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Background: Minimally invasive endovascular aneurysm repair (EVAR) could be a surgical technique that improves outcome of patients with ruptured abdominal aortic aneurysm (rAAA). The aim of this study was to analyse the cost-effectiveness and cost-utility of EVAR compared with standard open repair (OR) in the treatment of rAAA, with costs per 30-day and 6-month survivor as outcome parameters., Methods: Resource use was determined from the Amsterdam Acute Aneurysm (AJAX) trial, a multicentre randomized trial comparing EVAR with OR in patients with rAAA. The analysis was performed from a provider perspective. All costs were calculated as if all patients had been treated in the same hospital (Onze Lieve Vrouwe Gasthuis, teaching hospital)., Results: A total of 116 patients were randomized. The 30-day mortality rate was 21 per cent after EVAR and 25 per cent for OR: absolute risk reduction (ARR) 4·4 (95 per cent confidence interval (c.i.) -11·0 to 19·7) per cent. At 6 months, the total mortality rate for EVAR was 28 per cent, compared with 31 per cent among those assigned to OR: ARR 2·4 (-14·2 to 19·0) per cent. The mean cost difference between EVAR and OR was €5306 (95 per cent c.i. -1854 to 12,659) at 30 days and €10,189 (-2477 to 24,506) at 6 months. The incremental cost-effectiveness ratio per prevented death was €120,591 at 30 days and €424,542 at 6 months. There was no significant difference in quality of life between EVAR and OR. Nor was EVAR superior regarding cost-utility., Conclusion: EVAR may be more effective for rAAA, but its increased costs mean that it is unaffordable based on current standards of societal willingness-to-pay for health gains., (© 2014 BJS Society Ltd. Published by John Wiley & Sons Ltd.)

Aim: Complication rates after laparoscopic cholecystectomy vary but are still reported to be up to 17 %. Identifying risk factors for an adverse complication outcome could help to reduce morbidity after laparoscopic cholecystectomy. Our aim was to analyze whether surgeon volume is a vital issue for complication outcome., Methods: All complications-minor, major, local and general-were reviewed in a single institution between January 2004 and December 2008 and recorded in a database. Patient's variables, disease related variables and surgeon's variables were noted. The role of surgeon's individual volume per year was analyzed. A stepwise logistic regression model was used., Results: A total of 942 patients were analyzed, among which 70 (7 %) patients with acute cholecystitis and 52 (6 %) patients with delayed surgery for acute cholecystitis. Preoperative endoscopic retrograde cholangiography (ERC) had been performed in 142 (15 %) patients. Complication rates did not differ significantly for surgeon's individual volume (≤10 vs. >10 LC/year, 5.2 vs. 8.2 %, p = 0.203) nor for specialization (laparoscopic vs. non-laparoscopic; 9.2 vs. 6.4 %, p = 0.085) and experience (specialty registration ≤5 vs. >5 years; 5.1 vs. 8.7 %, p = 0.069). The only significant predictors for complications were acute surgery (OR 3.9, 95 % CI 1.8-8.7, p = 0.001) and a history preceding laparoscopic cholecystectomy (LC) (ERC and delayed surgery for cholecystitis) (OR 8.1, 95 % CI 4.5-14.6: p <0.001)., Conclusion: Complications after LC were not significantly associated with a surgeon's individual volume, but most prominently determined by the type of biliary disease.

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.

Background: Studies on selective decontamination of the digestive tract (SDD) in elective gastrointestinal surgery have shown decreased rates of postoperative infection and anastomotic leakage. However, the prophylactic use of perioperative SDD in elective gastrointestinal surgery is not generally accepted., Methods: A systematic review of randomized clinical trials (RCTs) was conducted to compare the effect of perioperative SDD with systemic antibiotics (SDD group) with systemic antibiotic prophylaxis alone (control group), using MEDLINE, Embase and the Cochrane Central Register of Controlled Trials. Endpoints included postoperative infection, anastomotic leakage, and in-hospital or 30-day mortality., Results: Eight RCTs published between 1988 and 2011, with a total of 1668 patients (828 in the SDD group and 840 in the control group), were included in the meta-analysis. The total number of patients with infection (reported in 5 trials) was 77 (19.2 per cent) of 401 in the SDD group, compared with 118 (28.2 per cent) of 418 in the control group (odds ratio 0.58, 95 per cent confidence interval 0.42 to 0.82; P = 0.002). The incidence of anastomotic leakage was significantly lower in the SDD group: 19 (3.3 per cent) of 582 patients versus 44 (7.4 per cent) of 595 patients in the control group (odds ratio 0.42, 0.24 to 0.73; P = 0.002)., Conclusion: This systematic review and meta-analysis suggests that a combination of perioperative SDD and perioperative intravenous antibiotics in elective gastrointestinal surgery reduces the rate of postoperative infection including anastomotic leakage compared with use of intravenous antibiotics alone., (© 2013 British Journal of Surgery Society Ltd. Published by John Wiley & Sons Ltd.)

