Laser-assisted surface alloying of titanium with silver to enhance antibacterial and bone-cell mineralization properties of orthopedic implants.

Orthopedic device-related infection (ODRI) poses a significant threat to patients with titanium-based implants. The challenge lies in developing antibacterial surfaces that preserve the bulk mechanical properties of titanium implants while exhibiting characteristics similar to bone tissue. In response, we present a two-step approach: silver nanoparticle (AgNP) coating followed by selective laser-assisted surface alloying on commonly used titanium alumina vanadium (TiAl6V4) implant surfaces. This process imparts antibacterial properties without compromising the bulk mechanical characteristics of the titanium alloy. Systematic optimization of laser beam power (8-40 W) resulted in an optimized surface (32 W) with uniform TiAg alloy formation. This surface displayed a distinctive hierarchical mesoporous textured surface, featuring cauliflower-like nanostructures measuring between 5-10 nm uniformly covering spatial line periods of 25 µm while demonstrating homogenous elemental distribution of silver throughout the laser processed surface. The optimized laser processed surface exhibited prolonged superhydrophilicity (40 days) and antibacterial efficacy (12 days) against Staphylococcus aureus and Escherichia coli. Additionally, there was a significant twofold increase in bone mineralization compared to the pristine Ti6Al4V surface (p < 0.05). Rockwell hardness tests confirmed minimal (<1%) change in bulk mechanical properties compared to the pristine surface. This innovative laser-assisted approach, with its precisely tailored surface morphology, holds promise for providing enduring antibacterial and osteointegration properties, rendering it an optimal choice for modifying load-bearing implant devices without altering material bulk characteristics.

Side-Stream Enhanced Biological Phosphorus Removal (S2EBPR) enables effective phosphorus removal in a pilot-scale A-B stage shortcut nitrogen removal system for mainstream municipal wastewater treatment.

While the adsorption/bio-oxidation (A/B) process has been widely studied for carbon capture and shortcut nitrogen (N) removal, its integration with enhanced biological phosphorus (P) removal (EBPR) has been considered challenging and thus unexplored. Here, full-scale pilot testing with an integrated system combining A-stage high-rate activated sludge with B-stage partial (de)nitrification/anammox and side-stream EBPR (HRAS-P(D)N/A-S2EBPR) was conducted treating real municipal wastewater. The results demonstrated that, despite the relatively low influent carbon load, the B-stage P(D)N-S2EBPR system could achieve effective P removal performance, with the carbon supplement and redirection of the A-stage sludge fermentate to the S2EBPR. The novel process configuration design enabled a system shift in carbon flux and distribution for efficient EBPR, and provided unique selective factors for ecological niche partitioning among different key functionally relevant microorganisms including polyphosphate accumulating organisms (PAOs) and glycogen-accumulating organisms (GAOs). The combined nitrite from B-stage to S2EBPR and aerobic-anoxic conditions in our HRAS-P(D)N/A-S2EBPR system promoted DPAOs for simultaneous internal carbon-driven denitrification via nitrite and P removal. 16S rRNA gene-based oligotyping analysis revealed high phylogenetic microdiversity within the Accumulibacter population and discovered coexistence of certain oligotypes of Accumulibacter and Competibacter correlated with efficient P removal. Single-cell Raman micro-spectroscopy-based phenotypic profiling showed high phenotypic microdiversity in the active PAO community and the involvement of unidentified PAOs and internal carbon-accumulating organisms that potentially played an important role in system performance. This is the first pilot study to demonstrate that the P(D)N-S2EBPR system could achieve shortcut N removal and influent carbon-independent EBPR simultaneously, and the results provided insights into the effects of incorporating S2EBPR into A/B process on metabolic activities, microbial ecology, and resulted system performance.

Improved epitaxial growth and multiferroic properties of Bi3Fe2Mn2Ox using CeO2 re-seeding layers.

