ECMO for drug-refractory electrical storm without a reversible trigger: a retrospective multicentric observational study.

AIMS: Drug-refractory electrical storm (ES) is a life-threatening medical emergency. We describe the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in drug-refractory ES without a reversible trigger, for which specific guideline recommendations are still lacking. METHODS AND RESULTS: Retrospective observational study in four Iberian centres on the indications, treatment, complications, and outcome of drug-refractory ES not associated with acute coronary syndromes, decompensated heart failure, drug toxicity, electrolyte disturbances, endocrine emergencies, concomitant acute illness with fever, or poor compliance with anti-arrhythmic drugs, requiring VA-ECMO for circulatory support. Thirty-four (6%) out of 552 patients with VA-ECMO for cardiogenic shock were included [71% men; 57 (44-62) years], 65% underwent cardiopulmonary resuscitation before VA-ECMO implantation, and 26% during cannulation. Left ventricular unloading during VA-ECMO was used in 8 (24%) patients: 3 (9%) with intraaortic balloon pump, 3 (9%) with LV vent, and 2 (6%) with Impella. Thirty (88%) had structural heart disease and 8 (24%) had an implantable cardioverter-defibrillator. The drug-refractory ES was mostly due to monomorphic ventricular tachycardia (VT) and ventricular fibrillation (VF) (59%), isolated monomorphic VT (26%), polymorphic VT (9%), or VF (6%). Thirty-one (91%) required deep sedation, 44% overdrive pacing, 36% catheter ablation, and 26% acute autonomic modulation. The main complications were nosocomial infection (47%), bleeding (24%), and limb ischaemia (21%). Eighteen (53%) were weaned from VA-ECMO, and 29% had heart transplantation. Twenty-seven (79%) survived to hospital discharge (48 (33-82) days). Non-survivors were older [62 (58-67) vs. 54 (43-58); P < 0.01] and had a higher first rhythm disorder-to-ECMO interval [0 (0-2) vs. 2 (1-11) days; P = 0.02]. Seven (20%) had rehospitalization during follow-up [29 (12-48) months], with ES recurrence in 6%. CONCLUSIONS: VA-ECMO bridged drug-refractory ES without a reversible trigger with a high success rate. This required prolonged hospital stays and coordination between the ECMO centre, the electrophysiology laboratory, and the heart transplant programme.

Screening of cardiac allograft vasculopathy in heart transplant patients with coronary computed tomography angiography.

Although coronary angiography (CA) is the gold standard for coronary allograft vasculopathy (CAV) screening, non-invasive modalities have arisen as potential alternatives, such as coronary computed tomography angiography (CCTA). CCTA also quantifies plaque burden, which may influence medical treatment. From January 2021 to April 2022, we prospectively included heart transplant recipients who performed CCTA as a first-line method for CAV detection in a single center. Clinical, CCTA, and CA data were collected. 38 patients were included, 60.5% men, aged 58±14 years. The most frequent cause of transplantation was dilated cardiomyopathy (42.1%), and the median graft duration was 10 years [interquartile range (IQR) 9]. The median left ventricle ejection fraction was 61.5% (IQR 6). The median calcium score was 17 (IQR 231) and 32 patients (84.2%) proceeded to CCTA: 7, 24, and 1 patients had a graded CAV of 0, 1, and 2, respectively. Most patients (37.5%) had both calcified and non-calcified plaques, and the median number of affected segments was 2 (IQR 3). The remaining six patients had extensive coronary calcification, so CA was performed: 4 had CAV1, 1 had CAV2, and 1 had CAV3. During follow-up (12.2±4.2 months), there were neither deaths nor acute coronary syndromes. After CCTA, therapeutic changes occurred in about 10 (26.3%) of patients, mainly related to anti-lipid intensification; such changes were more frequent in patients with diabetes after heart transplant. In this cohort, CCTA led to therapeutic changes in about one-quarter of patients; more studies are needed to assess how CCT may guide therapy according to plaque burden.

Ventricular Pseudoaneurysm After Myocardial Infarction: A Case Report.

A 66-year-old female patient was admitted to hospital care in March 2021 due to aggravating fatigue and dyspnoea. Her past medical history was relevant for chronic anaemia, smoking, dyslipidaemia, antiphospholipid syndrome and lupus-like mixed connective tissue disease, for which she was taking corticosteroids. She had suffered an acute coronary syndrome in August 2020, complicated with postinfarction pericarditis; at the time, coronariography diagnosed moderate disease of the anterior descending artery and occlusion of the circumflex artery. Echocardiography showed a discontinuity in the lateral and posterior walls of the left ventricle to a thin walled, loculated cavity, with doppler blood flow (Figure 1). A diagnosis of pseudoaneurysm was assumed, and the patient was transferred to our centre for surgical treatment.

