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Biomedical subjects

Raymond Cartier

Publications and source records attributed to Raymond Cartier.

At least 37 records · Page 2Linked to original sources
PubMed2004

Increased early postoperative morbidity with off-pump coronary artery bypass grafting surgery in patients with diabetes.

BACKGROUND: Patients with diabetes constitute a high-risk population for myocardial revascularization due to extensive coronary disease. OBJECTIVE: To compare the early postoperative outcomes of patients with diabetes undergoing off-pump or on-pump coronary artery bypass surgery. METHODS AND RESULTS: Over a four-year period (1995 to 1998), 885 diabetics were operated for primary isolated coronary bypass; 156 patients had off-pump and 729 had on-pump coronary artery bypass surgery. Patients in the off-pump group were significantly older, had a higher incidence of hypertension and renal failure, and received fewer distal anastomoses (2.7 versus 2.9, P=0.004). Postoperative myocardial infarction, reintubation and postoperative use of intra-aortic balloon pump occurred significantly more frequently in the off-pump group (10.3% versus 5.5%, P=0.04; 8.3% versus 3.6%, P=0.03; 7.7% versus 1.5%, P=0.0001, respectively). Multivariate analysis revealed that type of surgery was an independent predictor of these complications, which occurred 1.9, 2.7 and 7.9 times more often, respectively, in the off-pump group. The 30-day mortality rate was not significantly different between the groups. CONCLUSIONS: Off-pump coronary artery bypass surgery is associated with an increased early postoperative morbidity in patients with diabetes and, thus, should be used with caution.

Aged↗
PubMed2003

Effects of acute rejection on L-arginine/iNOS pathway in canine heart transplantation.

BACKGROUND: The inflammatory process resulting from ischemia-reperfusion and acute rejection is a strong modulator of the endothelial nitric oxide synthase expression of both constitutive and inducible isoforms. OBJECTIVE: To assess the expression of the endothelial constitutive nitric oxide synthase (ecNOS) and inducible nitric oxide synthase (iNOS) activity in conductance coronary arteries after reperfusion and acute rejection in the canine heart transplantation setting. METHODS: Expression of ecNOS and iNOS was evaluated in two groups of mongrel dogs (n=7) that underwent heterotopic heart transplantation without immunosuppression. The first group was studied after 24 h of reperfusion and the second after five days of acute untreated rejection. A third group (n=7) consisting of normal unoperated dogs was used as control. Functional vascular status of iNOS isoforms was studied in organ chambers, and tissue enzyme expression by histological and immunohistochemical studies. RESULTS: At harvest, vonWillebrand factor was present on the coronary endothelium of all groups. Both transplanted groups displayed iNOS and ecNOS expression by immunohistochemical study. The control group only displayed ecNOS expression. L-arginine induced endothelium-dependent relaxations in group 1 and group 2 but not in the control group. This was inhibited by the iNOS inhibitor aminoguanidine. Endothelium-independent contractility and relaxation were unaffected. CONCLUSIONS: In this experimental setting, a specific endothelial expression of iNOS was observed early on after acute rejection. The functional aspect of this endothelial iNOS expression was reversible with aminoguanidine.

Animals↗
PubMed2003

Partial inferior vena cava snaring to control ischemic left ventricular dysfunction.

PURPOSE: To describe the hemodynamic and intraoperative transesophageal echocardiographic evaluation of cardiac systolic and diastolic function in a patient undergoing off-pump coronary artery bypass graft (OP-CABG) surgery who developed pulmonary artery hypertension controlled by inferior vena cava (IVC) snaring. CLINICAL FEATURES: A 63-yr-old man was referred to our hospital for elective OP-CABG surgery. His preoperative ventriculopathy revealed a decreased systolic function (ejection fraction of 35%), and a mild mitral regurgitation. Intraoperatively, after application of the stabilizer and clamping of the diagonal artery, he developed a marked increase in pulmonary artery pressure (PAP) with a decrease in systemic arterial pressure, non responsive to iv norepinephrine and nitroglycerin. Transesophageal echocardiographic evaluation revealed a marked decrease in systolic function and presence of a restrictive diastolic filling pattern. Partial IVC snaring decreased the venous return and PAP decreased cardiac chamber dimensions, improved systolic function and improved diastolic filling pattern. CONCLUSION: Partial IVC snaring was used successfully to treat a hemodynamically unstable patient with sudden increase in PAP caused by ischemic left ventricular failure during OP-CABG.