In ferroelectric and multiferroic-based devices, it is often necessary to grow thicker films for enhanced properties. For certain phases that rely on substrate strain for growth, such thicker film growths beyond the typical thin film regime could be challenging. As an example, the Bi3Fe2Mn2Ox (BFMO) Aurivillius supercell (SC) phase possesses highly desirable multiferroic (i.e., ferromagnetic and ferroelectric) properties and a unique layered structure but relies heavily on substrate strain. Beyond the thin film regime (approximately 100 nm), a less desirable pseudo-cubic (PC) phase is formed. In this work, a novel heterogeneous re-seeding method is applied to maintain the strained growth in this SC phase beyond the thin film regime, thus enabling the growth of thick BFMO SC phase films. The insertion of periodic CeO2 interlayers reintroduces the heteroepitaxial strain and effectively re-initiates the growth of the SC phase. The thick BFMO SC phase maintains the overall multiferroic and interesting anisotropic optical properties, even exceeding those of the typical 100 nm SC film. This re-seeding method can be effectively adopted with other SC systems or strain-dependent thin films, thus introducing practical applications of the new SC phases without thickness limitations.

Modeling versatile and dynamic anaerobic metabolism for PAOs/GAOs competition using agent-based model and verification via single cell Raman Micro-spectroscopy.

Side-stream enhanced biological phosphorus removal process (S2EBPR) has been demonstrated to improve performance stability and offers a suite of advantages compared to conventional EBPR design. Design and optimization of S2EBPR require modification of the current EBPR models that were not able to fully reflect the metabolic functions of and competition between the polyphosphate-accumulating organisms (PAOs) and glycogen-accumulating organisms (GAOs) under extended anaerobic conditions as in the S2EBPR conditions. In this study, we proposed and validated an improved model (iEBPR) for simulating PAO and GAO competition that incorporated heterogeneity and versatility in PAO sequential polymer usage, staged maintenance-decay, and glycolysis-TCA pathway shifts. The iEBPR model was first calibrated against bulk batch testing experiment data and proved to perform better than the previous EBPR model for predicting the soluble orthoP, ammonia, biomass glycogen, and PHA temporal profiles in a starvation batch testing under prolonged anaerobic conditions. We further validated the model with another independent set of anaerobic testing data that included high-resolution single-cell and specific population level intracellular polymer measurements acquired with single-cell Raman micro-spectroscopy technique. The model accurately predicted the temporal changes in the intracellular polymers at cellular and population levels within PAOs and GAOs, and further confirmed the proposed mechanism of sequential polymer utilization, and polymer availability-dependent and staged maintenance-decay in PAOs. These results indicate that under extended anaerobic phases as in S2EBPR, the PAOs may gain competitive advantages over GAOs due to the possession of multiple intracellular polymers and the adaptive switching of the anaerobic metabolic pathways that consequently lead to the later and slower decay in PAOs than GAOs. The iEBPR model can be applied to facilitate and optimize the design and operations of S2EBPR for more reliable nutrient removal and recovery from wastewater.

Impact of operational strategies on a sidestream enhanced biological phosphorus removal (S2EBPR) reactor in a carbon limited wastewater plant.

Water resource recovery facilities are faced with stringent effluent phosphorus limits to reduce nutrient pollution. Enhanced biological phosphorus removal (EBPR) is the most common biological route to remove phosphorus; however, many facilities struggle to achieve consistent performance due to limited carbon availability in the influent wastewater. A promising process to improve carbon availability is through return activated sludge (RAS) fermentation via sidestream EBPR (S2EBPR). In this study, a full-scale S2EBPR pilot was operated with a sidestream plus carbon configuration (SSRC) at a carbon-limited facility. A model based on the pilot test was developed and calibrated in the SUMO platform and used to explore routes for improving orthophosphate (OP) effluent compliance. Modeling results showed that RAS diversion by itself was not sufficient to drive OP removal to permit limits of 1 mg L-1, therefore, other strategies were evaluated. Supplemental carbon addition of MicroC® at 1.90 L min-1 and controlling the phosphorus concentration below 3.5 mgP L-1 in the primary effluent (PE) proved to be valid supplemental strategies to achieve OP removal below 1 mg L-1 most of the time. In particular, the proposed supplemental carbon flow rate would result in an improvement of the rbCOD:P ratio from 17:1 to 26:1. The synergistic approach of RAS diversion and supplemental carbon addition increased the polyphosphate accumulating organisms (PAO) population while minimizing the supplemental carbon needed to achieve consistent phosphorus removal. Overall, this pilot and modeling study shows that joint strategies, including RAS diversion, carbon addition and PE control, can be effective to achieve optimal control of OP effluent.

Enhancing resource recovery via cranberry syrup waste at the Wisconsin Rapids WRRF: An experimental and modeling study.

