area has remained limited to only seriously ill, highly complex patients. Because of this and the relatively high number of contraindications and complications, the use of this technique is limited to Intensive Care.

Timely prenatal, maternally administered, corticosteroids improve the outcome of preterm newborns. The general aim should therefore be optimal identification of actual imminent preterm birth to provide protection of all preterm infants that are at risk of a substantial level of post-natal morbidity. Unnecessary use of maternal corticosteroids by inadequate estimate of imminent preterm birth, now seems associated with mental and behavioural problems in the offspring during the life course, which calls for a more restricted use. Opportunities to reduce futile use of maternal corticosteroids in case of preterm birth might be found in better timing of administration, improved selection of women at risk and by potential restraint re-use at later gestational ages. Timing and selection can be further improved by the development of better (non-invasive) predictors to pinpoint those women who actual will deliver within 48 hours. Future prospective studies should provide additional evidence to improve antenatal corticosteroid administration.

To safely and effectively train the exercise capacity of post-COVID-19 patients it is important to test for cardiopulmonary risk factors and to assess exercise limitations. The goal of this study was to describe the exercise capacity and underlying exercise limitations of mechanically ventilated post-COVID-19 patients in clinical rehabilitation.A retrospective cohort study.Twenty-four post-COVID-19patients that were mechanically ventilated at ICU and thereafter admitted for clinical rehabilitation performed a symptom-limited cardiopulmonary exercise test (CPET) with breath-by-breath gas-exchange monitoring, ECG-registration, blood pressure- and saturation monitoring. In absence of a primary cardiac or ventilatory exercise limitation patients were considered to be limited primarily by decreased peripheral muscle mass.Twenty-three patients could perform a maximal exercise test and no adverse events occurred. Cardiorespiratory fitness was very poor with a median peak oxygen uptake of 15.0 [10.1-21.4] mlO2/kg/min (57% of predicted values). However, we observed large differences within the group in both exercise capacity and exercise limitations. While 7/23 patients were primarily limited by ventilatory function, the majority (70%) was limited primarily by the decreased peripheral muscle mass.Cardiorespiratory fitness of post-COVID-19 patients in clinical rehabilitation is strongly deteriorated. The majority of patients seemed primarily limited for exercise by the decreased peripheral muscle mass.

Nitrofurantoin is a commonly prescribed antibiotic for uncomplicated urinary tract infections. The Dutch College of General Practitioners guideline recommends the use of this drug for the treatment of uncomplicated urinary tract infections in both male and female patients. Treatment with nitrofurantoin has several advantages. Resistance to this antibiotic is low and does not increase in the hospitalized patient population. Treatment with nitrofurantoin is generally well-tolerated. However, two independent studies estimated that approximately 27% of male patients are undertreated with nitrofurantoin. The main downside of nitrofurantoin is the low blood concentration that leads to insufficient tissue penetration. There is little evidence on how often prostatic tissues are involved in male urinary tract infections. Unrecognized tissue involvement can lead to breakthrough urinary tract infections despite nitrofurantoin treatment. Because of this, the safety of nitrofurantoin for male patients is unknown and treatment with this antibiotic should be administered with caution.

OBJECTIVE: To safely and effectively train the exercise capacity of post-COVID-19 patients it is important to test for cardiopulmonary risk factors and to assess exercise limitations. The goal of this study was to describe the exercise capacity and underlying exercise limitations of mechanically ventilated post-COVID-19 patients in clinical rehabilitation. DESIGN: A retrospective cohort study. METHOD: Twenty-four post-COVID-19patients that were mechanically ventilated at ICU and thereafter admitted for clinical rehabilitation performed a symptom-limited cardiopulmonary exercise test (CPET) with breath-by-breath gas-exchange monitoring, ECG-registration, blood pressure- and saturation monitoring. In absence of a primary cardiac or ventilatory exercise limitation patients were considered to be limited primarily by decreased peripheral muscle mass. RESULTS: Twenty-three patients could perform a maximal exercise test and no adverse events occurred. Cardiorespiratory fitness was very poor with a median peak oxygen uptake of 15.0 [10.1-21.4] mlO2/kg/min (57% of predicted values). However, we observed large differences within the group in both exercise capacity and exercise limitations. While 7/23 patients were primarily limited by ventilatory function, the majority (70%) was limited primarily by the decreased peripheral muscle mass. CONCLUSION: Cardiorespiratory fitness of post-COVID-19 patients in clinical rehabilitation is strongly deteriorated. The majority of patients seemed primarily limited for exercise by the decreased peripheral muscle mass.