Coronary Artery Bypass↗
PubMed2003

Tricuspid valve replacement: an analysis of 25 years of experience at a single center.

BACKGROUND: Tricuspid valve replacement is seldom used in clinical practice, but the choice between mechanical and biologic prostheses remains controversial. METHODS: Between 1977 and 2002, 97 patients underwent tricuspid valve replacement and were followed at the Montreal Heart Institute Valve Clinic. Patients underwent replacement with bioprostheses (n = 82) and mechanical valves (n = 15). RESULTS: Patients with bioprosthetic tricuspid replacements averaged 53 +/- 13 years of age compared with 48 +/- 11 years in those with tricuspid mechanical valve replacements (p = 0.2). Isolated tricuspid valve replacement was performed in 11 patients (73%) in the mechanical valve group compared with 31 patients (38%. p = 0.01) in the bioprosthetic replacement group. In patients undergoing bioprosthetic tricuspid replacement, 51 (62%) underwent multiple associated valve replacements. The 5-year survival after tricuspid replacement averaged 60% +/- 13% in the mechanical valve group and 56% +/- 6% in the biologic replacement group (p = 0.8). The 5-year freedom rate from tricuspid valve reoperation averaged 91% +/- 9% in patients with mechanical valves and 97% +/- 3% in those with biologic valves (p = 0.2). CONCLUSIONS; Patient survival after tricuspid valve replacement is suboptimal but related to the clinical condition at operation. The use of biologic prostheses for tricuspid valve replacement remains a good option in young patients because of limited life expectancy unrelated to the type of tricuspid prostheses at long-term follow-up.

Bioprosthesis↗
PubMed2003

Cloth tears in asymptomatic survivors of aortic valve replacement with Starr-Edwards prostheses: detection by transesophageal echocardiography.

Cloth-covered Starr-Edwards valves were withdrawn in the 1970s because of complications of cloth tear. Nevertheless, many patients are still alive with their prosthesis in place. We evaluated the ability of transesophageal echocardiography (TEE) to detect cloth tear in 9 asymptomatic patients operated on with a cloth-covered Starr-Edwards aortic valve at our institution. An echogenic mobile structure attached to the prosthesis, suggestive of a tear, was detected in 5 patients (55%). A tear was diagnosed in a sixth patient when TEE was repeated during follow-up because of neurologic symptoms. In all cases, transthoracic echocardiography failed to detect any abnormality. Two patients had symptoms develop and underwent reoperation; cloth tear was more extensive than suspected by TEE. Cloth tear is a frequent finding that can be detected by TEE in asymptomatic patients with cloth-covered Starr-Edwards aortic prosthesis. TEE is recommended in these patients and reoperation should be considered as soon as symptoms appear.

Aged↗
PubMed2003

Heparin versus danaparoid in off-pump coronary bypass grafting: results of a prospective randomized clinical trial.

OBJECTIVE: The incidence of heparin-induced thrombocytopenia is increasing, and the thrombin inhibitor danaparoid could be a useful alternative. The objective of the present study was to compare danaparoid and heparin in patients undergoing off-pump coronary artery bypass grafting. METHODS: In a prospective, randomized, double-blind clinical trial comparing heparin (bolus of 1 mg/kg) with danaparoid (bolus of 40 U/kg), 71 patients underwent off-pump coronary artery bypass grafting with one of the study drugs. The amount of blood lost, the number of homologous blood products transfused, the troponin T levels, and the amount of anti-Xa activity were monitored. RESULTS: Thirty-four patients underwent 2.6 +/- 0.7 bypasses with danaparoid, and 37 patients underwent 2.5 +/- 0.9 grafts with heparin (P =.8). Postoperative blood losses averaged 1394 +/- 1033 mL in patients receiving danaparoid and 1130 +/- 868 mL in patients receiving heparin (P =.2). The number of homologous blood products transfused averaged 3.6 +/- 7 units in patients receiving danaparoid and 1.9 +/- 4.4 units in patients receiving heparin (P =.2). The number of patients requiring homologous blood transfusion was higher in patients receiving danaparoid (18/34 [53%]) than in patients receiving heparin (10/37 [27%], P =.03). Serum anti-Xa activity averaged 1.6 +/- 0.6 U/mL in patients receiving danaparoid and 1.9 +/- 0.8 U/mL in patients receiving heparin 30 minutes after injection of the drugs (P =.1) and 0.3 +/- 0.1 and 0.04 +/- 0.08 U/mL, respectively, 12 hours after coronary artery bypass grafting (P =.001). Troponin serum levels were similar 48 hours after coronary artery bypass grafting (0.5 +/- 0.6 and 0.4 +/- 0.6 microg/L, respectively). CONCLUSION: Although off-pump coronary artery bypass grafting with danaparoid versus heparin increases the number of patients exposed to homologous blood transfusion (relative risk, 2; 95% confidence limits, 1-4), off-pump coronary artery bypass grafting with danaparoid is a valuable alternative to heparin in patients with thrombocytopenia requiring surgical intervention.