The Wisconsin Rapids Wastewater Treatment Plant (WRWWTP) is faced with a more stringent effluent phosphorus requirement that will drive capital investment between 2020 and 2025. The facility will need to achieve a monthly average value of 0.36 mg L-1 of total phosphorus (TP). While the facility has sufficient influent carbon to drive a conventional enhanced biological phosphorus removal (EBPR) configuration, the existing infrastructure makes the addition of influent selector zones cost prohibitive. Underutilized aeration basin capacity was repurposed for testing return activated sludge (RAS) fermentation. The WRWWTP began pilot testing of RAS fermentation in April 2021. The facility moved through a series of operational setpoints to optimize phosphorus removal in a sidestream RAS (SSR) configuration, including RAS diversion, decrease of DO in aeration basins and chemical dosing shutoff. One of the key implementations was the addition of cranberry syrup waste to provide additional carbon for RAS fermentation, converting the process to a SSR plus carbon (SSRC) configuration. By the end of the testing period, effluent total phosphorus was averaging less than 0.4 mg L-1 with no chemical addition. A model was developed in the SUMO platform and was used to capture orthophosphate trends during the testing period. The model investigated microbial population dynamics and found that the operational changes including RAS diversion, chemical dosing shutoff and cranberry syrup waste addition impacted the enrichment of phosphorus accumulating organisms (PAO). After performing a sensitivity analysis on hydrolysis parameters, the predicted hydrolysis rate around 1.8-1.9 mg COD g VSS-1 hr-1 was found to match the batch rate testing data. This is the first study where cranberry syrup waste was used to successfully enhance EBPR performance, resulting in 90% TP removal. While further research is needed regarding the composition of the waste matrix and the microbial community composition, this expands the routes for resource recovery in the field of wastewater treatment.

Single-Step Fabrication of Au-Fe-BaTiO3 Nanocomposite Thin Films Embedded with Non-Equilibrium Au-Fe Alloyed Nanostructures.

Nanocomposite thin film materials present great opportunities in coupling materials and functionalities in unique nanostructures including nanoparticles-in-matrix, vertically aligned nanocomposites (VANs), and nanolayers. Interestingly the nanocomposites processed through a non-equilibrium processing method, e.g., pulsed laser deposition (PLD), often possess unique metastable phases and microstructures that could not achieve using equilibrium techniques, and thus lead to novel physical properties. In this work, a unique three-phase system composed of BaTiO3 (BTO), with two immiscible metals, Au and Fe, is demonstrated. By adjusting the deposition laser frequency from 2 Hz to 10 Hz, the phase and morphology of Au and Fe nanoparticles in BTO matrix vary from separated Au and Fe nanoparticles to well-mixed Au-Fe alloy pillars. This is attributed to the non-equilibrium process of PLD and the limited diffusion under high laser frequency (e.g., 10 Hz). The magnetic and optical properties are effectively tuned based on the morphology variation. This work demonstrates the stabilization of non-equilibrium alloy structures in the VAN form and allows for the exploration of new non-equilibrium materials systems and their properties that could not be easily achieved through traditional equilibrium methods.

ZnO-ferromagnetic metal vertically aligned nanocomposite thin films for magnetic, optical and acoustic metamaterials.

Magnetoacoustic waves generated in piezoelectric and ferromagnetic coupled nanocomposite films through magnetically driven surface acoustic waves present great promise of loss-less data transmission. In this work, ferromagnetic metals of Ni, Co and Co x Ni1-x are coupled with a piezoelectric ZnO matrix in a vertically-aligned nanocomposite (VAN) thin film platform. Oxidation was found to occur in the cases of ZnO-Co, forming a ZnO-CoO VAN, while only very minor oxidation was found in the case of ZnO-Ni VAN. An alloy approach of Co x Ni1-x has been explored to overcome the oxidation during growth. Detailed microstructural analysis reveals limited oxidation of both metals and distinct phase separation between the ZnO and the metallic phases. Highly anisotropic properties including anisotropic ferromagnetic properties and hyperbolic dielectric functions are found in the ZnO-Ni and ZnO-Co x Ni1-x systems. The magnetic metal-ZnO-based hybrid metamaterials in this report present great potential in coupling of optical, magnetic, and piezoelectric properties towards future magnetoacoustic wave devices.

Aortic Dissection in a Case of Peripartum Cardiomyopathy.

