(Circulation. 1995;92:2245-2251.)
© 1995 American Heart Association, Inc.
Articles |
Mediastinitis After Coronary Artery Bypass Graft Surgery
Risk Factors and Long-term Survival
From the Departments of Surgery (Cardiothoracic) (C.A.M., K.K., N.A., R.H.J.) and Medicine (D.J.S.) and the Center for Health Policy Research and Education (N.A.), Duke University Medical Center, Durham, NC.
Correspondence to Robert H. Jones, MD, PO. Box 2986, Duke University Medical Center, Durham, NC 27710.
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Abstract |
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 Top Abstract IntroductionMethods Results Discussion References |
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Background Mediastinitis is a severe complication of coronary artery bypass graft surgery (CABG). The purpose of the present study was to determine preoperative and intraoperative variables that predict mediastinitis and to determine the impact of this complication on long-term survival.
Methods and Results Data on 20 preoperative and intraoperative variables were collected prospectively on 6459 consecutive patients who underwent CABG between January 1987 and January 1994. Eighty-three patients (1.3%) developed mediastinitis postoperatively, and a total of 24 patients (29%) died. Multivariate analysis identified 4 of the 20 variables as highly significant independent predictors for the development of mediastinitis: obesity (P=.0002), New York Heart Association congestive heart failure class (P=.002), previous heart surgery (P=.008), and duration of cardiopulmonary bypass (P=.05). A comprehensive review of the literature identified 13 other studies that evaluated 48 factors as predictors of mediastinitis; these data were critically analyzed and compared with the results from this series. In this series, postoperative interval mortality during the first 90 days after surgery for the patients with mediastinitis was 11.8% compared with 5.5% for the patients without mediastinitis. Interval mortality between 1 and 2 years after surgery remained high for the mediastinitis group (8.1%) relative to the nonmediastinitis group (2.3%). These differences were not eliminated by adjusting for important variables that influenced late survival in this population.
Conclusions The present study and a review of the literature suggest that obesity and duration of surgery are the most important predictors of mediastinitis. Furthermore, although the early increase in mortality has been well described, the present study documents for the first time that mediastinitis has a significant negative influence on long-term survival independent of the patient's preoperative condition.
Key Words: mediastinitis • risk factors • mortality • bypass • surgery
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Introduction |
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TopAbstractIntroductionMethods Results Discussion References |
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Mediastinitis after cardiac surgery continues to represent an important complication associated with tremendous morbidity and cost.1 2 The exact mechanism by which mediastinitis develops is unknown and multifactorial. In the present report, a wide variety of preoperative and operative variables are examined with multivariate analysis to determine independent predictors of mediastinitis. A total of 6459 consecutive patients were analyzed; all data were collected prospectively. In an effort to define consensus risk factors for the development of mediastinitis, a comprehensive review of the literature was performed, and results from this analysis were compared with results from previous reports.1 2 3 4 5 6 7 8 9 10 11 12 13
Modern management of mediastinitis with early, aggressive debridement followed by delayed closure has been reported to reduce early mortality to less than 20%.2 8 The effect of mediastinitis and its current treatments on long-term survival has not been investigated; whether long-term sequelae exist in patients who survive acute therapy is unknown. Therefore, we examined whether the rates of mortality up to 2 years after surgery were different for patients who developed mediastinitis than for patients who did not have this complication. Mortality rates in the two groups were adjusted with the use of a Cox proportional hazards model for a number of variables that influenced late survival; this adjustment helped to identify the influence of mediastinitis on long-term survival.
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Methods |
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TopAbstractIntroductionMethods Results Discussion References |
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The study group consisted of 6459 consecutive patients who underwent both cardiac catheterization and CABG at Duke University Medical Center between January 1987 and January 1994. Patients undergoing CABG with other procedures (valve repair, valve replacement, and so on) were included in the analysis. Twenty preoperative and intraoperative variables were collected prospectively by either the cardiologist, cardiology fellow, cardiac surgeon, or cardiac surgery fellow. Data were recorded at the time of catheterization or at the time of the operative procedure. For most variables, data were missing for fewer than 0.5% of patients. For three variables (renal failure, COPD, and other comorbid conditions), data were collected for only 3 years (1991 through 1993).