Aged↗
PubMed2003

Improving neurologic outcome in off-pump surgery: the "no touch" technique.

BACKGROUND: As patients referred for cardiac surgery include increasingly older individuals, the prevalence of comorbid factors, such as previous cerebrovascular disease, carotid disease, aortic atherosclerosis, and reoperations, is on the rise. Avoiding manipulation of the ascending aorta in this high-risk subgroup may become a necessity to perform safe coronary artery bypass grafting (CABG) surgery. METHODS: We retrospectively reviewed our database of 640 off-pump CABG patients and identified 84 patients in whom we adopted the "no touch" technique (NTT). Revascularization was carried out with single or bilateral internal thoracic arteries (ITA) and by connecting additional coronary grafts (saphenous vein, radial artery) in a T or Y configuration. The right gastroepiploic artery was used as a conduit in 2 patients. The brachiocephalic artery was used as an alternative inflow site in 3 patients (reoperation). RESULTS: Age, sex, risk factors, functional class, and history of congestive heart failure were comparable in the two groups. In the NTT group, the frequencies were higher for severe atherosclerosis of the aorta (13% versus 0%; P =.00), carotid disease (25% versus 16%; P =.02), and history of previous cerebrovascular accidents (17% versus 8%; P =.04). Complete revascularization was achieved in 96% of the patients in the off-pump CABG group, compared with 90% in the NTT group (P =.17). No differences in the prevalence of postoperative low cardiac output syndrome, intra-aortic balloon pump use, perioperative myocardial infarction, or operative mortality at 30 days were observed between the two groups. In the NTT group, weak trends toward a lower incidence of postoperative delirium (8% versus 15%; P =.12), a lower incidence of stroke (0% versus 1%; P =.85), and a shorter intensive care unit stay (P =.07) were observed. Hospital stay was also shorter in the NTT group (P =.04). CONCLUSION: Avoiding aortic manipulations in patients with severe atherosclerosis of the aorta, carotid disease, and a previous history of cerebrovascular accidents is technically feasible and is associated with a low risk of mortality and good shortterm results. Adopting this practice may reduce the incidence of stroke and improve early outcome in this subset of patients.

Cardiac Output, Low↗
PubMed2003

Randomized trial comparing off-pump to on-pump coronary artery bypass grafting in high-risk patients.

OBJECTIVE: The subset of patients most likely to benefit from off-pump coronary artery bypass grafting (CABG) remains a controversial issue, but the technique has been proposed to decrease postoperative mortality and morbidity. Th e objective of this study was to compare off-pump to onpump CABG in patients with known risk factors for mortality and morbidity. METHODS: Between October 2001 and September 2002, 65 high-risk patients were prospectively randomized to undergo off-pump or o n-pump CABG. Recruited patients had at least 3 of the following criteria: age greater than 65 years, high blood pressure, diabetes, serum creatinine greater than 133 mol/L, left ventricular ejection fraction lower than 45%, chronic pulmonary diseas e, unstable angina, congestive heart failure, repeat CABG, anemia, and carotid atherosclerosis. Hospital mortality and morbidity were the primary end-points of the study. RESULTS: Six patients (9%) crossed over from the original randomized group. Twenty-eight patients averaging 70 +/- 8 years of age underwent 3 +/- 1 grafts off pump, and 37 patients averaging 70 +/- 6 years of age underwent 3.4 +/- 1 grafts on pump. Revascularization was considered complete in 21 (7 5 %) of off-pump patients compared to 33 (89%) of onpump patients (P =.1). There were no hospital deaths in off-pump patients, and 2 patients (5%) undergoing onpump CABG died early following surgery (P =.2). Two offpump (7%) compared to 11 on-pump (30%) of patients presented composite end-points including death, neurological injury, renal failure, respiratory failure, and operative myocardial infarction after CABG (P =.02). CONCLUSION: The present study suggests that off-pump CABG, when technically feasible, significantly reduces morbidity following surgery in a group of high-risk patients.

