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We describe a patient with of acute right ventricular dysfunction secondary to right ventricular isolated Takotsubo syndrome (TTS). The importance of appropriate differential diagnosis for acute right ventricular dysfunction differential diagnosis of acute right ventricular dysfunction and the differences in diagnosis and management of right ventricular TTS and typical left ventricular TTS are highlighted. ( Level of Difficulty: Intermediate. )

Funding Acknowledgements Type of funding sources: None. INTRODUCTION Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is an essential tool for the management of refractory cardiogenic shock. Little is known about the incidence of thromboembolic events after V-A ECMO decannulation, although some studies report a high incidence of cannula-related venous thrombosis after venovenous extracorporeal membrane oxygenation (VV-ECMO). Due to this fact, in our institution anticoagulation therapy is systematically prescribed for at least 3 months after VA-ECMO per protocol.  AIM The main objective of this study was to explore the feasibility of 3-month anticoagulation therapy after VA-ECMO decannulation. METHODS We performed a prospective study that included 27 consecutive patients who were successfully treated with VA-ECMO in a medical ICU between 2016 and 2019 and were prescribed 3-month anticoagulation therapy per protocol after decannulation. Exclusion criteria was dying on ECMO or while on the ICU. Data analysis included demographics, mean days on ECMO, 3-month survival, and thromboembolic and bleeding events (excluding immediate post-decannulation bleeding, since anticoagulation was prescribed 24h after). RESULTS Our cohort consisted mainly of men (N = 21, 78%), with a mean age of 60 ± 11 years and a mean time on VA-ECMO of 8 ± 3 days, who primarily suffered from post-cardiotomy cardiogenic shock (N = 9, 34%) or acute myocardial infarction (N = 6, 23%). 5 patients (18%) received a heart transplant. Regarding anticoagulation, 15 patients (60%) had other indications apart from the protocol, like incidental thrombus diagnosis (N = 7, 26%) or valve surgery (N = 5, 18%). Anticoagulation therapy was not feasible in 1 patient (4%) with severe thrombopenia. No patients had severe or life-threatening bleeding events in the follow-up, although 8 patients (30%) had bleeding events, mainly gastrointestinal bleeding (N = 4, 15%), requiring withdrawal of anticoagulation in 1 patient. The incidence of thromboembolic events was 7%; two patients with low-risk pulmonary embolisms. During the 3-month follow-up survival rate was 95%. CONCLUSIONS This is the only study to date addressing the strategy of 3-month anticoagulation therapy after VAECMO, showing it is feasible and safe and may be helpful in reducing or ameliorate thromboembolic complications in the follow-up, although it is not exempt of complications. Abstract Figure. Kaplan-Meier survival analysis

Funding Acknowledgements Type of funding sources: None. Background A rapid and efficient disposition of patients with chest pain and a suspected acute coronary syndrome (ACS) diagnosis represents a clinical challenge in the emergency department (ED). The latest European clinical guidelines recommend the use of diagnostic algorithms at 0/1 and 0/2 hours, but their performance in different patient populations needs to be further investigated. Purpose To evaluate the performance of the 0/1-h and 0/2-h high-sensitivity cardiac troponin T (hs-cTnT) algorithms in a cohort of patients admitted to an ED in an academic center in Spain. Methods We performed a single-center, prospective study in patients admitted with suspected non-ST elevation ACS (NSTEACS). Hs-cTnT (Roche Diagnostics) was measured at admission (t0) and one (t1) and two hours (t2) later; hs-cTnT differences between times were named Delta 0/1h (D-0/1) or Delta 0/2h (D-0/2). Patients were sub-grouped according to the following: "Rule out" when the time of pain-debut was >3 hours and t0 hs-cTnT <5 ng/L; for remaining patients, t0 hs-cTnT <12 ng/L and D-0/1 <3 ng/L or t0 <14 ng/L and D-0/2 <4 ng/L; "Rule-in" when hs-cTnT at t0 ≥52 ng/L or in remaining patients when D-0/1 ≥5 ng/L or D-0/2 ≥10 ng/L); "Observe" were those not fulfilling described rules, in whom further diagnostic testing was needed. Final diagnosis was adjudicated by two independent cardiologists according to the Fourth Universal Definition of Myocardial Infarction. Performance of both algorithms was made by quantification of the negative predictive value (NPV) and the positive predictive value (PPV) in the "Rule-out" and "Rule-in" group, respectively. Results 286 patients were enrolled in the study. Median age was 70 (higher than in previous validation studies of rapid rule-in and rule-out algorithms; see Table 1 for baseline characteristics). The overall prevalence of NSTEACS was 17% (n = 49/286). A hs-cTnT<5 ng/L at t0 correctly ruled out NSTEACS in all patients (n = 48) fulfilling the rule; by contrast, a t0 value >52 ng/L existed in 39 patients, but only 69% were NSTEACS. The 0/1-h algorithm demonstrated an NPV of 97.3% and a PPV of 72% while the 0/2-h algorithm achieved an NPV of 100% and a PPV of 72.9% for the "Rule-out" and "Rule-in" group, respectively (Figure 1). Both algorithms allocated same percentage of patients (~30%) in the "Observe" group. Overall, the algorithms performed well, but in the 0/1-h algorithm, four patients with final diagnosis of NSTEACS were wrongly allocated to the "Rule-out" group. This did not occur in the 0/2-h algorithm where the same patients were allocated to the "Observe" group. Conclusion In our prospective cohort, the performance of the two recommended rapid rule-in and rule-out algorithms were good, but the 0/2-h algorithm achieved a better NPV and allowed for a more precise disposition of patients with respect to the 0/1-h algorithm.

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