The objective was to define the relationship between histopathological changes after pre-operative chemo-radiotherapy (CRT) and clinical outcome following tri-modality therapy in patients with superior sulcus tumours. A retrospective analysis of tumour material was performed in a series of 46 patients who received tri-modality therapy between 1997 and 2007. Median follow-up was 34 months (5-154). Pathological complete response (pCR) was present in 20/46 tumours (43 %). The most common RECIST score after CRT in patients with pCR was a partial response (PR; 10/17, three unknown), whereas in patients without a pCR, stable disease was the most common (22/26) (p = 0.002). In 26 specimens with residual tumour, this was mainly located in the periphery of the lesion rather than the centre (Spearman's correlation = 0.67, p < 0.001). Prognosis was significantly better after a pCR compared to residual tumour (70 % 5-year overall survival vs. 20 %; p = 0.001) and in patients with fewer than 10 % vital tumour cells as compared to those with >10 % (65 % 5-year overall survival vs. 18 %; p < 0.001). A low mitotic count was associated with a longer disease-free survival (p = 0.02). Complete pathological response and the presence of fewer than 10 % vital tumour cells after pre-operative CRT are both associated with a more favourable prognosis. A modification of the pathological staging system after radiotherapy, incorporating the percentage of vital tumour cells, is proposed.

Background: Risk factors for conversion in cholecystectomy may be of clinical value. This study aimed to investigate whether a set of risk factors, including the surgeon's specialization, can be used for the development of a preoperative strategy to optimize conversion outcome., Methods: The data for all patients who underwent laparoscopic cholecystectomy at a single institution between January 2004 and December 2008 were retrospectively reviewed. Factors predictive for conversion were identified, and a preoperative strategy model was deduced., Results: Of the 1,126 patients analyzed, 106 (9%) underwent laparoscopic cholecystectomy in an emergency setting. Delayed surgery was performed for 63 (46%) of 138 patients (12%) with acute cholecystitis. Preoperative endoscopic retrograde cholangiography was achieved for 161 of the patients (14%). Risk factors predictive of conversion (for 65 patients) were male gender [odds ratio (OR), 2.3; 95% confidence interval (CI), 1.3-3.9; p = 0.004], age older than 65 years (OR, 2.6; 95% CI, 1.4-4.8; p = 0.002), body mass index (BMI) exceeding 25 kg/m(2) (OR, 3.4; 95% CI, 1.7-7.1; p < 0.001), history of complicated biliary disease (HCBD) (OR, 5.6; 95% CI, 3.2-9.8; p = < 0.001), and surgery by a non-gastrointestinal (non-GI) surgeon (OR, 4.9; 95% CI, 2.2-10.6; p < 0.001). The conversion rate for patients with a history of no complications who had two or more risk factors (gender, age, BMI > 25) and for patients with a HCBD who had one or more risk factors was significantly higher if the surgery was performed by non-GI rather than GI surgeons., Conclusion: Male gender, age older than 65 years, BMI exceeding 25 kg/m(2), HCBD, and surgery by a non-GI surgeon are predictive for conversion. A preoperative triage for surgeon selection based on risk factors and a HCBD is proposed to optimize conversion outcome.

