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Background We performed a qualitative study to investigate the experiences of participants in a multicentre randomized controlled trial on a home-based palliative approach (HPA) for adults with severe multiple sclerosis (MS) and their caregivers. Our aim was to explore the strengths and challenges of the intervention, and circumstances that may have influenced its efficacy. Methods Participants to the qualitative study were the patients, their caregivers, patient referring physicians, and the teams who delivered the HPA intervention. We performed semi-structured one-on-one interviews with 12 patients and 15 informal caregivers chosen using a maximum variation strategy, two focus group meetings with patient referring physicians (4 participants each), and one with the HPA teams (9 participants). Results From data analysis (framework method) 38 sub-categories emerged, which were grouped into 10 categories and 3 themes: 'expectations,' 'met and unmet needs', and 'barriers’. Intervention benefits were improved control of symptoms and reduced sense of isolation of the patient-caregiver dyads. Limitations were: factors related to experimental design (difficulty of dyads in identifying examiner and team roles, additional burden for caregivers); team issues (insufficient team building /supervision, competing priorities); limitations of the intervention itself (insufficient length, lack of rehabilitation input); and external factors (resource limitations, under-responsive services/professionals). The referring physician focus groups provided little experiential data. Conclusions The HPA reduced patient symptoms and sense of isolation in patients and caregivers. The indirect role of the HPA teams, and insufficient length of the intervention were key limitations. The experimental design imposed additional burdens on the dyads. Key barriers were the paucity of available services, the demanding administrative procedures, and lack of networking facilities. These findings suggest that two major requirements are necessary for home palliative care to be effective in this patient population: HPA teams well-connected with MS rehabilitation services, and care delivered over the long-term, with variable intensity. Trial registration Current Controlled Trials ISRCTN73082124 (Registered 19/06/2014).

Dabigatran is a novel target specific oral anticoagulant for stroke prevention in non valvular atrial fibrillation. Little is still known about its real-world effectiveness and safety in the italian population. Aim of our study was to evaluate the efficacy and safety of dabigatran in a large single-center cohort of "real-life" italian population with non-valvular AF and to compare the results with those obtained from the RE-LY trial and the Medicare study.We studied a prospective cohort of 2108 patients (1119 male; mean age 69.4 ± 9.4 years) who started the oral anticoagulant treatment with dabigatran 110 mg twice-daily (DAB 110; N = 1075; 51%) or 150 mg twice-daily (DAB 150; N = 1033; 49%). Follow-up data were obtained trough outpatients visits each 3-6 months for assessing the clinical status, adherence to treatment, occurrence of side effects and major cardiovascular complications.In DAB 150 group the mean age was 64.9 ± 8.8 years, 56.8% of patients was male. CHA2DS2Vasc Score was ≥ 3 in 94.3% and HAS-BLED was ≥ 3 in 59.7%. In DAB 110 group (N = 1075) the mean age was 73.9 ± 7.5 years; 49.5% of patients was male. CHA2DS2Vasc Score was ≥ 3 in 73.4% and HAS-BLED was ≥ 3 in 87.4% of DAB 110 patients. One patient taking Dabigatran 110 mg bid had ischemic stroke without significantly neurological sequelae. In both groups, no patient experienced hemorrhagic stroke during the follow-up period. 147 patients (6.9%) of MonaldiCare population reported adverse effects from treatment with dabigatran, of whom 121 patients (5.7%) discontinued therapy. We reported one case of subarachnoid hemorrhage (0.05%) in a patient with high thrombo-embolic and high hemorrhagic risk score who was taking dabigatran 150 mg bid and one case (0.05%) of bladder bleeding in a patient who was taking dabigatran 110 mg bid. No major gastrointestinal bleeding was observed in the MonaldiCare population.MonaldiCare registry showed a safety profile of both dosages of dabigatran regarding major of fatal bleeding in a "real life" single center italian population at high thromboembolic and hemorrhagic risk. The majority of MonaldiCare patients tolerated dabigatran treatment without significant side effects. The efficacy of dabigatran was demonstrated by very low prevalence of ictus/TIA, also when patients underwent electrical AF cardioversion independently of the transesophageal examination.

The authors present a case of coronary sinus spasm during left ventricular lead implantation for biventricular pacing relieved by direct infusion of nitroglycerin.

