A 55–years–old patient presents to emergency room with extensive anterior STEMI, complicated by acute pulmonary edema. The ECG showed sinusal tachycardia, Q waves in V1–V3, ST elevation >2mm V2–V6. The echocardiogram showed akinesia of the apex and anterolateral wall with severe reduction of contractile function (LVEF 30%). The patient was treated with CPAP, dual antiplatelet therapy and diuretics; the urgent coronary angiography showed three–vessel disease with occlusion of the proximal LAD, treated with PCI and two drug–eluting stents implantation. 48 after admission to ICU, the patient developed "combined" shock (IC↓ RVS↓ WP↑), sustained by both severe cardiac dysfunction and a septic complication, requiring inotropes and targeted antibiotic therapy (noradrenaline 0.02 gamma/Kg/min and piperacillin/tazobactam i.v). At 96 hours there was a recovery of contractile function and haemodynamics (CI from 1.8 to 2.7). Weaned from inotropes, he began therapy with low doses of ACE inhibitor, beta blocker, antialdosteronic. On the 7th day of hospitalization, without ischemic and/or electrolyte "triggers", the patient developed "arrhythmic storm" with incessant sustained ventricular tachycardias. Arrhythmias persisted despite antiarrhythmics (magnesium sulfate, amiodarone, lidocaine), IOT, sedation, mechanical ventilation. The temporary pacemaker for overdrive pacing was placed in. After placement of IABP, the patient underwent revascularization of residual coronary artery stenosis. Despite 1 hour of assistance (ABLS), incessant ventricular tachycardia persisted; a third–level center for VA–ECMO inside support was called. After positioning VA–ECMO there was progressive clinical stabilization and –concomitantly– a progressive reduction of ventricular tachycardias. ECMO support was needed for over 7 days due to persistence of arrhythmic storm; it was slowly weaned with stabilization of the patient; an AICD was implanted. Residual function of the left ventricle was mild reduced (LVEF40%) despite protracted CPR. There wasn’t residual cognitive impairment. Implementation of multidisciplinary teams in the spoke centers would improve protocols and early treatments in patients with cardiogenic shock; spoke centers would provide early access to life–saving therapies and safe transfer to hub centers.

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Novartis Background The first year after hospitalisation for Acute Coronary Syndrome (ACS) or Acute Heart Failure (AHF) is the most critical period, with the highest incidence of complications and re-hospitalisations. Multiple epidemiological studies have documented that while hospital mortality in the acute phase has gradually decreased, the mortality trend after discharge remains stable or even increased. These trends may be an expression of inadequate follow-up and poor patient involvement, resulting in poor control of risk factors, and suboptimal adherence to treatments. Aim To present a protocol design for a quality improvement intervention regarding a supported discharge pathway for ACS and AHF patients. Methods The construction of the DIMACC protocol is based on the Plan, Do, Check, Act methodology. Pre-intervention phase: A research project has been developed to introduce a supported discharge pathway from Cardiology wards. The objective and motivation for the change from the existing situation were defined and supported by the theoretical model and international guidelines. Development of the study tools: This phase included the Consensus Conference held with the local institutions, the University delegation, the Head Manager of the District, doctors and nurses, where the actors shared intentions, thus proceeding to their formal approval. Data collection instrument was set. Intervention phase: The group identified strategies to ensure the best possible dissemination of the procedure and the professionals' adherence. A data processing company was involved, which created an online platform to collect the study data. Recruitment within the pilot study started in November 2022. Results The DIMACC project is a PROSPECTIVE OBSERVATIONAL STUDY evaluating the feasibility and performance of a quality improvement intervention on patients discharged from Cardiology following admission for ACS and AHF. The study consists of TWO phases. Phase one aims to implement a structured follow-up in the first year after discharge, with examinations and visits planned according to the severity of the single case. As primary endpoint, there is the achievement of clinical objectives defined on discharge, based on ESC guidelines, improve disease control and reduce the number of admissions to the Emergency dept. and re-hospitalisations. In the second phase, the group plans a series of structured educational interventions held by community nurses care to promote patient engagement and further reduce the elements listed in phase one. In the first two months of the pilot phase, 41 patients were included, with a progressive increase compared to total admissions for ACS or AHF (41% in November and 72% in December). Conclusions This study will generate essential knowledge on CVD patients' experiences and self-empowerment. Findings will be of considerable interest and benefit to many health and care organizations beyond the immediate community of interest.