Background: For most arrhythmia syndromes, the risk of sudden cardiac death for asymptomatic mutation carriers is ill defined. Data on the natural history of these diseases, therefore, are essential. The family tree mortality ratio method offers the unique possibility to study the natural history at a time when the disease was not known and patients received no treatment., Methods and Results: In 6 inherited arrhythmia syndromes caused by specific mutations, we analyzed all-cause mortality with the family tree mortality ratio method (main outcome measure, standardized mortality ratio [SMR]). In long-QT syndrome (LQTS) type 1, severely increased mortality risk during all years of childhood was observed (1-19 years), in particular during the first 10 years of life (SMR, 2.9; 95% CI, 1.5-5.1). In LQTS type 2, we observed increasing SMRs starting from age 15 years, which just reached significance between age 30 and 39 (SMR, 4.0; 95% CI, 1.1-10.0). In LQTS type 3, the SMR was increased between age 15 and 19 years (SMR, 5.8; 95% CI, 1.2-16.9). In the SCN5A overlap syndrome, excess mortality was observed between age 10 and 59 years, with a peak between 20 and 39 years (SMR, 3.8; 95% CI, 2.5-5.7). In catecholaminergic polymorphic ventricular tachycardia, excess mortality was restricted to ages 20 to 39 years (SMR, 3.0; 95% CI, 1.3-6.0). In Brugada syndrome, excess mortality was observed between age 40 and 59 (SMR, 1.79; 95% CI, 1.2-2.4), particularly in men., Conclusions: We identified age ranges during which the mortality risk manifests in an unselected and untreated population, which can guide screening in these families.

Objective: We compared the routine use of perioperative selective decontamination of the digestive tract (SDD) for elective gastrointestinal surgery with placebo in a randomized controlled trial. Alongside this trial, a cost-effectiveness analysis from a provider perspective was performed., Methods and Results: A total of 289 patients undergoing elective surgery of the digestive tract were randomized to either SDD (143 patients) or placebo (146 patients). Routine use of SDD led to less patients with an infectious complication compared with placebo (p = 0.028). Mean total costs per patient were slightly less (EUR 2,604; 95% CI -6,292 to 1,084) in patients randomized to SDD (EUR 12,031) compared to patients randomized to placebo (EUR 14,635). Costs of hospitalization were the main determinant of the cost difference between the groups. The incremental cost-effectiveness ratio per prevented occurrence of ≥1 infectious complications per patient was -EUR 23,164, indicating the superiority of SDD over placebo., Conclusion: This study shows that in patients undergoing elective gastrointestinal surgery, the routine use of SDD is less expensive and economically more efficient than placebo in reducing the number of patients with infectious complications., (Copyright © 2012 S. Karger AG, Basel.)

Background: Arthroscopic stabilization using suture anchors is widely used to restore stability after anterior shoulder dislocations and is associated with low recurrence rates in short-term follow-up studies., Purpose: To evaluate the long-term follow-up after arthroscopic stabilization for traumatic recurrent anterior instability using suture anchors with emphasis on both redislocations and subjective shoulder function., Study Design: Case series; Level of evidence, 4., Methods: We included 67 consecutive patients with 70 affected shoulders. After 8 to 10 years, patients were asked to report the presence and course of their redislocations. Subjective shoulder function was addressed using the Oxford Instability Score (OIS), the Western Ontario Shoulder Instability Index (WOSI), and the Simple Shoulder Test (SST). Patients rated their health status using the Short Form-36 (SF-36)., Results: Sixty-five patients with 68 affected shoulders (97%) were evaluated for follow-up; 35% reported a redislocation. Median shoulder function scores were 16 of 12 to 60, 22 of 0 to 210, and 12 of 0 to 12 for the OIS, WOSI, and SST, respectively. There was a significant difference in subjective function between patients with and without recurrent instability, respectively, 16 versus 24 for the OIS (P = .004), and 16 versus 47 for the WOSI (P = .05). We found a trend for an inverse relationship between the number of suture anchors and recurrent instability, with 2 having a higher recurrence rate than 3 or more (P = .06). Another trend was found with the presence of a Hill-Sachs defect slightly increasing the risk of a redislocation (P = .07)., Conclusion: With a follow-up of 97%, about one third of the stabilized shoulders experienced at least one redislocation after 8 to 10 years. The presence of a Hill-Sachs defect and the use of less than 3 suture anchors might increase the chance of a redislocation. Patients without a redislocation have a significantly better shoulder function compared with patients with a redislocation.