The flash mob method is a new way of conducting prospective research whereby relatively simple - but clinically relevant - questions can be answered in a short period of time. The design and intensity of the spirited action - the 'flash' - with which the research is initiated determines the size of the group - the 'mob' - of researchers who will collect research data, and therefore determine the size of the study population. The reach of a flash mob study differs from that of traditional studies and gives flash mob studies a special character. In this article we show how the flash mob method works, the opportunities that it presents, its limitations and the kinds of questions it is able to answer.

The DENSE trial has demonstrated that offering an MRI scan to women with very dense glandular breast tissue and normal results on screening mammography reduces the number of interval cancers by 50%. In the women who agreed to undergo an MRI (59%), this reduction was 80% (from 5 per 1000 to 1 per 1000 participants). DENSE will continue in order to answer the only question that is relevant to patients: does additional MRI lead to less invasive treatment and, above all, to a decrease in mortality? Even in the event where additional MRI screening would lead to a decrease in mortality, we still need to have an open discussion on whether investing in additional MRI screening for women with very dense glandular tissue is the most effective way to improve the health of the Dutch female population. Thanks to the great effort of the DENSE research team, such a discussion can be pursued thoroughly, based on facts.

The consideration for treatment of mitral regurgitation is dependent on its underlying cause: degenerative or functional. The percutaneous MitraClip treatment is mostly suitable for patients with severe, symptomatic mitral regurgitation and additional risk factors, who therefore do not qualify for surgical treatment but still have a life expectancy of more than one year. The MitraClip treatment has undergone technical improvements in the past ten years and has a low rate of periprocedural and postprocedural complications. Patients with severe functional mitral regurgitation, a relatively preserved left ventricular function, and a limited left ventricular volume benefit most from a MitraClip treatment. The number of MitraClip procedures in the Netherlands is strongly increasing and has shown good results. Besides the development of the MitraClip and introduction of new devices, careful patient selection is the most important instrument to achieve better results.

The flash mob method is a new way of conducting prospective research whereby relatively simple - but clinically relevant - questions can be answered in a short period of time. The design and intensity of the spirited action - the 'flash' - with which the research is initiated determines the size of the group - the 'mob' - of researchers who will collect research data, and therefore determine the size of the study population. The reach of a flash mob study differs from that of traditional studies and gives flash mob studies a special character. In this article we show how the flash mob method works, the opportunities that it presents, its limitations and the kinds of questions it is able to answer.

The flash mob method is a new way of conducting prospective research whereby relatively simple - but clinically relevant - questions can be answered in a short period of time. The design and intensity of the spirited action - the 'flash' - with which the research is initiated determines the size of the group - the 'mob' - of researchers who will collect research data, and therefore determine the size of the study population. The reach of a flash mob study differs from that of traditional studies and gives flash mob studies a special character. In this article we show how the flash mob method works, the opportunities that it presents, its limitations and the kinds of questions it is able to answer.

The results of a recent randomised phase 3 clinical trial show that the androgen receptor antagonist darolutamide improves metastasis-free survival in men with non-metastatic, castration-resistant prostate cancer, compared with placebo. The trial included 1509 men with a prostate-specific antigen doubling time of 10 months or less. Non-metastatic disease was defined as the absence of metastases, using conventional imaging rather than the substantially more sensitive PSMA scans. The effect of darolutamide is similar to that of other androgen inhibitors, such as apalutamide and enzalutamide. The value of the current trial to Dutch clinical practice is limited, as the number of patients with non-metastatic, castration-resistant prostate cancer is low due to the increased use of PSMA scans and the reluctance of urologists to start androgen-deprivation therapy in the absence of metastatic disease.

In recent years, transcatheter aortic valve implantation (TAVI) has evolved from a treatment for patients who are inoperable or at high risk of surgical complications, to an equivalent alternative to surgical valve replacement for almost all patients with symptomatic, severe aortic valve stenosis. In the Netherlands, the number of patients who undergo TAVI gradually increases, while outcomes after TAVI improve and complication rates decrease. Before TAVI can be considered as the preferred treatment for aortic valve stenosis, however, additional insight is needed in valve durability, selection criteria for patients who benefit most from TAVI, and treatment outcomes regarding quality of life.