Aged↗
PubMed2002

Reduced mortality and strokes with off-pump coronary artery bypass grafting surgery in octogenarians.

BACKGROUND: Off-pump coronary artery bypass surgery (OPCAB) has been revived and has gained popularity, although the exact subsets of patients who might benefit most from this technique are unknown. The aim of this retrospective study was to compare the results of coronary artery bypass grafting surgery (CABG) in octogenarians using cardiopulmonary bypass (CPB) or OPCAB techniques. METHODS AND RESULTS: Over a 5-year period (1995-1999), 125 patients older than 80 years of age were operated for isolated myocardial revascularization (63 using CPB and 62 with OPCAB). There was no statistically significant difference in preoperative comorbidities between groups or in mean left ventricular ejection fraction (54.5+/-15.3% in the CPB group and 50.9+/-13.5% in the OPCAB group, respectively). The mean number of distal anastomosis per patient was 2.9 in CPB group and 2.6 in OPCAB group (P=ns). The majority of patients in both groups had unstable angina and were operated on an urgent basis. The operative mortality was 15.9% in the CPB group and 4.8% in the OPCAB group (P=0.04). There were 4 postoperative strokes (6.3%) in the CPB group and none (0%) in the OPCAB group (P=0.04). The percentage of patients transfused was 92.1% in the CPB group and 72.6% in the OPCAB group (P<0.01). Postoperative myocardial infarction occurred in 11.3% in the CPB group and 14.5% in the OPCAB group (P=NS). For all the parameters entered in the multivariate analysis with logistic regression model, the type of surgery (CPB or OPCAB) was an independent predictor of operative mortality and stroke (P=0.0375). The odds ratio (OR) indicates that operative mortality and stroke occur 4 times (OR=4.171) more often in CPB patients than in OPCAB patients. Follow-up showed no significant difference between the 2 groups in terms of cardiac events and mortality. CONCLUSIONS: This retrospective study suggests a benefit of OPCAB in terms of operative mortality and stroke for octogenarian patients when compared with CPB in our institution.

Aged↗
PubMed2002

Mechanisms of hemodynamic changes during off-pump coronary artery bypass surgery.

PURPOSE: To describe the mechanisms of hemodynamic changes during off-pump coronary artery bypass graft surgery (OP-CABG). SOURCE: Pertinent medical literature in the English and French languages was identified through a Medline computerized literature search and a manual search of selected articles, using off-pump coronary artery surgery, beating heart surgery, hemodynamic, and transesophageal echocardiography as key words. Human and animal studies were included. PRINCIPAL FINDING: Hemodynamic variations in OP-CABG may be due to mobilization and stabilization of the heart, or myocardial ischemia occurring during coronary occlusion. Suction type and compression type stabilizers produce hemodynamic effects through different mechanisms. Heart dislocation (90 degrees anterior displacement) and compression of the right ventricle to a greater extent than the left ventricle are responsible for hemodynamic alterations when using suction type stabilizers. Compression of the left ventricular outflow tract and abnormal diastolic expansion secondary to direct deformation of the left ventricular geometry are proposed mechanisms for hemodynamic derangements with compression type stabilizer. Coronary occlusion during the anastomosis can have additional effects on left ventricular function, depending on the status of collateral flow. The value and limitations of electrocardiographic (ECG), hemodynamic and echocardiographic monitoring modalities during OP-CABG are reviewed. CONCLUSIONS: In summary, hemodynamic changes which can either be secondary to the stabilization technique or to transient ischemia represent an important diagnostic challenge during off-bypass procedures. The mechanism can vary according to the stabilization system. Current monitoring such as ECG and hemodynamic monitoring are used but remain limited in establishing the cause of hemodynamic instability. Transesophageal echocardiography is used in selected patients to diagnose the etiology of hemodynamic instability and can direct therapy, particularly in those with severe myocardial systolic and diastolic dysfunction, mild to moderate mitral regurgitation, or for patients who are unstable during the procedure.

