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Observational Study
. 2024 Oct;168(4):1144-1154.e3.
doi: 10.1016/j.jtcvs.2023.09.056. Epub 2023 Oct 4.

The association of intraoperative and early postoperative events with risk of pneumonia following cardiac surgery

Noah M Barnett  1 , Daniel R Liesman  2 , Raymond J Strobel  3 , Xiaoting Wu  4 , Gaetano Paone  5 , Alphonse DeLucia 3rd  6 , Min Zhang  7 , Carol Ling  4 , Francis D Pagani  4 , Donald S Likosky  8 ; Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative
Affiliations
Observational Study

The association of intraoperative and early postoperative events with risk of pneumonia following cardiac surgery

Noah M Barnett et al. J Thorac Cardiovasc Surg. 2024 Oct.

Abstract

Background: Pneumonia, the most common infection following cardiac surgery, is associated with major morbidity and mortality. Although prior work has identified preoperative risk factors for pneumonia, the present study evaluated the role and associated impact of intraoperative and postoperative risk factors on pneumonia after cardiac surgery.

Methods: This observational cohort study evaluated 71,165 patients undergoing coronary and/or aortic valve surgery across 33 institutions between 2011 and 2021. Terciles of estimated pneumonia risk were compared between a validated preoperative model (Model One) and a model additionally accounting for significant intraoperative (eg, bypass duration) and postoperative (eg, extubation time) factors (Model Two). Logistic regression was used to develop and validate Model Two.

Results: Postoperative pneumonia occurred in 2.62% of the patients. A total of 9 significant intraoperative and early postoperative risk factors were identified. The absolute risk of pneumonia increased across Model One terciles: low (≤1.04%), medium (1.04%-2.40%), and high (>2.40%). Model two performed well (c-statistic = 0.771). Most patients (60.1%) had no change in their preoperative versus intraoperative/postoperative risk tercile. The 19.6% of patients who increased their risk tercile with Model Two accounted for 18.6% of all pneumonia events.

Conclusions: This study identified 9 significant perioperative risk factors for pneumonia. Nearly 1 of every 5 patients moved into a higher pneumonia risk category based on their intraoperative and postoperative course. These findings may serve as the focus of future quality improvement efforts to reduce a patient's risk of postoperative pneumonia.

Keywords: coronary artery bypass grafting; outcomes; pneumonia; surgical aortic valve replacement.

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Conflict of interest statement

Conflict of Interest Statement Dr Pagani is an ad hoc, uncompensated scientific advisor for Medtronic, Abbott, FineHeart, and CH Biomedical; an uncompensated medical monitor for Abiomed; and a member of the data safety monitoring board for Carmat and the National Heart, Lung, and Blood Institute PumpKIN Study. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

Figures

Figure 1:
Figure 1:
Correlation between hospital procedural volume and pneumonia rate.
Figure 2:
Figure 2:
Forest plot of the final multivariate analysis of intra- and postoperative factors (“Model Two”) for the development of postoperative pneumonia.
Figure 3:
Figure 3:
Sankey diagram depicting the flow of patients based on their preoperative (Model 1, left side) and intra- and postoperative risk (Model 2, right side). The line thickness is proportional to the cohort size. The choice of color is based on a patient’s pre-operative risk tercile (Model 1).
Figure 4:
Figure 4:
Graphical Abstract
See this image and copyright information in PMC

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