Management of acute Type A aortic dissection can be complicated by patient comorbidities. We describe the case of a 29-year-old female with preexisting peripartum cardiomyopathy who developed a Type A dissection. Surgery was performed and venoarterial extracorporeal membrane oxygenation (ECMO) was instituted. She left hospital on the 71st postoperative day. It is extremely rare for a patient with cardiomyopathy to develop an aortic dissection. Deferring this patient's surgery to an ECMO center was crucial for her survival.

Effects of Secondary Package on Freeze-Dried Biopharmaceutical Formulation Stability During Dropping.

Previously our laboratory first reported that dropping of freeze-dried monoclonal antibody (mAb) formulations could cause protein degradation and aggregation (J Pharm Sci, 2021, 1625). In this manuscript, we evaluated effects of secondary package on stability of several freeze-dried biopharmaceutical formulations during dropping. The degradation of mAb-Y during dropping with different secondary packages was determined by the sensitive particle analyzing techniques micro-flow imaging (MFI) and dynamic light scattering (DLS). Electron paramagnetic resonance (EPR) was used to detect free radicals after repeated dropping in different secondary packages. The amount of free radicals and SbVPs was correlated to the sample temperature as well as the secondary package during dropping. Our observations suggest that secondary packaging has significant effect on freeze-dried biopharmaceutical stability during dropping and therefore should be thoroughly screened and optimized to assure high product quality even for the presumed highly stable freeze-dried biopharmaceuticals.

Twelve tips for integrating ultrasound guided peripheral intravenous access clinical skills teaching into undergraduate medical education.

Peripheral Intravenous access (PIV) is a procedure undertaken by Medical Practitioners and Non-Medical Practitioners. Traditional PIV uses a visual and tactile technique to locate blood vessels close to the surface of the skin. Chronic medical conditions, dehydration, obesity and recurrent intravenous access can make PIV challenging. Ultrasound (US) guided PIV is recommended to aid the identification of the arm arteries and veins and improve the success rate of needle placement in difficult cases. Medical and non-medical schools, and hospital organisations, are recognising the importance of US guided PIV education for undergraduate and postgraduate Medical and Non-Medical Practitioners. This to promote independence, efficiency and to improve patient safety. The aim of this 12 tips article is to highlight the considerations and practicalities of integrating and delivering, a practical based skills (PBS) session, on the use of US guided practice as an adjunct in difficult PIV, into the undergraduate medical education curricula.

Formation of an Unprecedented Impurity during CE-SDS Analysis of a Recombinant Protein.

PURPOSES: The main purposes of this article are to describe an unprecedented phenomenon in which significant amount of a shoulder peak impurity was observed during normal non-reducing capillary electrophoresis-sodium dodecyl sulfate (CE-SDS) analysis of a recombinant fusion protein X, and to evaluate the root cause for this phenomenon. METHODS: A series of experiments were conducted to study the nature of this degradation. Effects of iodoacetamide (IAM), heating temperature, duration, and SDS on the formation of this specific impurity were evaluated using a variety of characterization techniques. RESULTS: The formation of the impurity as observed in CE-SDS was actually due to alkylation of lysine and serine residues with IAM, as confirmed by peptide mapping and LC-MS/MS, which increased the molecular weight and therefore decreased the electrophoretic mobility. The amount of impurity was also strongly dependent on sample preparation conditions including the presence or absence of SDS. CONCLUSIONS: Our study clearly suggested that even though IAM has been used extensively as an alkylation reagent in the traditional non-reducing CE-SDS analysis of monoclonal antibodies and other proteins, alkylation with IAM could potentially lead to additional impurity peak, and therefore complicating analysis. Therefore, before performing CE-SDS and other analyses, the effects of sample preparation procedures on analytical results must be evaluated. For protein X, IAM should be excluded for CE-SDS analysis.

Formation of protein sub-visible particles during powder grinding of a monoclonal antibody.

We have observed an interesting phenomenon in which grinding of freeze-dried monoclonal antibody X (mAb-X) formulation powder resulted to significant protein sub-visible particles (SbVPs) in the reconstituted liquid, which could only be observed by sensitive particle analytical methods such as MFI and DLS. Effects of grinding temperature and the free radical scavengers methionine and 3-carbamoyl-2,2,5,5-tetramethyl-1-pyrrolidin-yloxy free radical (CTPO) on the formation of SbVPs were also evaluated. Free radicals were observed by EPR and the amount of free radicals was correlated to the sample temperature prior to grinding. Formation of SbVPs could be partially inhibited by methionine and CTPO. The amount of SbVPs formed was dependent on the amount of free radicals/sample temperature prior to grinding. At higher temperatures, more free radicals and SbVPs formed. Other than the previously known protein degradation due to high temperature formed during mechanical grinding, we propose an unreported and supplementary mechanism, i.e., the formation of free radicals (i.e., due to break of CO or CS bonds) in the dried state during mechanical grinding, leading to protein particle formation in the reconstituted solution. Our observation suggested that mechanical grinding of protein powder should be avoided or used cautiously (i.e., grinding temperature, strength and time) and the effects on radical and particle formation be fully evaluated.

Venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock-A six-year service evaluation.

Only a small number of English hospitals provide postcardiotomy venoarterial extracorporeal membrane oxygenation (VA-ECMO) and there are doubts about its efficacy and safety. The aim of this service evaluation was to determine local survival rates and report on patient demographics. This was a retrospective service evaluation of prospectively recorded routine clinical data from a tertiary cardiothoracic center in the United Kingdom offering services including cardiac and thoracic surgery, heart and lung transplantation, venovenous extracorporeal membrane oxygenation (VV-ECMO) for respiratory failure, and all types of mechanical circulatory support. In six years, 39 patients were supported with VA-ECMO for refractory postcardiotomy cardiogenic shock (PCCS). We analyzed survival data and looked for associations between survival rates and patient characteristics. The intervention was venoarterial-ECMO in patients with PCCS either following weaning from cardiopulmonary bypass or following a trial of inotropes and intra-aortic balloon counterpulsation on the intensive care unit. 30-day, hospital discharge, 1-year and 2-year survivals were 51.3%, 41%, 37.5%, and 38.5%, respectively. The median (IQR [range]) duration of support was 6 (4-9 [1-35]) days. Nonsurvival was associated with advanced age, shorter intensive care length of stay, and the requirement for postoperative hemofiltration. Reasonable survival rates can be achieved in selected patients who may have been expected to have a worse mortality without VA-ECMO. We suggest postoperative VA-ECMO should be available to all patients undergoing cardiac surgery be it in their own center or through an established pathway to a specialist center.

Survey of full-scale sidestream enhanced biological phosphorus removal (S2EBPR) systems and comparison with conventional EBPRs in North America: Process stability, kinetics, and microbial populations.

Sidestream EBPR (S2EBPR) is an emerging alternative process to address common challenges in EBPR related to weak wastewater influent and may improve EBPR process stability. A systematic evaluation and comparison of the process performance and microbial community structure was conducted between conventional and S2EBPR facilities in North America. The statistical analysis suggested higher performance stability in S2EBPR than conventional EBPR, although possible bias associated with other plant-specific factors might have affected the comparison. Variations in stoichiometric values related to EBPR activity and discrepancies between the observed values and current model predictions suggested a varying degree of metabolic versatility of PAOs in S2EBPR systems that warrant further investigation. Microbial community analysis using various techniques suggested comparable known candidate PAO relative abundances in S2EBPR and conventional EBPR systems, whereas the relative abundance of known candidate GAOs seemed to be consistently lower in S2EBPR facilities than conventional EBPR facilities. 16S rRNA gene sequencing analysis revealed differences in the community phylogenetic fingerprints between S2EBPR and conventional facilities and indicated statistically higher microbial diversity index values in S2EBPR facilities than those in conventional EBPRs. PRACTITIONER POINTS: Sidestream EBPR (S2EBPR) can be implemented with varying and flexible configurations, and they offer advantages over conventional configurations for addressing the common challenges in EBPR related to weak wastewater influent and may improve EBPR process stability. Survey of S2EBPR plants in North America suggested statistically more stable phosphorus removal performance in S2EBPR plants than conventional EBPRs, although possible bias might affect the comparison due to other plant-specific factors. The EBPR kinetics and stoichiometry of the S2EBPR facilities seemed to vary and are associated with metabolic versatility of PAOs in S2EBPR systems that warrant further investigation. The abundance of known candidate PAOs in S2EBPR plants was similar to those in conventional EBPRs, and the abundance of known candidate GAOs was generally lower in S2EBPR than conventional EBPR facilities. Further finer-resolution analysis of PAOs and GAOs, as well as identification of other unknown PAOs and GAOs, is needed. Microbial diversity is higher in S2EBPR facilities compared with conventional ones, implying that S2EBPR microbial communities could show better resilience to perturbations due to potential functional redundancy.

