1 Central Message: In patients who experienced severe COVID-19, pulmonary fibrosis, chronic pulmonary heart disease and post-intensive care syndrome represent the major problems at followup.
Central Picture Legend: Crisis after crisis?
The pandemic storm occurred in the last months taught us that COVID-19 is a severe illness associated with poor outcomes in frail people or those with chronic diseases like diabetes and cardiovascular diseases [1] . General population and, more relevantly, the whole health care system experienced a deep and progressive change of mentality and habits. Social distancing, masks and travelling limitations became the normality for community dwelling adults. A thorough reorganization was required and levels of priority for cardiovascular surgery and mitigation strategies were established [2] . We stressed on the importance of performing nasal swabs in all patients and having dedicated COVID-19 and COVID-19 free paths with the aim of minimizing the risk of exposure to SARS-CoV-2. In this issue of Journal, Fattouch et al reported outcomes of 18 patients who developed COVID-19 after cardiac surgery in a "COVID-19 free" hub for urgent and emergent cardiovascular procedures in Palermo, Italy. Mortality and morbidities were higher than expected. Specifically, overall mortality was 16.6% and rate of acute kidney failure and postoperative atrial fibrillation were 72.2% and 67.2%, respectively. Interestingly, no heart failure was observed. There were twelve care workers infected, of whom one developed interstitial chest pneumonia. As result, the surgical activity was stopped and patients transferred to dedicated COVID-19 units. The Palermo experience drives to the following conclusions:
1. The importance of preoperative nasal swabs, as this was not included as recommended criteria for COVID-19 screening J o u r n a l P r e -p r o o f 2. The difficulties in identifying infected patients after cardiac surgery as cardiopulmonary bypass induces inflammation and may mimic some laboratory finding COVID-19-like 3. The continuous surveillance of health care workers in a COVID free hospital, as they might be asymptomatic carrier of SARS-CoV-2.
On 18 th May 2020, Italy moved to Phase 2 with a total of 225,435 infected patients and 31,908 deaths (14.1%). Since then, we have been started taking care post COVID-19 patients, highlighting the importance of monitoring their vital signs and the need for rehabilitation programs within 12 weeks after COVID-19. More than 4,000 patients who required mechanical ventilation for severe disease are now facing with some sequelae [3] . Impairment of diffusion capacity and restrictive ventilatory defects are the most common abnormalities of lung function [4] . As consequence, pulmonary fibrosis and chronic pulmonary heart disease represent the major problems at follow-up associated with these patients. In this regard, the implementation of pulmonary rehabilitation is recommended to improve lung function, exercise tolerance and reduce fatigue. In addition, the long-term intensive care unit stay may developed the post-intensive care syndrome, characterized by diminished physical abilities sarcopenia-related, cognitive decline and mental health disorders such as neurophaty, anxiety and depression and post-traumatic stress disorder that can persist for a protracted amount of time [5] . Integrated education and rehabilitation programs are mandatory to reduce the risk of new hospitalization with consequent higher cost for the publish health system. Physicians such as physiatrist, pneumologists and cardiologists as well as physical therapists, psychologists and nutritionists should work together to 1) create algorithm that take into account the patient's morbidities integrated with the complication of severe form of disease, 2) identify some care pathways for a holistic assessment of post COVID-19 patient. Telehealth consulting and virtual educational programs have been useful during the COVID-19 outbreak and might be helpful in facing this deficiency [6] (Figure 1) . The final result is that Phase 2 should be able to manage high rate of people with rehabilitation needs associated with a low number of new infected patients.
Nevertheless, a second wave COVID-19 pandemic is coming and we hope we stem it. Whilst we J o u r n a l P r e -p r o o f