In part because the patients reported by Domart et al were referred from other institutions, some important questions cannot be answered by this study. We do not know the denominator from which these patients were derived and hence, cannot calculate the overall infection rate. We cannot ask about the corre­lation between the presence of CMV infection and the incidence of mediastinitis.

Another difficulty in the methodology might have skewed the results by failure to detect some (VE +) patients. The first positive culture in the VE + patients occurred at 37 ±22 days (range 9-98 days), whereas the last negative culture in the VE — patients occurred at 39 ± 25 days. Thus, many of the VE — patients might have demonstrated positive cultures had each patient s cultures been obtained over a period extending to at least the last day (98 days) of positive culture in the VE+ patients.

Despite these shortcomings, the implications of this article are ominous. Cardiac surgical patients may, in fact, fall into an immunocompromised group. Circum­stantial evidence that this may be so is the extraordi­narily high rate of mediastinitis (21 to 44 percent) in patients receiving no prophylactic antibiotics or in whom inadequate serum levels were present during the heart operation. CMV probably further immu­nocompromises these patients. The amount of exoge­nous blood transfused correlates with the incidence of increased antibody titers to the virus Since we have no means of directly treating CMV infection, this study suggests that the morbidity of blood transfusion may be even higher than was thought, and reempha- sizes the importance of its reduction through the use of blood salvage techniques, and auto-donation. Since the transmission/reactivation of CMV through blood transfusion can be prevented by using deglycerolyzed red cells or blood from CMV antibody negative donors, an argument could be made for employing these two methods when transfusions become neces­sary for the cardiac surgical patient.
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Perhaps this study from Hopital Bichat will encour­age a prospective study of cardiac surgical patients that will examine the incidence of CMV antibody rise after operation, the incidence of viral shedding over a long period after operation, and will correlate these with the incidence of mediastinitis, its severity, and the incidence of perioperative blood transfusion.