Age, ejection fraction, duration of preoperative stay, and duration of CPB were analyzed as continuous variables. Internal mammary artery graft (none, unilateral, or bilateral) and the NYHA CHF class (0-IV) were analyzed as graded variables. The Coronary Artery Disease Index, a previously described grading system for coronary angiograms ranging from 0 (least severe disease) to 100 (most severe disease), was also included in the analysis.14 Hemostasis at the time of closure was graded by the surgeon as either adequate or poor. Operation type was categorized as CABG alone versus CABG with other cardiac procedures. Obesity was defined as a weight-to-height ratio of more than 50% above the ideal ratio (Metropolitan Life tables). DM included both insulin-dependent and non–insulin-dependent types. History of prior cardiac surgical procedure was included as a variable. Preoperative insertion of an intra-aortic balloon pump and cardiogenic shock (defined as a preoperative cardiac index of <2.0 L · min-1 · m-2) were included as parameters of acuity. Peripheral vascular disease was defined as the presence of symptomatic disease (claudication, rest pain, and so on). COPD included patients whose disease limited daily activity. Renal failure was defined as a serum creatinine level of more than 2.0. The variable comorbid condition included the presence of one or more other pulmonary, gastrointestinal, or hepatic diseases or any malignant disease process that interfered with the patient's daily life or was likely to limit life expectancy. In addition, rates of mediastinitis for the five attending surgeons who performed the most cases were compared with the use of Student's t test with Bonferroni's correction.
Patients who developed mediastinitis were retrospectively identified through medical records coding, which required that the attending physician confirm the diagnosis. These records were then checked against the hospital infection control records that had been maintained independently by the Division of Infectious Disease. Charts of both the mediastinitis group and the uncomplicated group were then sampled for review. All patients in the mediastinitis group had purulent deep sternal wound infections requiring extensive debridement and drainage. Superficial wound infections that did not involve the sternum and did not require extensive debridement and drainage were not classified as mediastinitis.
All variables were initially evaluated with univariate
logistic regression analysis as predictors of mediastinitis.
Variables with univariate P<.1 value were
then used in a multivariate analysis.
Variables were considered independent predictors of mediastinitis
if final multivariate P
.05. A model was
generated with the three variables whose final
multivariate P values were most significant;
this model was validated with a standard boot-strapping method.
Survival for both the mediastinitis and nonmediastinitis groups was expressed and compared with the use of a Kaplan-Meier plot. Complete follow-up was obtained on all patients with mediastinitis except for two patients who refused further follow-up at 6 and 18 months, respectively. With a Cox proportional hazards model, Kaplan-Meier plots were then adjusted for seven variables that had been previously demonstrated to be determinants of late survival for patients with coronary artery disease14 : age, ejection fraction, Coronary Artery Disease Index, presence of cerebrovascular or peripheral vascular disease, angina, mitral regurgitation, and acute myocardial infarction. The adjusted Kaplan-Meier plot included only the patients for whom all seven of these variables were recorded. Interval mortality rates were also calculated for both groups by dividing the number of deaths in a given postoperative interval by the number of patients living at the beginning of the interval for whom follow-up through the given period was available.
To further study the contribution of preoperative and operative risk factors in the development of mediastinitis, a comprehensive review of the literature was performed by searching the National Library of Medicine's MEDLINE database with the use of the CD PLUS search engine with the Ovid interface. The years 1966 to October 1994 were searched by exploding and combining the terms "heart surgery," "heart," and "heart disease"; this set was then combined with a second set generated with the terms "sternotomy," "sternum," and "mediastinitis." From this search, 63 articles were identified that were investigations of risk factors for mediastinitis after adult cardiac surgery. These studies were reviewed and excluded if 10 or fewer cases of mediastinitis were reported or if patient enrollment, data analysis, or variables studied were incompletely defined. A total of nine observational and four case-control studies were included in the final review. A total of 33 preoperative and 15 intraoperative variables were analyzed in these 13 studies.
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Results |
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TopAbstractIntroductionMethods Results Discussion References |
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Eighty-three of 6459 patients studied (1.3%) developed postoperative mediastinitis; 73 of the 83 mediastinitis patients (88%) were treated with soft tissue flaps. The average postoperative length of stay was 25 days for the mediastinitis group compared with 10 days for the nonmediastinitis patients. Table 1
describes the
prevalence of the preoperative and intraoperative variables
studied. The majority of patients were male and underwent CABG with a
single internal mammary graft without other procedures.