Background: This randomized clinical trial analysed the effect of perioperative selective decontamination of the digestive tract (SDD) in elective gastrointestinal surgery on postoperative infectious complications and leakage., Methods: All patients undergoing elective gastrointestinal surgery during a 5-year period were evaluated for inclusion. Randomized patients received either SDD (polymyxin B sulphate, tobramycin and amphotericin) or placebo in addition to standard antibiotic prophylaxis. The primary endpoint was postoperative infectious complications and anastomotic leakage during the hospital stay or 30 days after surgery., Results: A total of 289 patients were randomized to either SDD (143) or placebo (146). Most patients (190, 65·7 per cent) underwent colonic surgery. There were 28 patients (19·6 per cent) with infectious complications in the SDD group compared with 45 (30·8 per cent) in the placebo group (P = 0·028). The incidence of anastomotic leakage in the SDD group was 6·3 per cent versus 15·1 per cent in the placebo group (P = 0·016). Hospital stay and mortality did not differ between groups., Conclusion: Perioperative SDD in elective gastrointestinal surgery combined with standard intravenous antibiotics reduced the rate of postoperative infectious complications and anastomotic leakage compared with standard intravenous antibiotics alone. Perioperative SD.D should be considered for patients undergoing gastrointestinal surgery., Registration Number: P02.1187L (Dutch Central Committee on Research Involving Human Subjects)., (Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Objectives: To evaluate the safety and effectiveness of procedural sedation with propofol by newly trained Dutch emergency physicians., Methods: A prospective observational cohort study of patients in emergency department undergoing procedural sedation at two teaching hospitals. Primary outcomes were serious adverse events, sedation events, and efficacy. A standardized protocol and data collection form was used at both sites., Results: Three hundred and eighty-six patients were enrolled over 18 months. The median age was 57 years (range 6-94, interquartile range 38-70), 55% were male patients. All had an American Society of Anesthesiologists class score of 3 or less. Indications for procedural sedation were reduction of dislocations (51%), electrocardioversion (32%), fracture reduction (8%), and abscess/wound treatment (6%). The median propofol dose was 1.0 mg/kg (0.70-1.5) and 45% received fentanyl in addition; median dose was 1 mcg/kg (0.6-1.3). Most had a Ramsay sedation score of 4 or 5. The procedural success rate was 99.5%. No serious adverse events were reported. Sedation events included; hypoventilation (11%), desaturation (5%), hypotension (3%), and bradycardia (1%), all of which resolved with simple supportive interventions. One patient vomited without aspirating. Increased age (>60 years) (P=0.001) and high Ramsay score (>3) (P=0.024) were the only significant predictors of events. Sex, weight, total dose of propofol, use of fentanyl, and type of procedure were not independent risk factors for any event., Conclusion: Newly trained Dutch emergency physicians can perform procedural sedation with propofol safely and effectively. Increased age and high Ramsay scores were the only risk factors for sedation events. All events were minor and responded to simple interventions.

Background: Surgical procedures during pregnancy carry the risk of adverse fetal outcome. We analyzed outcomes of open and laparoscopic approaches in patients treated for symptomatic cholelithiasis and suspected appendicitis. We reviewed the literature for evidence on the safety of both procedures., Methods: We retrospectively reviewed the data of all patients who underwent surgery for symptomatic cholelithiasis and suspicion of appendicitis during pregnancy between January 2004 and March 2009. Fetal loss, preterm delivery, maternal outcome, and surgical complications were assessed., Results: Twenty patients were operated on during pregnancy: 5 of 652 (0.8%) patients with symptomatic cholelithiasis and 15 (4.5%) of 331 for suspected appendicitis. All cholecystectomies were performed by laparoscopic procedure; no premature deliveries or fetal death occurred. In patients with suspicion of appendicitis, three appendices sana were diagnosed laparoscopically, and nine laparoscopic appendectomies and three open appendectomies were performed. The outcome was two preterm deliveries and one fetal death., Conclusion: Reviewing our results and the available literature, we believe that the outcome of surgery during pregnancy is not dictated by the type of procedure but by the type of disease. The gain for fetal outcome in the future most likely lies in the diagnostic pathway rather than the type of surgery.