Aims The aim of our study was to evaluate the effect of cardiac resyncronization therapy on QT dispersion (QTd), JT dispersion (JTd), and transmural dispersion of repolarization (TDR), markers of heterogeneity of ventricular repolarization in a study population with severe heart failure. Methods and results Fifty patients (43 male, 7 female, age 60.2+3.1 years) suffering from congestive heart failure (n ¼ 39 NYHA class III; n ¼ 11 NYHA class IV) as a result of coronary artery disease (n ¼ 19)or of dilated cardiomyopathy (n ¼ 31), with sinus rhythm (SR), QRS duration .120 ms (mean QRS duration ¼ 156+21 ms), an ejection fraction ,35%, left ventricular end-diastolic diameter .55 mm, presence of atrioventricular asynchrony, intra- and inter-ventricular asynchrony, underwent permanent biventricular pacemaker implantation. A 12-lead standard electrocardiogram was performed at baseline, during right-, left-, and biventricular pacing (BiVP) and QTd, JTd, and TDR were assessed. BiVP significantly reduced QTd (73.93+19.4 ms during BiVP vs. 91+6.7 ms in SR, P ¼ 0.004), JTd (73.18+17.16 ms during BiVP vs. 100.72+39.04 at baseline, P ¼ 0.003), TDR (93.16+15.60 vs.101.55+19.08 at baseline, P , 0.004), compared with SR. Right ventricular endocardial pacing and left ventricular epicardial pacing both increased QTd (RVendoP 94+51 ms, P , 0.03; LVepiP 116+71 ms, P , 0.02), and TDR (RVendoP 108.13+19.94 ms, P , 0.002; LVepiP 114.71+26.1, P , 0.05). There was no effect on JTd during right and left ventricular stimulation. Conclusions BiVP causes a statistically significant reduction of ventricular heterogeneity of repolarization and has an electrophysiological anti-arrhythmic influence on the arrhythmogenic substrate of dilated cardiomyopathy.

Purpose: The use of electrophysiologic studies (EPS) for the localization of accessory atrioventricular connections in Wolff-Parkinson-White syndrome (WPW) requires accurate evaluation of the site of bypass tract insertion. Doppler myocardial imaging (DMI) is a new ultrasound technique that allows the detection of abnormal and early regional myocardial depolarization. The purpose of this study was to identify an abnormal pathway site in WPW patients. Methods: Twenty-one patients with ventricular preexcitation were studied by DMI. Two-dimensional color DMI, velocity maps, acceleration maps, and pulsed-wave applications were used. A subsequent diagnostic EPS was performed. The results of EPS were taken as the gold standard diagnostic procedure. Radiofrequency catheter ablation therapy was then performed on all patients. Results: The anomalous pathway was detected by DMI in 16 (76%) of 21 patients (9 [90%] of 10 with left pathways and 7 [64%] of 11 with right pathways), with respect to results of the EPS. Pathway detection was better with pulsed-wave DMI (76%) with its higher temporal resolution as compared with M-mode velocity map (57%) and acceleration map (47%). In most of the patients with successful radiofrequency ablation, an immediate resolution of the abnormal ventricular depolarization occurred and was detectable by DMI. Conclusions: Our findings demonstrate the feasibility of DMI to assess the early ventricular contraction associated with atrioventricular accessory pathways. Therefore, DMI appears to be a clinically useful adjunct to noninvasive evaluation of abnormal myocardial depolarization in WPW and to evaluate the results after radiofrequency ablation, even though its accuracy is considerably better for left-sided accessory pathways than for right-sided ones.

Junctional ectopic tachycardia (JET) is a rare arrhythmia presenting either as a primary form1 or more often as a transient phenomenon immediately after heart surgery.2 Congenital JET usually occurs in the first six months of life as a persistent arrhythmia, associated in up to 60% of cases with cardiomegaly and/or heart failure.1 Congenital JET has been described in sporadic case reports or larger multicentre populations. The purpose of this study is to examine retrospectively the clinical presentation and outcome of a cohort of nine patients with congenital JET referred during a 20 year period time to a single unit and all medically treated. Nine patients (two male, seven female) suffering from persistent sustained JET were referred to our hospital between 1980 and 1999. All the patients underwent a complete medical history, physical examination, 12 lead ECG, 24 hour Holter recording, and echocardiogram. The diagnosis of JET was based on electrocardiographic evidence of a narrow complex tachycardia and atrioventricular dissociation. All the patients underwent medical treatment according to the following regimen: A Ic antiarrhythmic drug (propafenone or flecainide) was administered in combination with amiodarone when the latter proved ineffective alone in controlling the arrhythmia. This combination of drugs was also used in an attempt to reduce the dose of amiodarone, and prevent signs of …