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Rates of mediastinitis by attending surgeon ranged from 0.49% to 2.31%. These differences were compared with the use of Student's t test with Bonferroni's correction and were not statistically significant (P>.05). Attending surgeon was, therefore, not included in the multivariate analysis.
Seven variables were associated with increased risk of
mediastinitis by univariate analysis
(P<.1). In order of significance, these were obesity, NYHA
CHF class, DM, prior heart surgery, duration of CPB, presence of
comorbid conditions, and poor hemostasis at the time of closure (Table
2). These seven variables were then included in a
multivariate logistic regression analysis. Four
independent predictors of mediastinitis were identified: NYHA CHF class
(P=.002), obesity (P=.0002), prior heart
surgery
(P=.008), and duration of CPB (P=.05). As
prior
heart surgery and duration of CPB were closely linked variables,
two final models were generated with NYHA CHF class, obesity, and
either prior heart surgery (Table 3, top) or duration of
CPB (Table 3, bottom). Higher CHF class related to the
incidence of
mediastinitis in a near-linear manner from class 0 through IV. For
asymptomatic patients, for example, the incidence of
mediastinitis was less than 1%, whereas patients with class IV CHF had
a more than 3% incidence.
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Median duration of follow-up was 1.5 years for the mediastinitis
patients and 3.4 years for the nonmediastinitis patients. During the
period of follow-up, a total of 24 of the mediastinitis patients
died (28.6%). The Figure (A) illustrates the
Kaplan-Meier survival curve for the mediastinitis and nonmediastinitis
patients. The Figure (B) also illustrates adjusted mortality
for both
groups. Interval mortality rate was also determined and remained higher
for the mediastinitis group throughout the 2-year postoperative
follow-up period (Table 4).
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Review of the literature identified nine observational studies and four
case-control studies that analyzed risk factors for the
development of mediastinitis after open heart
surgery.1 2 3 4 5 6 7 8 9 10 11 12 13
A total of 33 preoperative and 15 intraoperative variables were
analyzed in these studies; both univariate and
multivariate analysis results are listed (Table 5). Studies
used either univariate or both
univariate and multivariate
analyses to determine risk factors. Included in Table 5 is the
present study, which represents the largest group of
mediastinitis patients in which both univariate and
multivariate analyses were used to determine
risk factors.
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Discussion |
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TopAbstractIntroductionMethods Results Discussion References |
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The exact mechanism by which mediastinitis develops is unknown and multifactorial. Intraoperative wound contamination has been conclusively demonstrated in a small number of cases15 16 and probably represents an important source of many infections. In addition, a variety of patient characteristics have been associated with an increased incidence of mediastinitis, suggesting that certain factors may predispose patients to the development of this complication.1 2 3 4 5 6 7 8 9 10 11 12 13 These risk factors, however, have varied widely among different studies, resulting in confusion. Many of the studies evaluating different variables were conducted on small numbers of patients with mediastinitis and therefore have limited applicability. Frequently, only univariate analysis was used, and the independent ability of statistically significant risk factors to predict the development of mediastinitis was not evaluated. In addition, some studies with relatively small patient populations used inappropriately large numbers of variables in their multivariate models. Furthermore, postoperative conditions, which are themselves complications, were analyzed as potential predictors of mediastinitis. To help identify true independent predictors of mediastinitis and avoid further confusion, we included a large group of patients and used a multivariate analysis to study preoperative and operative variables as potential predictors of mediastinitis. In addition, a comprehensive review of the literature is presented, and the results of our series are evaluated relative to these previous studies.
The most important independent predictor of mediastinitis in this study
was the presence of obesity, and other studies strongly support this
finding (Table 5
, top). Four other studies using
multivariate analysis evaluated obesity as a
potential risk factor; three concluded that it was an independent
predictor of mediastinitis. Nagachinta et al4
identified obesity as the strongest predictor, with 14% of the obese
patients developing mediastinitis. Loop et al2 identified
obesity as the second most important independent predictor of
mediastinitis, defining obesity as only a 20% increase in
height-adjusted weight. The exact mechanisms by which obese
patients are predisposed to wound infection are not known.
Perioperative antibiotics are generally not adjusted
for the increased volume of distribution in these patients at this
institution, and tissue drug levels may be inadequate. Furthermore,
deep skin folds in obese patients make skin preparation difficult and
probably at times inadequate. The inframammary creases and the lower
extremity vein harvest site can be particularly difficult areas for
preparation and require special attention. Large amounts of adipose
tissue probably also serve as a better substrate for wound infection.