In this commentary we discuss the findings of the recently published OPTiMiSE trial. In terms of design, important advantages of the trial are the naturalistic, open label set-up that allowed the authors to assess the efficacy of the sequential use of amisulpride followed by olanzapine and clozapine. In terms of results, we highlight the efficacy of amisulpride, while we disagree with the authors of OPTiMiSE when they claim clozapine should be tried in the clinic after one unsuccessful trial of amisulpride. We also show how the actual percentages of those complaining of sexual side effects during amisulpride use are higher than computed by the authors. On a general note, we suggest that whenever symptoms of patients allow it - and gradual improvement is observed - clinicians may wish to wait several weeks before considering a switch to amisulpride.

The number of laparoscopic cholecystectomies in the Netherlands has increased significantly in recent years. However, there is a large variation in practice. This is a sign of inefficient use of cholecystectomy. Cholecystectomy is the treatment of choice in patients with uncomplicated symptomatic gallstones, but 30% of the patients has persistent pain after surgery. In a large prospective multicentre randomised trial, a restrictive strategy was compared to usual care in patients with symptomatic gallstones. The results show suboptimal pain reduction in both groups. There were fewer cholecystectomies in the restrictive strategy group and no difference in gallstone related complications between the groups. It is therefore still unclear which patients with gallstones and abdominal symptoms should undergo cholecystectomy. The data could be used in new studies to construct algorithms for patient selection. In the meantime, the use of a decision aid is recommended. Well-informed patients can, in consultation with their doctors, opt for cholecystectomy or a conservative approach. This strategy will lead to fewer unnecessary cholecystectomies.

Broader indications for treatment of ischaemic stroke Current guidelines suggest that selected patients with ischaemic stroke can be treated with intravenous thrombolysis or mechanical thrombectomy within 4.5 or 6 hours, respectively, after onset of the stroke. Recent developments in imaging have made it possible to distinguish permanently damaged brain tissue from brain tissue that is potentially salvageable after reperfusion, and recent trials have demonstrated that the window of time for intravenous thrombolysis and mechanical thrombectomy can be extended by selecting patients on the basis of the amount of potentially salvageable brain tissue. Patients with symptoms of acute stroke must be referred to a specialist stroke centre as soon as possible, even if more than 6 hours have passed since the onset of clinical symptoms.

Several studies and meta-analyses have recently shown a positive effect of maintenance treatment with macrolide antibiotics in patients with chronic obstructive pulmonary disease (COPD). The next step is not to implement this therapy on a large scale, but to restrict the use of antibiotics as much as possible. In a recent meta-analysis, maintenance therapy with macrolides reduced exacerbation frequency and improved quality of life (Wang et al., 2018). Comparable effects have been observed in patients with rare inflammatory pulmonary diseases. However, it is arguable to restrict maintenance therapy in clinical practice, since the effects on exacerbation rate and quality of life are limited. Furthermore, long-term antibiotics have various side effects and induce microbial resistance. A practical approach is to restrict maintenance therapy to patients with three or more exacerbations per year despite optimal treatment. We propose that macrolide treatment should only be continued long-term after a successful initial six-month trial with clearly defined end-points.

Whole genome sequencing (WGS) is increasingly being used in clinical practice. As a result, various healthcare professionals now encounter ethical dilemmas that were formerly confined within the genetics clinic. In addition to autonomy and well-being of both patients and their family members, which need to be balanced carefully, a societal perspective is also vital to ensure the ethically sound introduction of whole genome sequencing into daily practice. Important choices to be made are: who is eligible for whole genome sequencing; how can informed consent be sensibly obtained, when dealing with such vast quantities of genomic information; which type of information should be offered to patients; should professionals actively search for pathogenic mutations. The rise of WGS has an impact on the moral responsibilities incumbent on healthcare professionals and necessitates a comprehensive societal debate on the advent of personalized medicine.

A lumbar puncture (LP) is often essential for the diagnosis of bacterial meningitis. An LP can worsen brain displacement in case of a space-occupying lesion. Therefore, in selected patients a CT scan of the brain is made prior to performing the LP. However, the level of agreement between experts in diagnosing a contraindication for LP on CT scan is low. More importantly, in a substantial part of patients, empirical treatment with antibiotics was delayed due to the CT scan being performed first. The only effective treatment for patients with bacterial meningitis is early administration of antibiotics. Therefore, delay in administrating antibiotics should be prevented. Thus, should a CT scan of the brain be indicated, antibiotic treatment should be started before said imaging diagnostics and/or a potential LP procedure.