Background: Laparoscopic cholecystectomy (LC) after an endoscopic retrograde cholangiography (ERC) has higher rates for complications and conversion caused by unpredictable adhesions. The risk factors for an adverse outcome of LC after an ERC were analyzed., Methods: Variables from patients treated by LC after ERC for cholelithiasis in two clinics from 1996 to 2003 were retrospectively stored in a database. Complications and conversions were recorded., Results: A total of 140 patients underwent LC after ERC (83 from clinic A and 57 from clinic B), 31% (44/140) of whom were men. Peri- or postoperative complications occurred for 28 patients (20%). For 19 patients (14%), a conversion was necessary. Significant variables associated with complications and conversions were an elevated level of C-reactive protein (CRP) at the time of LC (odds ratio [OR], 10.2; 95% confidence interval [CI], 1.1-91, P = 0.037 for both) and severe adhesions during laparoscopy (OR, 3.6; 95% CI, 1.5-8.6; P = 0.003 and OR, 5.2; 95% CI, 1.9-14.4; P = 0.002, respectively). Male gender (OR, 2.8; 95% CI, 1.1-7.6; P = 0.037) and serum bilirubin level at the time of ERC (OR, 3.7; 95% CI, 1.24-11; P = 0.014) were associated with conversion only. Time after ERC (LC within 1 week vs. >1 week or < or = 2 weeks vs. 2-6 weeks vs. >6 weeks or < or = 6 weeks vs. >6 weeks) was not associated with complications or conversion. Multivariate regression analysis showed a pre-LC CRP exceeding 6 to be predictive of complications (OR, 10.5; 95% CI, 1.1-95; P = 0.040) and conversion (OR, 10.6; 95% CI, 1.1-99; P = 0.034)., Conclusion: Male gender, bilirubin levels during ERC, severe adhesions during LC, and pre-LC CRP levels were associated with an adverse outcome for an LC after endoscopic cholangiography. The time between LC and ERC failed to be a significant risk factor in this larger series.

Background: Selective decontamination of the digestive tract (SDD) decreases morbidity and mortality in critically ill patients and morbidity in patients undergoing esophageal resection. This study analyzes the effect of perioperative SDD in patients undergoing elective colorectal surgery on postoperative infections and anastomotic leakage., Methods: This is a retrospective analysis of prospectively collected data in a 3-year cohort of 162 patients undergoing elective resection of colon and or rectum. Of these patients, 76 (47%) received SDD (polymyxine B sulfate, tobramycin, and amphotericin) perioperatively. The control group consisted of 86 patients who were not treated with SDD. Postoperative complications, hospital stay, and mortality were analyzed., Results: In the SDD group, there were six patients (7.9%) with infectious complications compared with 17 patients (19.8%) in the control group (p = 0.031). The incidence of the combined endpoint infectious complications and anastomotic leakage was 8 (11%) in the SDD group vs. 22 (26%) in the control group (p = 0.014). Multivariate analysis showed that no-SDD, aged above 60 years and diabetes were independent predictors of postoperative complications., Conclusion: Perioperative SDD in elective colorectal surgery seems to reduce postoperative surgical complications including infectious complications and anastomotic leakage. Prospective, randomized, placebo-controlled studies are needed to confirm this conclusion.

Aim: To determine the prognostic value of reversible myocardial perfusion defects on myocardial perfusion scintigraphy (MPS) in patients with type 2 diabetes mellitus and mild anginal complaints., Methods and Results: In the MERIDIAN trial, patients with diabetes mellitus type 2, stable, mild anginal symptoms (Canadian Cardiovascular Society classification (CCS) I-II/IV) and reversible perfusion defects were randomized to either continued pharmacological treatment or early invasive treatment. In this sub analysis, the severity of the myocardial perfusion defect was related to the occurrence of cardiac death and non-fatal myocardial infarction, in 319 patients (63% male, 65 +/- 9 years). During follow-up (2.2 +/- 0.6 years), 14 patients had a cardiac event: 3 in 171 patients without myocardial ischemia and 11 in 148 patients with myocardial ischemia. Annual event rates rose from 0.8% to 5.8% with increasing severity of myocardial ischemia. Multivariable analysis identified the presence of severe myocardial ischemia (hazard ratio (HR) 5.45, 95%CI 1.89-15.71) and insulin use (HR 4.00, 95%CI 1.25-12.75) as independent predictors of cardiac events., Conclusions: Type 2 diabetics with mild anginal symptoms with no or moderate myocardial ischemia have a low annual cardiac event rate. In patients with severe myocardial ischemia event rate increased 3-6 fold.