Attention to sterile technique and efforts to reduce the length of the
procedure are probably critical in obese patients in whom the risk of
mediastinitis is increased.
Prior heart surgery and prolonged CPB time were closely linked
variables in our study; both were significant independent
predictors of mediastinitis. Four other studies have evaluated prior
heart surgery: by univariate analysis, three of the
four found it to be predictive. However, only one of these studies
found it to be predictive by multivariate
analysis (Table 5). Repeat median sternotomy generally requires
more extensive dissection because of mediastinal adhesions, and this
may increase the length of the procedure and the risk for
intraoperative wound contamination. Repeat median sternotomy and CPB
time are both markers for the overall duration of the procedure, and
two other large studies2 10 found parameters
that assess duration of the procedure to be important predictors by
multivariate analysis. Based on the results of
the present study and from these two other large studies, duration
of the procedure is probably an important independent predictor of
mediastinitis.
Another independent predictor of mediastinitis in this study was NYHA
CHF class. In the review of the literature, only two other studies
evaluated CHF (Table 5, top), and one small study concluded
that it was
not predictive of mediastinitis. However, in a large cooperative
Veterans Administration study, CHF was one of only two variables
that predicted increased risk of mediastinitis.3
Furthermore, the American Society of Anesthesiology score, which
includes CHF as a component, has also been shown to be an important
predictor of postoperative wound infection.17 Together,
these data suggest that CHF may be an important risk factor for
mediastinitis.
Bleeding at the time of closure was only a significant
univariate predictor for the development of mediastinitis
in this study. However, in the two previous studies,
parameters of bleeding were significant predictors by
multivariate analysis (Table 5, bottom).
Although the degree of bleeding at the conclusion of surgery is
difficult to quantify, these data suggest that bleeding may predispose
a patient to the development of mediastinitis. This effect, however, is
probably less important than the obesity or the duration of the
procedure.
DM in this study was found to be a predictor by univariate
but not multivariate analysis. Loop et
al2 similarly concluded that DM was not a predictor of
mediastinitis by multivariate
analysis.2 However, three of five other studies
that evaluated DM found it to be a predictor of mediastinitis by
multivariate analysis (Table 5, top). In two of
these three studies, obesity was simultaneously evaluated
and found to be a considerably stronger predictor than
DM.4 9 These data suggest that DM predisposes to the
development of mediastinitis but probably is less of a risk factor than
duration of the procedure or obesity.
In the present study, bilateral IMA grafting was not a predictor of
mediastinitis by either univariate or
multivariate analysis. Furthermore, the
combination of bilateral IMA grafting and DM was not predictive of
mediastinitis (Table 2). Only two other
studies2 6 used
multivariate analysis to determine whether
bilateral IMA grafting was a risk factor for mediastinitis. In a very
large series, Loop et al2 demonstrated that in the absence
of other risk factors, bilateral IMA grafting was not a risk factor for
mediastinitis. In a much smaller series, Grossi et al6
concluded that bilateral IMA grafting was a risk factor. Of note is
that techniques for IMA takedown may vary between institutions and may
affect the preservation of collateral blood supply to the
sternum.6 Bilateral IMA grafting probably has a minimal
effect on the development of mediastinitis, and its influence on the
development of mediastinitis may be important when other risk factors
are also present,2 but in general, denying a patient
this procedure because of this association is not warranted.
Other reports associated the incidence of postoperative mediastinitis
with different intraoperative techniques. For example, more
discriminate use of electrocautery was reported to markedly decrease
the incidence of mediastinitis.18 In this study comparing
five different surgeons, each with a slightly different operative
technique, statistically significant differences in the rates of
mediastinitis were not present. In addition, in the review of the
literature, surgeon and surgical experience were not reported as
significant risk factors for mediastinitis (Table 5, bottom).
This
suggests that although differences in technique may affect the
incidence of mediastinitis, this effect is probably overshadowed by
other, more powerful risk factors.