Animals↗
PubMed2002

Long-term results with triple valve surgery.

BACKGROUND: Whether to use biological or mechanical prostheses and whether to repair or replace the tricuspid valve during primary and reoperative triple valve surgery remains controversial. The objective of the present study was to review our experience with primary and reoperative triple valve surgery using CarboMedics (CM) and Carpentier-Edwards (C-E) heart valves. METHODS: All 73 patients undergoing triple valve surgery since 1982 were prospectively followed at the Montreal Heart Institute valve clinic. Aortic valve replacement was performed with CM prostheses (57 patients) and with C-E prostheses (16 patients). Mitral valve replacement was performed with mechanical prostheses (56 patients) and with biological valves (14 patients). Mitral valve repair was done in 3 patients. Tricuspid valve annuloplasty or commissurotomy or both were performed in 66 patients and the tricuspid valve was replaced in 7 patients. Patient survival, complications, and the type of valve procedures were analyzed. RESULTS: Thirty patients averaging 62+/-10 years of age underwent primary triple valve surgery and 43 patients averaging 60+/-10 years of age underwent reoperative triple valve surgery (p = 0.5). Tricuspid repair consisted of annuloplasty with the Bex linear reducer (n = 47), the C-E ring (n = 13), or the De Vega technique (n = 5). Tricuspid valve replacement was done using the C-E pericardial prostheses. The 30-day mortality was 17% and 12% in patients with primary and reoperative surgery, respectively (p = 0.5) and patient survival averaged 80%+/-7%, 75%+/-8%, and 41%+/-15%, and 70%+/-7%, 57%+/-9%, and 50%+/-10%, respectively 1, 5, and 10 years following surgery (p = 0.5). The freedom rate from thromboembolism and from bleeding complications were 87%+/-6% and 95%+/-3% in primary and reoperative patients, respectively, 5 years following surgery. CONCLUSIONS: Triple valve surgery, either as a primary or a reoperative procedure, results in acceptable long-term survival with both mechanical and biological prostheses.

Aged↗
PubMed2002

Changing pattern in beating heart operations: use of skeletonized internal thoracic artery.

BACKGROUND: The use of skeletonized internal thoracic artery (ITA) was reported to be technically and hemodynamically beneficial in conventional coronary artery bypass grafting with cardiopulmonary bypass assistance. The purpose of this study is to evaluate the impact of changing from conventional to skeletonized ITA harvesting on early off-pump coronary artery bypass grafting outcome. METHODS: Between 1996 and 2001, 640 patients underwent systematic off-pump coronary artery bypass grafting (single surgeon experience). The ITA was pedicled (P) in the first consecutive 440 patients and skeletonized (S) in the subsequent 200 consecutive patients. Mean age, preoperative risk factors, sex, number of involved territories, and incidence of reoperations were similar in both groups. RESULTS: In group S, number of ITAs per patient (1.7 +/- 0.08 versus 1.2 +/- 0.05; p < 0.001), bilateral ITA (46% versus 27%; p < 0.001), ITA sequential grafts (27% versus 1%; p < 0.001), and T grafts (16% versus 3%; p < 0.001) were higher. Deep sternal infections were comparable in both groups (group S: 1%, group P: 1.2%; p = 0.38). Perioperative myocardial infarction, maximal creatinine kinase-MB level, and requirement for more than 24 hours of inotropic support were comparable in both groups. Thirty-day mortality was also similar (S: 1.7%, P: 1.6%). CONCLUSIONS: Changing to routine use of skeletonized ITA in off-pump coronary artery bypass grafting is a safe alternative to routine pedicled ITA. In our experience, this procedure has facilitated the use of ITA anastomosis without increasing sternal wound complications.

Aged↗
PubMed2002

Hemodynamic changes during off-pump CABG surgery.