Cutaneous Tuberculosis in Heart Transplant.

Tuberculosis is a disease with a significant global burden in terms of morbidity and mortality. It usually presents as a pulmonary disease but can occasionally have extrapulmonary presentations. Immunosuppressed people are at an increased risk of tuberculosis and more frequently have atypical manifestations of the disease. Cutaneous involvement is estimated to occur in only 2% of extrapulmonary presentations. We report a case of a heart transplant recipient with disseminated tuberculosis who initially presented with cutaneous manifestations in the form of multiple abscesses that were mistaken for a community-acquired bacterial infection. The diagnosis was made after positive nucleic acid amplification testing and cultures for Mycobacterium tuberculosis from the drainage of the abscesses. After initiating antituberculous treatment, the patient had 2 instances of immune reconstitution inflammatory syndrome. A combination of diminished immunosuppression due to discontinuation of mycophenolate mofetil in the setting of acute infection, rifampin drug interactions with cyclosporine, and the beginning of treatment of tuberculosis all contributed to this paradoxical worsening. The patient responded favorably to increased glucocorticoid therapy and showed no signs of treatment failure after 6 months of antituberculous therapy.

Response surface approach to optimize the removal of the critical raw material dysprosium from water through living seaweeds.

Dysprosium (Dy) is a rare earth element with a high economic and strategic value, and simultaneously an emerging contaminant, whose removal from wastewaters is gaining increasing attention. In this work, the Response Surface Methodology (RSM) combined with a Box-Behnken Design (3 factors-3 levels) was used to optimize the key operational conditions that influence the uptake of Dy by two living seaweed, Ulva sp. and Gracilaria sp.. The initial concentration of Dy (10-500 µg/L), water salinity (10-30), and seaweed dosage (0.5-5.5 g/L) were the independent variables, while the removal efficiency (%) and bioaccumulation (q, µg/g) were the response variables. Results highlighted the high capacity of both species to capture Dy. After 168 h, the optimal conditions that led to a maximum of 91 % of Dy removed by Gracilaria sp. were: 500 µg of Dy per L of water, salinity 10, and 5.5 g of seaweed per L. For Ulva sp., a maximum removal percentage of 79 % was achieved in the conditions: any initial concentration of Dy, salinity 20, and seaweed dosage of 3.7 g/L. Independently of the species, the response surfaces showed that the most important variable for the removal is the seaweed dosage, while for bioaccumulation is the initial concentration of Dy. Using RSM, it was possible to obtain the optimal operating conditions for Dy removal from waters, which is a fundamental step toward the application of the proposed technology at large scale.

Sustainable recovery of neodymium and dysprosium from waters through seaweeds: Influence of operational parameters.

The high demand for greener energy and technological innovation require some crucial elements, such as the rare earths Nd and Dy. Being considered two of the most critical elements (high supply risk), it is vital to recover them from wastes/wastewaters, for later reuse. Here, the influence of operational parameters, such as biosorbent stock density (0.5, 3.0, and 5.5 g L-1), ionic strength (salinity 10 and 30) and contact time (24, 72 and 168 h), in the biosorption/bioaccumulation of Nd and Dy by two living marine macroalgae was evaluated in artificial seawater, seeking the improvement of the process. Results demonstrated that stock density is the most influential parameter, while the ionic strength showed to be a selective parameter, with a major influence only for Dy removal, which can be attributed to the different chemical characteristics observed between light rare earth elements (LREE) and heavy rare earth elements (HREE). For the ranges studied, the greatest removal/recovery for Gracilaria sp. was achieved with a stock density of 3.0 g L-1 at salinity 10, after 72 h for both REEs. For Ulva lactuca optimal conditions were: stock density of 5.5 g L-1 at salinity 10 with a contact time of 72 h for both REEs. Between species, U. lactuca showed to be the most promising, with removal efficiencies up to 98% for Nd and 89% for Dy. Findings substantiate the potential of the proposed process for obtaining Nd and Dy from secondary sources, particularly from low-level contaminated waters.

Can the recycling of europium from contaminated waters be achieved through living macroalgae? Study on accumulation and toxicological impacts under realistic concentrations.