Objective: Continuous venovenous hemofiltration (CVVH) is applied in critically ill patients with acute renal failure for renal replacement. Heparins used to prevent circuit clotting may cause bleeding. Regional anticoagulation with citrate reduces bleeding, but has metabolic risks. The aim was to compare the safety and efficacy of the two., Design: Randomized, nonblinded, controlled single-center trial., Setting: General intensive care unit of a teaching hospital., Patients: Adult critically ill patients needing CVVH for acute renal failure and without an increased bleeding risk., Interventions: Regional anticoagulation with citrate or systemic anticoagulation with the low-molecular weight heparin nadroparin., Measurements and Main Results: End points were adverse events necessitating discontinuation of study anticoagulant, transfusion, metabolic and clinical outcomes, and circuit survival. Of the 215 randomized patients, 200 received CVVH per protocol (97 citrate and 103 nadroparin). Adverse events required discontinuation of citrate in two patients (accumulation and clotting) of nadroparin in 20 (bleeding and thrombocytopenia) (p < 0.001). Bleeding occurred in 6 vs. 16 patients (p = 0.08). The median number of red blood cell units transfused per CVVH day was 0.27 (interquartile range, 0.0-0.63) for citrate, 0.36 (interquartile range, 0-0.83) for nadroparin (p = 0.31). Citrate conferred less metabolic alkalosis (p = 0.001) and lower plasma calcium (p < 0.001). Circuit survival was similar. Three-month mortality on intention-to-treat was 48% (citrate) and 63% (nadroparin) (p = 0.03), per protocol 45% and 62% (p = 0.02). Citrate reduced mortality in surgical patients (p = 0.007), sepsis (p = 0.01), higher Sepsis-Related Organ Failure Assessment score (p = 0.006), and lower age (p = 0.009)., Conclusions: The efficacy of citrate and nadroparin anticoagulation for CVVH was similar, however, citrate was safer. Unexpectedly, citrate reduced mortality. Less bleeding could only partly explain this benefit, less clotting could not. Post hoc citrate appeared particularly beneficial after surgery, in sepsis and severe multiple organ failure, suggesting interference with inflammation.

Aims: The ICTUS trial compared an early invasive versus a selectively invasive strategy in high risk patients with a non-ST-segment elevation acute coronary syndrome and an elevated cardiac troponin T. Alongside the ICTUS trial a cost-effectiveness analysis from a provider perspective was performed., Methods and Results: A total of 1200 patients with a non-ST-segment elevation acute coronary syndrome and an elevated cardiac troponin T were randomized. An early invasive strategy was not superior to a selectively strategy. Total costs per patient were 1379 euros (95% CI 416-2356) more expensive in the early invasive group (13,364 euros) than in the selectively invasive group (11,985 euros). Costs of revascularization were the main determinant of the cost difference between the two groups. The incremental cost-effectiveness ratio of the extra costs per prevented cardiac event was minus 89,477 euros., Conclusions: The overall results of the ICTUS study showed that an early invasive strategy was not superior to a selectively invasive strategy for patients with non-ST-segment elevation acute coronary syndrome and an elevated cardiac troponin T. This economic analysis of the ICTUS study showed that an early invasive strategy was slightly more expensive during the first year without gain in prevented cardiac events. In fact, we demonstrated a very moderate probability of the early invasive strategy being cost-efficient, even at a high level of willingness-to-pay.