The model generated in the present report allowed the risk of
mediastinitis to be calculated for individual patients. Patients with
NYHA CHF class III or IV, obesity, or prior heart surgery each account
for 
5% of the total CABG population (Table 1). The
model-predicted incidence of mediastinitis for patients with one of
these risk factors is approximately three times greater than that of
patients with no risk factors. Patients with all three of the risk
factors identified by the model had a predicted incidence of
mediastinitis almost 20 times greater than patients with no risk
factors.
Although many studies have reported the in-hospital or early
mortality associated with mediastinitis, the independent effect of
mediastinitis and its treatment on long-term mortality and
morbidity has not been described. This is important because a variety
of treatment strategies are available, and appropriate follow-up
care for survivors has not been determined. For each of the four
postoperative intervals studied in this report, patients with
mediastinitis experienced much higher raw mortality. For example,
interval mortality between 1 and 2 years after surgery was almost four
times greater for the mediastinitis group (8.1% versus 2.3%) (Table
4). After adjustment for common risk factors for late mortality
among
CABG patients, mediastinitis remained a significant independent
predictor of late mortality (Figure, B). This study is the
first to
demonstrate that patients with mediastinitis have significantly
increased late mortality, independent of other factors that affect
mortality in this population. These data confirm the suggestion by Loop
et al2 that mediastinitis has a long-term negative
influence on survival. Despite control of sepsis and acute wound
management, the effects of mediastinitis on cardiac, pulmonary,
and renal functions are probably significant, and this condition is
best viewed as a chronic medical condition. Finally, these data suggest
the need to evaluate treatments for mediastinitis not only acutely but
also with regard to late morbidity and mortality.
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Selected Abbreviations and Acronyms |
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Received March 14, 1995; accepted May 3, 1995.
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References |
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TopAbstractIntroductionMethods Results Discussion References |
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 K.-M. Chiu, T.-Y. Lin, S.-H. Chu, and C.-W. Lu Managing Sternal Osteomyelitis with Antibiotic Bead Implantation Asian Cardiovasc Thorac Ann, April 1, 2006; 14(2): e41 - e42. [Abstract] [Full Text] [PDF]
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K. N. Cowan, L. Teague, S. C. Sue, and J. L. Mahoney Vacuum-Assisted Wound Closure of Deep Sternal Infections in High-Risk Patients After Cardiac Surgery Ann. Thorac. Surg., December 1, 2005; 80(6): 2205 - 2212. [Abstract] [Full Text] [PDF]
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D. J. Kumbhani, N. A. Healey, K. S. Biswas, V. Birjiniuk, M. D. Crittenden, P. R. Treanor, and S. F. Khuri Adverse 30-Day Outcomes After Cardiac Surgery: Predictive Role of Intraoperative Myocardial Acidosis Ann. Thorac. Surg., November 1, 2005; 80(5): 1751 - 1757. [Abstract] [Full Text] [PDF]
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J. Sjogren, J. Nilsson, R. Gustafsson, M. Malmsjo, and R. Ingemansson The Impact of Vacuum-Assisted Closure on Long-Term Survival After Post-Sternotomy Mediastinitis Ann. Thorac. Surg., October 1, 2005; 80(4): 1270 - 1275. [Abstract] [Full Text] [PDF]
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 V. G. Fowler Jr, S. M. O'Brien, L. H. Muhlbaier, G. R. Corey, T. B. Ferguson, and E. D. Peterson Clinical Predictors of Major Infections After Cardiac Surgery Circulation, August 30, 2005; 112(9_suppl): I-358 - I-365. [Abstract] [Full Text] [PDF]
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M. L. Williams, L. H. Muhlbaier, J. N. Schroder, J. A. Hata, E. D. Peterson, P. K. Smith, K. P. Landolfo, R. H. Messier, R. D. Davis, and C. A. Milano Risk-Adjusted Short- and Long-Term Outcomes for On-Pump Versus Off-Pump Coronary Artery Bypass Surgery Circulation, August 30, 2005; 112(9_suppl): I-366 - I-370. [Abstract] [Full Text] [PDF]