Europium (Eu) strategic importance for the manufacturing industry, high economic value and high supply risk, categorizes it as critical raw material. Due to anthropogenic contamination, Eu levels in ecosystems have been growing, which opens opportunities for innovation: its recovery and recycling from contaminated water as element source - circular economy. In this pioneering study, six widely available living marine macroalgae (Ulva intestinalis, Ulva lactuca, Gracilaria sp., Osmundea pinnatifida, Fucus vesiculosus and Fucus spiralis) were characterized (water content and specific surface area) and evaluated in the pre-concentration and recovery of Eu from contaminated seawater, under different relevant contamination scenarios (10, 152 and 500 µg L-1). U. lactuca and Gracilaria sp. (3 g L-1, fresh weight) proved to be the most effective in removing Eu, reaching up to 85% in 72 h, while the highest Eu enrichment was observed in U. intestinalis biomass, up to 827 µg g-1 (bioconcentration factor of 1800), which is higher than Eu levels in common apatite ores. The effect of Eu exposure on macroalgae growth rate and organism biochemical performance (LPO, SOD, GPx and GSTs) was also evaluated for the first time, to the best of our knowledge. Although no cellular damage was recorded, findings revealed toxicity and defence mechanisms activation, emphasizing the need of further studies on the potential risks associated with the presence of this emerging contaminant in aquatic ecosystems.

Bioaccumulation processes for mercury removal from saline waters by green, brown and red living marine macroalgae.

Mercury is a very toxic metal that persists and accumulates in the living organisms present in the aquatic systems and its elimination is an urgent need. Two green (Ulva intestinalis and Ulva lactuca), brown (Fucus spiralis and Fucus vesiculosus), and red (Gracilaria sp. and Osmundea pinnatifida) marine macroalgae were tested for mercury removal from saline waters. The ability of each species was evaluated to the initial mercury concentrations of 50, 200, and 500 µg dm-3 along 72 h. In general, all species exhibited good performances, removing 80.9-99.9% from solutions with 50 µg dm-3, 79.3-98.6% from solutions with 200 µg dm-3, and 69.8-97.7% from solutions containing 500 µg dm-3 of mercury. Among the macroalgae, Ulva intestinalis showed the highest affinity to mercury and it presented an uptake ability up to 1888 µg g-1 of Hg(II) and bioconcentration factors up to 3823, which proved its promising potential on Hg removal.

Assessment of marine macroalgae potential for gadolinium removal from contaminated aquatic systems.

Gadolinium (Gd) is a rare earth associated with hospital and urban wastewaters due to its application as a contrast agent for magnetic resonance imaging. In this work, the uptake of Gd from contaminated seawater by three living marine macroalgae, Ulva lactuca (Chlorophyta), Fucus spiralis (Phaeophyta) and Gracilaria sp. (Rhodophyta) was studied along 72 h. Surface analysis (FTIR), water content, kinetic modelling, and Gd quantification in seawater and biomass were performed. All species were able to accumulate Gd from seawater with 10, 157, and 500 µg Gd L-1, although green and red macroalgae performed better, following the order: green > red > brown. Removal efficiencies reached 85%, corresponding to a bioconcentration factor of 1700. In more complex solutions that intended to mimic real contaminated environments, namely mixtures with other rare earth elements (Y, La, Ce, Pr, Nd, Eu, Tb, Dy), and with potentially toxic elements commonly found in wastewaters (Cr, Ni, Cu, Cd, Hg, Pb), at two salinities (10 and 30), the macroalgae kept its efficiency: 84% and 88% of removal by green and red macroalgae, respectively. Overall, findings evidence that living macroalgae could be a countermeasure to the increasing anthropogenic enrichment of Gd observed in the aquatic environment.

Influence of salinity and rare earth elements on simultaneous removal of Cd, Cr, Cu, Hg, Ni and Pb from contaminated waters by living macroalgae.