The Wythenshawe Hybrid Circuit for lung transplantation: a previously undescribed circuit for lung transplant.

Extracorporeal membrane oxygenation is a safe modality of cardiorespiratory support for lung transplantation, with a reduction in coagulopathy and transfusion requirement when compared with cardiopulmonary bypass. In some scenarios, in lung transplantation, there are advantages to the use of cardiopulmonary bypass, which allows cardiac decompression, filtering of embolic air, easy addition and removal of volume, and a means to immediately reintroduce lost blood into circulation. We describe a novel circuit which allows safe and easy switch between modalities without prolonged interruption of flow. This circuit offers a safety net during surgery to minimise the risks influencing the use of extracorporeal membrane oxygenation.

Trichosporon japonicum Fungemia and Ventricular Assist Device Infection in an Immunocompetent Patient.

Trichosporon species are emerging opportunistic yeasts that cause life-threatening disseminated disease in severely immunocompromised patients. Trichosporon japonicum is a very rare cause of invasive trichosporonosis. We describe a case of Trichosporon japonicum fungemia in an immunocompetent patient with a transcutaneous biventricular assist device.

Side-stream enhanced biological phosphorus removal (S2EBPR) process improves system performance - A full-scale comparative study.

To address the common challenges in enhanced biological phosphorus removal (EBPR) related to stability and unfavorable influent carbon to phosphorus ratio, a side-stream EBPR (S2EBPR) process that involves a side-stream anaerobic biological sludge hydrolysis and fermentation reactor was proposed as an emerging alternative. In this study, a full-scale pilot testing was performed with side-by-side operation of a conventional anaerobic-anoxic-aerobic (A2O) process versus a S2EBPR process. A comparison of the performance, activity and microbial community between the two configurations was performed. The results demonstrated that, with the same influent wastewater characteristics, S2EBPR configuration showed improved P removal performance and stability than the conventional A2O configuration, especially when the mixers in the side-stream anaerobic reactor were operated intermittently. Mass balance analysis illustrated that both denitrification and EBPR were enhanced in S2EBPR configuration, where return activated sludge was diverted into the anaerobic zone to promote fermentation and enrichment of polyphosphate accumulating organisms (PAOs), and the influent was bypassed to the anoxic zone for enhancing denitrification. A relatively higher PAO activity and total PAO abundance were observed in S2EBPR than in A2O configuration, accompanied by a higher degree of dependence on glycolysis pathway than tricarboxylic acid cycle. No significant difference in the relative abundances of putative PAOs, including Ca. Accumulibacter and Tetrasphaera, were observed between the two configurations. However, higher microbial community diversity indices were observed in S2EBPR configuration than in conventional one. In addition, consistently lower relative abundance of known glycogen accumulating organisms (GAOs) was observed in S2EBPR system. Extended anaerobic retention time and conditions that generate continuous and more complex volatile fatty acids in the side-stream anaerobic reactor of S2EBPR process likely give more competitive advantage for PAOs over GAOs. PAOs exhibited sustained EBPR activity and delayed decay under extended anaerobic condition, likely due to their versatile metabolic pathways depending on the availability and utilization of multiple intracellular polymers. This study provided new insights into the effects of implementing side-stream EBPR configuration on microbial populations, EBPR activity profiles and resulted system performance.

Bomb blast shrapnel trauma to the main pulmonary artery: learning points to achieve a safe outcome.

A 47-year-old patient was injured in a bomb blast and sustained trauma due to multiple fragments of shrapnel from a terrorist explosive device. We report on the surgery required to safely remove a piece of shrapnel from the anterior wall of the main pulmonary artery (PA). A chest X-ray revealed a left-sided haemothorax. A computed tomography scan confirmed the trajectory and position of a metal bolt that had lodged between the main PA and the aortic arch. At surgery, a limited left anterior thoracotomy was performed initially. A significant quantity of blood was observed in the pericardium, and the incision was extended to perform a hemi-clamshell incision with a transverse division of the sternum. Cardiopulmonary bypass (CPB) was initiated before prizing the shrapnel from a haematoma involving the front wall of the main PA. The use of the CPB prevented uncontrolled haemorrhage, and the injury to the wall was successfully repaired. The patient subsequently developed acute respiratory distress syndrome and required a prolonged period of ventilation but made a full recovery after multiple further surgeries to remove the shrapnel from his neck and legs, having been injured by 11 pieces of the shrapnel in total.