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C. S. Abboud, S. B. Wey, and V. T. Baltar Reply Ann. Thorac. Surg., July 1, 2005; 80(1): 384 - 384. [Full Text] [PDF]
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J. Sjogren, R. Gustafsson, J. Nilsson, M. Malmsjo, and R. Ingemansson Clinical Outcome After Poststernotomy Mediastinitis: Vacuum-Assisted Closure Versus Conventional Treatment Ann. Thorac. Surg., June 1, 2005; 79(6): 2049 - 2055. [Abstract] [Full Text] [PDF]
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A. Wackenfors, R. Gustafsson, J. Sjogren, L. Algotsson, R. Ingemansson, and M. Malmsjo Blood Flow Responses in the Peristernal Thoracic Wall During Vacuum-Assisted Closure Therapy Ann. Thorac. Surg., May 1, 2005; 79(5): 1724 - 1730. [Abstract] [Full Text] [PDF]
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S. F. Khuri, N. A. Healey, M. Hossain, V. Birjiniuk, M. D. Crittenden, M. Josa, P. R. Treanor, S. F. Najjar, D. J. Kumbhani, and W. G. Henderson Intraoperative regional myocardial acidosis and reduction in long-term survival after cardiac surgery J. Thorac. Cardiovasc. Surg., February 1, 2005; 129(2): 372 - 381. [Abstract] [Full Text] [PDF]
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 I. K. Toumpoulis, C. E. Anagnostopoulos, J. J. DeRose Jr, and D. G. Swistel The Impact of Deep Sternal Wound Infection on Long-term Survival After Coronary Artery Bypass Grafting Chest, February 1, 2005; 127(2): 464 - 471. [Abstract] [Full Text] [PDF]
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O. Friberg, R. Svedjeholm, B. Soderquist, H. Granfeldt, T. Vikerfors, and J. Kallman Local Gentamicin Reduces Sternal Wound Infections After Cardiac Surgery: A Randomized Controlled Trial Ann. Thorac. Surg., January 1, 2005; 79(1): 153 - 161. [Abstract] [Full Text] [PDF]
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J. Sjogren, R. Gustafsson, A. Wackenfors, M. Malmsjo, L. Algotsson, and R. Ingemansson Effects of vacuum-assisted closure on central hemodynamics in a sternotomy wound model Interactive CardioVascular and Thoracic Surgery, December 1, 2004; 3(4): 666 - 671. [Abstract] [Full Text] [PDF]
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C. S. Abboud, S. B. Wey, and V. T. Baltar Risk factors for mediastinitis after cardiac surgery Ann. Thorac. Surg., February 1, 2004; 77(2): 676 - 683. [Abstract] [Full Text] [PDF]
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G. Orhan, Y. Bicer, S. A. Aka, M. Sargin, S. Simsek, S. Senay, Z. Aykac, and E. E. Eren Coronary artery bypass graft operations can be performed safely in obese patients Eur. J. Cardiothorac. Surg., February 1, 2004; 25(2): 212 - 217. [Abstract] [Full Text] [PDF]
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F. Bhatti and J. Dunning Does liberal use of bone wax increase the risk of mediastinitis? Interactive CardioVascular and Thoracic Surgery, December 1, 2003; 2(4): 410 - 412. [Abstract] [Full Text] [PDF]
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S. Dial, D. Nguyen, and D. Menzies Autotransfusion of Shed Mediastinal Blood: A Risk Factor for Mediastinitis After Cardiac Surgery? Results of a Cluster Investigation Chest, November 1, 2003; 124(5): 1847 - 1851. [Abstract] [Full Text] [PDF]
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P. W. Domkowski, M. L. Smith, D. L. Gonyon Jr, C. Drye, M. K. Wooten, L. S. Levin, and W. G. Wolfe Evaluation of vacuum-assisted closure in the treatment of poststernotomy mediastinitis J. Thorac. Cardiovasc. Surg., August 1, 2003; 126(2): 386 - 390. [Abstract] [Full Text] [PDF]
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J. C.Y. Lu, A. D. Grayson, P. Jha, A. K. Srinivasan, and B. M. Fabri Risk factors for sternal wound infection and mid-term survival following coronary artery bypass surgery Eur. J. Cardiothorac. Surg., June 1, 2003; 23(6): 943 - 949. [Abstract] [Full Text] [PDF]