Potentially toxic elements (PTEs) are of major concern due to their high persistence and toxicity. Recently, rare earth elements (REEs) concentration in aquatic ecosystems has been increasing due to their application in modern technologies. Thus, this work aimed to study, for the first time, the influence of REEs (lanthanum, cerium, praseodymium, neodymium, europium, gadolinium, terbium, dysprosium and yttrium) and of salinity (10 and 30) on the removal of PTEs (Cd, Cr, Cu, Hg, Ni and Pb) from contaminated waters by living macroalgae (Fucus spiralis, Fucus vesiculosus, Gracilaria sp., Osmundea pinnatifida, Ulva intestinalis and Ulva lactuca). Experiments ran for 168 h, with each macroalga exposed to saline water spiked with the six PTEs and with the six PTEs plus nine REEs (all at 1 µmol L-1) at both salinities. Results showed that all species have high affinity with Hg (90-99% of removal), not being affected neither by salinity changes nor by the presence of other PTEs or REEs. Cd showed the lowest affinity to most macroalgae, with residual concentrations in water varying between 50 and 108 µg L-1, while Pb removal always increased with salinity decline (up to 80% at salinity 10). REEs influence was clearer at salinity 30, and mainly for Pb. No substantial changes were observed in Ni and Hg sorption. For the remaining elements, the effect of REEs varied among algae species. Overall, the results highlight the role of marine macroalgae as living biofilters (particularly U. lactuca), capable of lowering the levels of top priority hazardous substances (particularly Hg) and other PTEs in water, even in the presence of the new emerging contaminants - REEs. Differences in removal efficiency between elements and macroalgae are explained by the contaminant chemistry in water and by macroalgae characteristics.

Influence of toxic elements on the simultaneous uptake of rare earth elements from contaminated waters by estuarine macroalgae.

The present study tested whether the presence of potentially toxic elements (PTEs) (Cd, Cr, Cu, Pb, Hg and Ni), commonly found in wastewaters, interferes with the ability of macroalgae (Ulva intestinalis, Ulva lactuca, Fucus spiralis, Fucus vesiculosus, Gracilaria sp. and Osmundea pinnatifida) to remove rare earth elements (REEs) (La, Ce, Pr, Nd, Eu, Gd, Tb, Dy and Y), which are key elements for most high technologies (e.g. electronics, aerospace, renewable energy). Results proved the high capacity of living macroalgae to remove REEs from multielement solutions, with the following sequence of bioconcentration factors being observed: U. intestinalis (2790) > Gracilaria sp. (2119) > O. pinnatifida (1742) > U. lactuca (1548) > F. vesiculosus (944) > F. spiralis (841). Competition among REEs to sorption sites on the six macroalgae was minor due to the chemical similarities between the elements. However, Ce and Y were the less removed while Gd, La and Eu the most removed among REEs. Ionic strength was an important factor in the sorption process, with salinity affecting differently the six macroalgae. Surprisingly, the presence of potential toxic elements in solution enhanced the removal of REEs. The most plausible explanation is the preferentially complexation of those elements by carbonates over REEs, which facilitates the binding of REEs cations onto the surface of macroalgae.

Negligible effect of potentially toxic elements and rare earth elements on mercury removal from contaminated waters by green, brown and red living marine macroalgae.

Mercury (Hg) removal by six different living marine macroalgae, namely, Ulva intestinalis, Ulva lactuca, Fucus spiralis, Fucus vesiculosus, Gracilaria sp., and Osmundea pinnatifida was investigated in mono and multi-contamination scenarios. All macroalgae were tested under the same experimental conditions, evaluating the competition effects with all elements at the same initial molar concentration of 1 µmol dm-3. The presence of the main potentially toxic elements (Cd, Cr, Cu, Ni, and Pb) and rare earth elements (La, Ce, Pr, Nd, Eu, Gd, Tb, and Y) has not affected the removal of Hg. Characterizations of the macroalgae by FTIR before and after the biosorption/bioaccumulation assays suggest that Hg was mainly linked to sulfur-functional groups, while the removal of other elements was related with other functional groups. The mechanisms involved point to biosorption of Hg on the macroalgae surface followed by possible incorporation of this metal into the macroalgae by metabolically active processes. Globally, the green macroalgae (Ulva intestinalis, Ulva lactuca) showed the best performances for Hg, potential toxic elements and rare earth elements removal from synthetic seawater spiked with 1 µmol dm-3 of each element, at room temperature and pH 8.5.

A green method based on living macroalgae for the removal of rare-earth elements from contaminated waters.