Abstract Introduction Large pleural and pericardial effusion is a common finding in lung cancer patients. However, a chronic large pleural effusion and the “lung entrapment” fenomenon, due to the neoplastic lung infiltration, could precipitate the re–expansion pulmonary edema (REPO) after the thoracentesis procedure. REPO is a rare and potentially life–threatening complication after large volume thoracentesis. It is characterized by alveolar infiltration in the reexpanded lung.Indeed, in the presence of “lung entrapment”, REPO development could be due not only to and excessive fluid removal, but also to the development of an excessively negative intrapleural pressure (< – 20 mmHg). As the REPO is often associated to an hemodynamic impairment, in patients with concomitant severe pericardial effusion, this condition could cause cardiac tamponade and the optimal therapeutic approach could be challenging.In this perspective, the decision on the effusion to be drained first, in this population, is not always straightforward.Case report In a 62 years –old woman with severe respiratory failure, a chest CT scan showed a massive left –sided pleural effusion with a complete collapse of the left lung, a severe pericardial effusion (35 mm) and the presence of malignant mediastinal nodes. (Figure 1).In the ICU a left thoracentesis was performed, with an early drainage of 1400 ml, the drain was then clamped. 30 minutes later, the patient developed a severe acute respiratory failure. An urgent chest x ray revealed an ipsilateral pulmonary oedema (Figure2). The patient was then treated with respiratory support with cPAP and intravenous diuretic therapy. Afterward, a rapid hemodynamic derangement occurred, with cardiac tamponade. An emergency echoguided pericardiocentesis was then performed followed by an immediate recovery. A repeated thorax CT scan revealed an advanced pulmonary tumor (Figure 3). Discussion In this case all the risk factors for REPO were coexistent: chronic pleural effusion and lung cancer. In addition, the large pericardial effusion represented a complicating factor in this situation as both the cPAP and the REPO’s hypovolemia may have brought to a clinical tamponade. In this context, where a neoplastic severe pleural and pericardial effusions are coexistent, it is essential to know which possible complications may occur after a large volume thoracentesis in order to prevent a high risk urgent pericardial drainage in patient with severe respiratory distress.

Aims: We assessed the effectiveness of early administration of corticosteroids in patients affected by COVID-19 with moderate to severe acute respiratory distress syndrome requiring oxygen support. Methods: This is a single-center, retrospective, controlled cohort study including patients admitted to our hospital from March 13th to April 20th, 2020. Patients received an intravenous bolus of 8mg dexamethasone twice daily for 5 days or standard care only. Clinical and laboratory characteristics were abstracted by medical records. The primary endpoint was clinical improvement, defined as an increase in the arterial partial pressure of oxygen/fraction of inspired oxygen ratio ≥50%, respiratory rate <24 breaths/min, and decrease in C-reactive protein (CRP) ≥50% compared to the baseline. The secondary endpoint was weaning from any ventilatory support. Outcomes were assessed using Kaplan-Meier analysis with Log-rank test and multivariable Cox regression. Results: Thirty-seven patients (21.6% female;mean age, 63.3±11.4 years) were identified who needed non-invasive mechanical ventilation, 23 of whom received steroids and 14 standard care. Median follow-up was 20 days (range 7-52). Treatment with dexamethasone was associated with faster clinical improvement than standard care [median days, 2 vs. 6;hazard ratio (HR), 3.28;95% confidence interval (CI), 1.64-6.55;P <.0001) and earlier weaning from ventilatory support (median days, 4 vs. 7;HR, 2.24;95% CI, 1.13-4.43;P =.014). CRP decreased over time only in patients on corticosteroids (treatment effect P <.001). Conclusion: In COVID-19 patients with moderate-to-severe ARDS the early use of dexamethasone prevented disease progression, resulting from host inflammatory response, and improved clinical outcome.

Background: To face the health emergency due to the first spread in Italy of COVID- 19, a nationwide lockdown was instituted from 9 March to 3 May 2020. During this period all the hospital outpatient activities were suspended except for urgent cases. Objective: To evaluate the cardiological urgent outpatient examinations done in our hospital during the lockdown in view of the reduced hospitalizations and the increased cardiovascular deaths observed during the COVID-19 outbreak. Methods: The urgent cardiological examinations (requests with priority U and B, i.e., to be done within 3 and 10 days respectively) performed during the 8-week period of lockdown (38 working days) were compared with those performed during the same period in the previous year (37 working days). During the lockdown and the control period, the availability of urgent cardiological visits was the same (2 per day with priority U and 2 per day with priority B). The number of cardiological examinations performed and the main characteristics of the subjects attending the outpatient clinic in the two periods were evaluated, comparing them with the chi-square test and considering as significant p values <0.05. Results: The table shows the number of urgent cardiological outpatient examinations done on those available in the two periods under comparison. Cardiological urgent outpatient examinations LOCKDOWN CONTROL Chi-square p • with priority U (performed/available) 41/76 (53.9%) 71/74 (95.9%) 34.96 <0.01 • with priority B (performed/available) 28/76 (36.8%) 69/74 (93.2%) 52.20 <0.01 The reduction in the number of urgent cardiological outpatient examinations done during the lockdown was observed from the first week with a nadir at the third and a subsequent slow return to normality at the end of eight weeks. No significant differences in age, sex, history of heart diseases, reasons and outcomes of the examinations were observed in patients evaluated in the two periods. Conclusion: During the first lockdown introduced in Italy to face the COVID-19 pandemic, a statistically significant reduction of accesses to the outpatient clinic for urgent cardiological examinations of our hospital was observed with possible negative consequences in the diagnosis and treatment of cardiovascular diseases in the community.