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Q. Abid, U. U. Nkere, A. Hasan, K. Gould, J. Forty, P. Corris, C. J. Hilton, and J. H. Dark Mediastinitis in heart and lung transplantation: 15 years experience Ann. Thorac. Surg., May 1, 2003; 75(5): 1565 - 1571. [Abstract] [Full Text] [PDF]
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I. Risnes, T. Ueland, P. Aukrust, R. Lundblad, S. T. Baksaas, T. E. Mollnes, and J. L. Svennevig Complement activation and cytokine and chemokines release during mediastinitis Ann. Thorac. Surg., March 1, 2003; 75(3): 981 - 985. [Abstract] [Full Text] [PDF]
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M. Doss, S. Martens, J. P. Wood, J. D. Wolff, C. Baier, and A. Moritz Vacuum-assisted suction drainage versus conventional treatment in the management of poststernotomy osteomyelitis Eur. J. Cardiothorac. Surg., December 1, 2002; 22(6): 934 - 938. [Abstract] [Full Text] [PDF]
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 S. P. Sedlis, D. A. Morrison, J. D. Lorin, R. Esposito, G. Sethi, J. Sacks, W. Henderson, F. Grover, K. B. Ramanathan, D. Weiman, et al. Percutaneous coronary intervention versus coronary bypass graft surgery for diabetic patients with unstable angina and risk factors for adverse outcomes with bypass: outcome of diabetic patients in the AWESOME randomized trial and registry J. Am. Coll. Cardiol., November 6, 2002; 40(9): 1555 - 1566. [Abstract] [Full Text] [PDF]
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M. A. Olsen, P. Lock-Buckley, D. Hopkins, L. B. Polish, T. M. Sundt, and V. J. Fraser The risk factors for deep and superficial chest surgical-site infections after coronary artery bypass graft surgery are different J. Thorac. Cardiovasc. Surg., July 1, 2002; 124(1): 136 - 145. [Abstract] [Full Text] [PDF]
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B. Gardlund, C.Y. Bitkover, and J. Vaage Postoperative mediastinitis in cardiac surgery -- microbiology and pathogenesis Eur. J. Cardiothorac. Surg., May 1, 2002; 21(5): 825 - 830. [Abstract] [Full Text] [PDF]
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A. Combes, J.-L. Trouillet, J. Baudot, M. Mokhtari, J. Chastre, and C. Gibert Is it possible to cure mediastinitis in patients with major postcardiac surgery complications? Ann. Thorac. Surg., November 1, 2001; 72(5): 1592 - 1597. [Abstract] [Full Text] [PDF]
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J. J. Curtis, N. C. Clark, C. A. McKenney, J. T. Walls, R. A. Schmaltz, T. L. Demmy, J. W. Jones, W. R. Wilson Jr, and C. C. Wagner-Mann Tracheostomy: a risk factor for mediastinitis after cardiac operation Ann. Thorac. Surg., September 1, 2001; 72(3): 731 - 734. [Abstract] [Full Text] [PDF]
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A. Borer, J. Gilad, N. Meydan, K. Riesenberg, F. Schlaeffer, M. Alkan, and P. Schlaeffer Impact of active monitoring of infection control practices on deep sternal infection after open-heart surgery Ann. Thorac. Surg., August 1, 2001; 72(2): 515 - 520. [Abstract] [Full Text] [PDF]
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R. Astudillo, J. Vaage, U. Myhre, A. Karevold, and B. Gardlund Fewer reoperations and shorter stay in the cardiac surgical ward when stabilising the sternum with the Ley prosthesis in post-operative mediastinitis Eur. J. Cardiothorac. Surg., July 1, 2001; 20(1): 133 - 139. [Abstract] [Full Text] [PDF]
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M. De Feo, R. Gregorio, A. Della Corte, C. Marra, C. Amarelli, A. Renzulli, R. Utili, and M. Cotrufo Deep sternal wound infection: the role of early debridement surgery Eur. J. Cardiothorac. Surg., June 1, 2001; 19(6): 811 - 816. [Abstract] [Full Text] [PDF]
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M. De Feo, A. Renzulli, G. Ismeno, R. Gregorio, A. Della Corte, R. Utili, and M. Cotrufo Variables predicting adverse outcome in patients with deep sternal wound infection Ann. Thorac. Surg., January 1, 2001; 71(1): 324 - 331. [Abstract] [Full Text] [PDF]
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P. A. Catarino, M. H. Chamberlain, N. C. Wright, E. Black, K. Campbell, D. Robson, and R. G. Pillai High-pressure suction drainage via a polyurethane foam in the management of poststernotomy mediastinitis Ann. Thorac. Surg., December 1, 2000; 70(6): 1891 - 1895. [Abstract] [Full Text] [PDF]