Low recycling rates of rare earth elements (REEs) are a consequence of inefficient, expensive and/or contaminating methods currently available for their extraction from solid wastes or from liquid wastes such as acid mine drainage or industrial wastewaters. The search for sustainable recovery alternatives was the motivation for this study. For the first time, the capabilities of 6 living macroalgae (Ulva lactuca, Ulva intestinalis, Fucus spiralis, Fucus vesiculosus, Osmundea pinnatifida and Gracilaria sp.) to remove REEs (Y, La, Ce, Pr, Nd, Eu, Gd, Tb, Dy) from laboratory-prepared seawater spiked with REE solutions were evaluated. The assays lasted 72 h with REEs concentrations ranging from 10 to 500 µg L-1. The link between REEs uptake and algal metabolism, surface morphology and chemistry were addressed. Kinetics varied among the species, although most of the removal occurred in the first 24 h, with no equilibrium being reached. Lack of mortality reveal that the algae maintained their metabolism in the presence of the REEs. Green alga U. lactuca stood out as the only capable of efficiently removing at least 60% of all elements, reaching removals up to 90% in some cases. The high bioconcentration factors, derived from mass balance analysis (c.a. 2500) support that the REEs enriched algal biomass (up to 1295 µg g-1) may constitute an effective and environmentally friendly alternative source of REEs to conventional extraction from ores.

Left ventricular noncompaction: A rare indication for pediatric heart transplantation.

Isolated left ventricular noncompaction is a rare congenital cardiomyopathy, characterized morphologically by a dilated left ventricle, prominent trabeculations and deep intertrabecular recesses in the ventricular myocardium, with no other structural heart disease. It is thought to be secondary to an arrest of normal myocardial compaction during fetal life. Clinically, the disease presents with heart failure, embolic events, arrhythmias or sudden death. Current diagnostic criteria are based on clinical and imaging data and two-dimensional and color Doppler echocardiography is the first-line exam. There is no specific therapy and treatment is aimed at associated comorbidities. Cases refractory to medical therapy may require heart transplantation. The authors describe a case of severe and refractory heart failure, which was the initial presentation of isolated left ventricular noncompaction in a previously healthy male child, who underwent successful heart transplantation.

A Travelling Projectile from the Head to the Right Ventricle. Surgical Management.

The migration of a bullet fired from a weapon from the jugular vein to the heart is a very rare condition in clinical practice and the management of such condition is not always straightforward. The authors report the case of a 49-year old female patient shot in the right temporal region with subsequent migration of the pellet through the venous system to the right ventricle. Surgical removal of the pellet was successfully accomplished using extracorporeal circulation and cardiac arrest.

Heart transplantation. A Portuguese hospital center's experience.

Cardiac transplantation is the gold standard therapy for patients below 60 years presenting with severe heart failure (HF) despite maximal medical therapy, who have no other surgical option and no contraindications to this procedure. We evaluated our experience with this important form of heart failure therapy. Between February 1987 and December 2002, 32 patients, aged 37 +/- 16 years, 19 males, with ejection fraction of 18 +/- 7%, underwent heart transplantation in our center. Seven (22%) patients were in NYHA class IV with hemodynamic support. Seventeen (53%) patients had idiopathic dilated cardiomyopathy (DCM), 7 (22%) had ischemic DCM, 3 (9%) had valvular DCM and the remainder had other causes of left ventricular dysfunction. Overall survival rate was 68% at first year post-transplantation, 59% at 5 years and 59% at 10 years. One year after cardiac transplantation, 95% of patients were in NYHA class I and the rest were in NYHA class II. Among the 13 patients who died, in five (18%) death occurred during the first month: the most frequent cause was hemodynamic failure. Causes of late death were: allograft vasculopathy (n = 3), allograft rejection (n = 1), infection (n = 1), sudden death (n = 1), hemodynamic failure (n = 1) and bradyarrhythmia (n = 1). Among the patients followed for more than one year, only three died. Early complications were: infection (8 episodes, 7 of respiratory location), right heart failure (3 patients), pericardial effusion (5 patients) and others (7 patients). Late complications were: a) allograft rejection: 17 (53%) patients, 72 episodes (10 ISHLT grade 3, 6 of whom were treated with intravenous corticotherapy, 8 grade 2 and 54 grade 1); b) infections: 19 (59%) patients; 35 episodes, 25 requiring hospitalization: 10 (28%) involving the respiratory tract, 6 (17%) the oropharynx, 5 (14%) the urinary tract, 4 (11%) the skin and 10 (28%) of undetermined location; c) chronic allograft rejection: 6 (19%) patients; d) arterial hypertension: 14 (45%) patients; d) renal failure: 5 (16%) patients; e) diabetes: 2 (6%) patients; f) cancer: 2 (6%) patients. Patients with severe heart failure and a very poor prognosis who underwent cardiac transplantation in our hospital showed marked improvement in functional capacity and quality of life and had an overall survival similar to the results of international heart transplantation registries. Complications during follow-up were similar to those usually described in the literature.