OBJECTIVES: The purpose of this study was to assess the patients' hemodynamics during off-pump coronary artery bypass graft (OPCABG) surgery. METHODS: Continuous monitoring of the mean systemic arterial pressure (SAP), mean pulmonary arterial pressure (PAP), mixed venous oxygen saturation (SvO(2)) and cardiac output index (COI) was done on 55 patients undergoing complete OPCAB revascularization. Hemodynamic changes were recorded at the completion of the anastomosis before releasing coronary snaring and stabilization and compared to baseline. RESULTS: The mean age of the patients was 66.4+/-9.2 years, and on average 3.3+/-0.8 grafts per patient were performed. The average SAP drop after manipulations was -8.3+/-16.9 mmHg for the left anterior descending artery (LAD), -13.5+/-19.6 mmHg for the diagonal artery (DG), -14.6+/-13 mmHg for the optuse marginal artery (OM), and -14.2+/-13.5 mmHg for the right coronary artery. This was significant for all territories (P<0.01). The PAP significantly increased in all territories except OM (LAD: 3.7+/-6.3 mmHg, DG: 4.3+/-8.6 mmHg, OM: 1.1+/-7.2 mmHg, posterior descending artery: 2.7+/-5.6 mmHg; P<0.05). Variations in COI were significant in all territories (P<0.01) but more significantly in LAD and DG territories (-15+/-3% and -13+/-9%, respectively). The SvO(2) variations were <10% for all territories and reached only borderline significance (P=0.05) in all territories except OM. All these hemodynamic changes were well tolerated by all patients. CONCLUSIONS: Manipulation of the beating heart during OPCABG surgery brings significant fluctuations in the patients' hemodynamics. Mean PAP increase and COI drop were more significant during manipulation of the anterior territories suggesting a more severe diastolic restrictive disease during anterior wall manipulation.

Aged↗
PubMed2002

Methicillin-resistant Staphylococcus aureus infection in a cardiac surgical unit.

BACKGROUND: Increased antibiotic resistance of common bacteria is attributed in part to the widespread use of various antibiotic agents. Prophylactic and therapeutic antibiotic treatments are routinely used in cardiac surgical units, and it is no surprise that methicillin-resistant Staphylococcus aureus infection is becoming a major cause of surgical infections in cardiac patients. METHODS: We reviewed our experience with patients who underwent cardiac surgery and experienced infection caused by methicillin-resistant Staphylococcus aureus. Between 1992 and 2000 at the Montreal Heart Institute, 39 patients had methicillin-resistant Staphylococcus aureus surgical infections, and 13,199 patients underwent cardiac surgery. The yearly incidence of methicillin-resistant Staphylococcus aureus infection, the relative risk of acute mediastinitis and of superficial wound infections or other types of methicillin-resistant Staphylococcus aureus infection episodes, and the effect of preventive measures were analyzed. RESULTS: The annual incidence of methicillin-resistant Staphylococcus aureus acute mediastinitis decreased from 0.37% (5/1321) of cardiac patients in 1992 and 0.44% (6/1355) in 1993 to 0% between 1994 and 1997, 0.13% (2/1528) in 1999, and 0% (0/1700) in 2000. The total incidence of methicillin-resistant Staphylococcus aureus infection, including mediastinitis, superficial and deep sternal and leg wound infection, and all systemic infection episodes ranged from 0.68% of patients in 1992 and 0.96% of patients in 1993 to 0.46% of patients in 1999 and 0.53% of patients in 2000. The relative risk of severe mediastinal methicillin-resistant Staphylococcus aureus infection to all other methicillin-resistant Staphylococcus aureus infection episodes decreased from 1.65 in 1992 to 0.41 in 1999 and 0 in 2000. Beginning in 1993, all patients given a diagnosis methicillin-resistant Staphylococcus aureus infection and all nasal carriers of methicillin-resistant Staphylococcus aureus were strictly isolated on the surgical unit, and vancomycin was used as the prophylactic antibiotic agent for cardiac surgery in these patients. Moreover, since 1998, all patients admitted in the hospital were screened, and nasal carriers were isolated and treated with topical antibiotic ointment. CONCLUSION: Mediastinal and other infections caused by methicillin-resistant Staphylococcus aureus have a significant morbidity in cardiac surgical patients. After an outbreak of methicillin-resistant Staphylococcus aureus mediastinal infections, several preventive measures to control methicillin-resistant Staphylococcus aureus contamination of surgical patients were implemented (nasal screening, preventive isolation, application of mupirocin, prophylaxis with vancomycin and alcohol gels) and were effective in decreasing the incidence of methicillin-resistant Staphylococcus aureus infection and mediastinitis after cardiac surgery.

Acute Disease↗