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J. H. Braxton, C. A.S. Marrin, P. D. McGrath, C. S. Ross, J. R. Morton, M. Norotsky, D. C. Charlesworth, S. J. Lahey, R. A. Clough, and G. T. O'Connor Mediastinitis and long-term survival after coronary artery bypass graft surgery Ann. Thorac. Surg., December 1, 2000; 70(6): 2004 - 2007. [Abstract] [Full Text] [PDF]
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H. F. Berg, W. G.B. Brands, T. R. van Geldorp, M. F.Q. Kluytmans-VandenBergh, and J. A.J.W. Kluytmans Comparison between closed drainage techniques for the treatment of postoperative mediastinitis Ann. Thorac. Surg., September 1, 2000; 70(3): 924 - 929. [Abstract] [Full Text] [PDF]
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C. S. Hollenbeak, D. M. Murphy, S. Koenig, R. S. Woodward, W. C. Dunagan, and V. J. Fraser The Clinical and Economic Impact of Deep Chest Surgical Site Infections Following Coronary Artery Bypass Graft Surgery Chest, August 1, 2000; 118(2): 397 - 402. [Abstract] [Full Text] [PDF]
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S. Harbarth, M. H. Samore, D. Lichtenberg, and Y. Carmeli Prolonged Antibiotic Prophylaxis After Cardiovascular Surgery and Its Effect on Surgical Site Infections and Antimicrobial Resistance Circulation, June 27, 2000; 101(25): 2916 - 2921. [Abstract] [Full Text] [PDF]
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H. R. Zurbrugg, T. Freestone, M. Bauer, and R. Hetzer Reinforcing the conventional sternal closure Ann. Thorac. Surg., June 1, 2000; 69(6): 1957 - 1958. [Abstract] [Full Text] [PDF]
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T. Szerafin, O. Jaber, and A. Peterffy Reduction of wound healing problems after median sternotomy Ann. Thorac. Surg., December 1, 1999; 68(6): 2388 - 2388. [Full Text] [PDF]
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K. A. Eagle, R. A. Guyton, R. Davidoff, G. A. Ewy, J. Fonger, T. J. Gardner, J. P. Gott, H. C. Herrmann, R. A. Marlow, W. C. Nugent, et al. ACC/AHA guidelines for coronary artery bypass graft surgery: A report of the American College of Cardiology/ American Heart Association task force on Practice Guidelines (Committee to revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery) J. Am. Coll. Cardiol., October 1, 1999; 34(4): 1262 - 1347. [Full Text] [PDF]
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C. A. Milano, G. Georgiade, L. H. Muhlbaier, P. K. Smith, and W. G. Wolfe Comparison of omental and pectoralis flaps for poststernotomy mediastinitis Ann. Thorac. Surg., February 1, 1999; 67(2): 377 - 380. [Abstract] [Full Text] [PDF]
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R. J.F. Baskett, C. E. MacDougall, and D. B. Ross Is mediastinitis a preventable complication? A 10-year review Ann. Thorac. Surg., February 1, 1999; 67(2): 462 - 465. [Abstract] [Full Text] [PDF]
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A. El Gamel Reply Ann. Thorac. Surg., July 1, 1998; 66(1): 297 - 298. [Full Text] [PDF]
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W. Ozaki, S. R. Buchman, M. D. Iannettoni, and E. P. Frankenburg Biomechanical Study of Sternal Closure Using Rigid Fixation Techniques in Human Cadavers Ann. Thorac. Surg., June 1, 1998; 65(6): 1660 - 1665. [Abstract] [Full Text] [PDF]
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F. S. Eckstein, J. M. Albes, M. J. Jurmann, A. M. Scheule, S. Raygrotzki, M. Laniado, and G. Ziemer Surgical Management of Persistent Mediastinitis After Coronary Bypass Grafting Ann. Thorac. Surg., September 1, 1997; 64(3): 854 - 856. [Abstract] [Full Text]
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J.-L. Trouillet, A. Scheimberg, A. Vuagnat, J.-Y. Fagon, J. Chastre, and C. Gibert LONG-TERM OUTCOME AND QUALITY OF LIFE OF PATIENTS REQUIRING MULTIDISCIPLINARY INTENSIVE CARE UNIT ADMISSION AFTER CARDIAC OPERATIONS J. Thorac. Cardiovasc. Surg., October 1, 1996; 112(4): 926 - 934. [Abstract] [Full Text]
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