The term priapism describes erections of4 hours that arise in the absence of or last well beyond sexual stimulation. Ischaemic priapism is the most common form and treatment success is strongly dependent on the duration of priapism. The aetiology is widely variable as a result of which several specialisms can be confronted with this condition. Over the past few years, urologists increasingly have to deal with patients who do not suffer from erectile dysfunction, but nevertheless use intracavernous injections with priapism as a result. These men are often reluctant to see a doctor due to shame and ignorance, which often leads to delayed treatment. According to current guidelines, early prosthesis implantation is recommended if the priapism lasted36 hours. Treatment of stuttering priapism should be focused on prevention of subsequent episodes. Non-ischaemic priapism generally follows a mild course and can initially be approached conservatively.

A combination of chemotherapy and high dose radiotherapy is the cornerstone of the treatment of locally-advanced non-small cell lung cancer (NSCLC). For selected patients with early stage NSCLC, stereotactic body radiation therapy (SBRT, also known as SABR, stereotactic ablative radiotherapy) is a good option. Unfortunately, metastases can occur in patients following these treatments. However, in some patients, the recurrence remains localized to the previous irradiated area, so-called local recurrence. For selected patients with such a recurrence, radical salvage surgery - a treatment modality with curative intent - is an option. In this article we describe two patients with local recurrence after high dose radiotherapy, who were subsequently treated operatively. We also discuss which subset of lung cancer patients should be selected for this type of surgery.

This short comment puts into perspective the value of randomised controlled clinical trials in comparison with nationwide audits in the field of aortic aneurysm treatment. RCTs represent greater scientific value but nationwide audits represent daily practices and seem to be more appropriate for shared decision-making.

Objective: Children with ADHD have an increased risk of poor academic performance. It is important to identify cognitive processes that may be related to this academic failure. In Western schooling systems, especially language processing skills may be of relevance. The present study, therefore, compares the ability to comprehend complex sentences of individuals with and without ADHD. Method: Fifteen children (aged 8-11) and 15 adolescents (aged 12-16) with ADHD combined subtype are matched for age, gender, and parental level of education to 30 control subjects. Language comprehension is measured using the neuropsychological procedure proposed by Luria and an adapted version of the Token Test. Results: Compared with the control group, children and adolescents with ADHD perform significantly slower on language comprehension tasks. Differences in accuracy are limited. No interaction between age and ADHD is found. Conclusions: Children and adolescents with ADHD are slower and less efficient than matched control subjects with regard to complex sentence comprehension. ( J. of Att. Dis. 2010; 13(4) 374-385)

OBJECTIVE: To identify additional risk factors and the corresponding probability of carrying a chromosome abnormality in couples with two or more miscarriages. DESIGN: Nested case-control study. METHOD: In 6 centres for clinical genetics in the Netherlands, data were collected from couples referred for karyotyping after 2 2 miscarriages from 1992-2000. Factors influencing the probability of carrier status were examined. The corresponding probability of carrier status was calculated for the various combinations of these factors. RESULTS: In total 279 carrier couples and 428 non-carrier couples were included. 4 independent factors influencing the probability of carrier status were identified: a younger maternal age at the time of second miscarriage, a history of > or = 3 miscarriages, a history of > 2 miscarriages in a brother or sister of either partner, and a history of> 2 miscarriages in parents of either partner. The calculated probability of carrier status in couples referred for chromosome analysis after two or more miscarriages, varied between 0.5-10.2%. In 18% of couples included, the risk was found to be so low (< 2.2%), that in couples with comparable risk factors, it may not be necessary to perform karyotyping. CONCLUSION: This study demonstrated that the probability of carrier status in couples with > or = 2 miscarriages is modified by additional factors. Selective chromosome analysis would result in a more effective referral policy and therefore decrease the number of chromosome analyses and lower the costs.

