BACKGROUND.: Based on experience from other countries, the Medical Centre Alkmaar was granted permission to start the first Dutch PCI programme without on-site cardiac surgery. The cardiology group of the Medical Centre Alkmaar started an off-site PCI programme in 2002 with only primary PCI in the first year and a full PCI programme from November 2003 onwards. We report the first Dutch experience with acute cardiac surgery following a failed PCI procedure in an off-site clinic. PATIENTS.: From October 2002 until February 2007, 2500 patients were treated by PCI in the Medical Centre Alkmaar. These patients were treated for an acute myocardial infarction (33%), acute coronary syndromes (37%) or progressive angina (30%). In this first series of off-site PCI in the Netherlands, the incidence of emergency cardiac surgery following failed PCI was 0.2% All five patients who needed emergency surgery underwent elective PCI for progressive stable coronary artery disease. No emergency surgery was needed for primary PCIs in patients with an acute myocardial infarction. All patients survived emergency surgery following failed PCI. CONCLUSION.: Adherence to the Dutch guidelines of interventional cardiology with protocols describing a close collaboration with cardiac surgeons and an immediate availability of rapid ground transportation are mandatory when performing off-site PCI. This series extends the current expertise of emergency surgery after failed PCI to off-site clinics. With appropriate settings, off-site PCI may not be associated with an increase in the risk of adverse events. (Neth Heart J 2007;15:173-7.).