Objectives: To compare the diagnostic and therapeutic confidence, patient outcome and costs between MRA and DSA as the initial diagnostic imaging test, in patients with symptomatic arterial disease of the leg., Design: Randomised controlled diagnostic trial., Materials and Methods: Patients were randomly allocated to MRA (n=97) or DSA (n=100). Primary outcomes were: ability to make treatment plan and patients satisfaction. Secondary endpoints were: type of treatment and costs., Results: A treatment plan was determined for each included patient. Additional imaging was necessary in 11% of patients in the MRA group compared to 10% in the DSA group (p=0.5). 84% of the patients who received MRA judged the diagnostic work up as comfortable compared to 57% who had DSA (p=0.013). Within 4 months of randomization 30 patients in the MRA group compared to 34 patients in de DSA group underwent operative procedures; 39 versus 36 patients respectively underwent angioplasty. The mean total in-hospital costs during the first 4 months were euro4768,- in the MRA group compared to euro4697,- in the DSA group (95% CI of difference -1331;1472)., Conclusions: In patients with peripheral arterial disease of the leg an adequate treatment plan can be made with MRA. This diagnostic strategy was experienced as more comfortable and less painful compared to DSA. Total diagnostic and treatment costs of both strategies were comparable.

Objectives: We evaluated deferral of PCI of intermediate coronary lesions (IL) using fractional (FFR) and coronary flow reserve (CFR) hyperemic stenosis resistance index (HSR) in patients with a negative or nondiagnostic and noninvasive stress tests., Background: Outcome after deferral of PCI of IL with discordant results between FFR and CFR is unknown., Methods: PCI was deferred in 186 IL (mean diameter stenosis: 52%). Patients were divided according to the results of FFR and CFR in group A; FFR >or= 0.75 and CFR >or= 2.0 (n = 129), group B; FFR >or= 0.75 and CFR 2.0 (n = 28), group C; FFR 0.75 and CFR >or= 2.0 (n = 23) and group D; FFR 0.75 and CFR 2.0 (n = 6). Patients were followed for one year to document major adverse cardiac events (MACE)., Results: Nineteen MACEs (0 deaths, 4 myocardial infarctions, 1 CABG, and 14 PCIs) occurred during a follow up of 323 +/- 88 days. MACE rate was lowest (4.7%) when FFR, CFR, and HSR were normal. A higher MACE rate was observed when concordant abnormal (group D) or discordant results between FFR and CFR (group B and C) were compared to concordant normal values (group A, 33.3% vs. 19.7% vs. 5.4%, P = 0.008). Multivariate regression analysis showed a higher predictive power for HSR than for FFR and CFR., Conclusions: Abnormal FFR or abnormal CFR was documented in 31% of intermediate coronary lesions. Deferral of PCI in this group was associated with a high MACE rate, which underscores the rationale of combined pressure and flow measurements providing a stenosis resistance index that is better suited for clinical decision making in these lesions., ((c) 2008 Wiley-Liss, Inc.)

The ESCAPE-HCM study is a prospective followup study of asymptomatic mutation-carrying relatives of HCM patients aiming at optimising anamnestic and cardiological evaluation and surveillance for this group. All relatives undergo regular cardiological evaluation and risk status is prospectively estimated, according to known HCM-related risk factors for sudden cardiac death. (Neth Heart J 2007;15:216-20.).

Background/objective: To compare early invasive treatment with continued pharmacological treatment in patients with diabetes mellitus type 2, mild anginal symptoms and documented myocardial ischaemia., Methods: Patients with type 2 diabetes mellitus and mild anginal symptoms underwent myocardial perfusion scintigraphy (MPS). Patients with myocardial ischaemia were randomly assigned to early invasive or continued pharmacological treatment. All patients were followed for the occurrence of MACE (death, nonfatal myocardial infarction or hospitalisation for unstable angina pectoris)., Results: A total of 156 patients were randomised when the sponsor (ZonMW) prematurely terminated the study because of a slow recruitment rate. With a mean follow-up of 2.1±0.6 years, 9 of 79 patients assigned to early invasive treatment developed MACE compared with 10 of 77 patients randomised to continued pharmacological treatment, annual event rate 5.4 vs. 6.3%, hazard ratio 0.89, 95% CI 0.36 to 2.20, p=0.34. Due to the limited number of included patients and the low event rate, the study did not have sufficient power for the study objective., Conclusion: Patients with diabetes mellitus type 2, mild anginal symptoms and documented myocardial ischaemia, under appropriate medical treatment, have a lower than anticipated annual event rate of MACE of ±5 to 6% which questions the beneficial effect of early revascularisation.