Older persons represent a growing proportion of the population. However, few of them participate in medical research. Moreover, amendments have been proposed to the Medical Research Involving Human Subjects Act (WMO) concerning the participation of vulnerable subjects such as older persons. In light of these changes, the Dutch Ministry of Health, Welfare and Sport sought to develop a guideline to improve the quality of research involving older persons. This guideline will also be a tool for researchers to enhance the inclusion of older persons in their medical research. It focuses on six aspects to consider when setting up a research project: recruitment, informed consent, attrition, reluctance to participate, proportionality between the burden for participants and the benefits for the investigator, and societal relevance.

Liver metastases have the poorest prognosis of all types of breast cancer metastases, with a 5-year survival rate of 0 to 12%. In comparison, the 5-year overall survival rate of patients with colorectal liver metastases undergoing curative liver resection is approximately 30 to 40% and even 50% in selected patients. Partial liver resection in combination with systemic treatment for patients with hepatogenic metastases from breast cancer may lead to improved survival rates for selected patients.

Recent randomised clinical trials have convincingly shown that endovascular therapy with the use of a retrievable stent considerably improves the chance of a good outcome in selected patients with acute ischaemic stroke and an occlusion of a proximal intracranial artery in the anterior circulation. The benefit of treatment strongly increases with shorter delays to reperfusion. This has major implications for the organisation of stroke care in the Netherlands. Agreements between all relevant parties are required in each region regarding the rapid referral of eligible patients to intervention centres. CT angiography must now become part of the standard evaluation of all patients with suspected ischaemic stroke presenting within six hours of symptom onset in order to achieve appropriate patient selection. Attention should be paid to workflow efficiencies to reduce delays. Since only a small proportion of stroke patients is eligible for endovascular therapy, the development of additional stroke therapies remains essential.

Kidney transplantation offers longer life expectancy and improves quality of life in selected patients with end-stage renal failure. The availability of living donors is critical, particularly to meet the increasing demand and potentially pre-emptive transplantation. In addition, living donor transplantation is associated with better outcomes on comparison with dialysis or transplants from deceased donors. The major disadvantage of living donation is that complications may occur both directly perioperatively and in the long-term. Two recent studies confirmed that the risk of renal failure among selected living donors is extremely low. This implies that there is no need to alter the existing positive attitude towards living donation. Finding a comparable long-term control group with relevant genetic and non-genetic risk factors remains a challenge to studies looking at long-term effects.

Current debate on complex medical care in the Netherlands includes the treatment of ruptured abdominal aortic aneurysm (RAAA). Topics of interest are hospital volume, patient selection and the use of minimally invasive but more expensive techniques. Based on two recent randomized trials investigating open and endovascular repair for RAAA, we discuss the advantages and disadvantages of techniques, quality of life and age. We conclude that optimal treatment can only be provided in a vascular centre with 24/7 availability of both open and endovascular repair, a top level intensive care unit and a demonstrable low decline rate for surgery. Age should be abandoned as an eligibility criterion for surgery.

During the last few decades, care for heart patients has significantly improved. The enormous increase in the number of diagnostic and therapeutic options has resulted in a much better prognosis for many patients with cardiovascular disorders. Implantable cardioverter defibrillators (ICDs) and resynchronization therapy combined with ICDs decrease the risk of sudden death due to ventricular arrhythmias and improve symptoms related to cardiovascular failure. Percutaneous valve implants and percutaneous techniques to repair valve leakages have improved the prognosis of patients deemed inoperable. As well as positive effects, all these interventions are associated with a risk of sometimes severe complications. Infections, perforations and even death can occur related to the procedure. Long term complications caused by infections in or failure of technically complicated devices and electrodes are still a threat for many patients. Careful multi-disciplinary patient selection prior to the procedure and extensive follow-up are therefore mandatory to achieve the best results for these procedures.

In patients with symptoms of ischaemic heart disease, despite optimal medical therapy, a PCI or CABG may be indicated if the coronary arteries are narrowed. Decisions regarding PCI or CABG need to be taken by the local heart team, consisting of a cardiothoracic surgeon and an interventional cardiologist. After a complete diagnostic work-up, the referring cardiologist presents the patient with accompanying written information supporting revascularisation. The decision of the heart team takes the characteristics of each individual patient into account and, most importantly, the coronary angiogram. Despite improvements in medical and interventional treatments, mortality and morbidity remain high among patients with NSTEMI. Early risk stratification is essential to determine those patients who can be treated safely with medical therapy and those who require interventional treatment. Ad hoc PCI is indicated in patients with STEMI or haemodynamic instability.