Analysis of risk factors for pulmonary infection after heart valve replacement and construction of nomogram prediction model_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

CAI Wenqian ^1,2 ,  WU Dequan ^2,1 , Lü Wenjing ^1,2 , LIU Bo ^1,2 , SUN Yue ^1,2

1. Nursing School of Anhui Medical University, Hefei, 230032, P. R. China;
2. Department of Infection Prevention and Control, The Second Affiliated Hospital of Anhui Medical University, 230601, Hefei, P. R. China;

Corresponding?author：

WU Dequan, Email: wdq2981288742@sina.com

Keywords：

Heart valve replacement; pulmonary infection; risk factors; nomogram; prediction model

DOI：

10.7507/1007-4848.202411031

Video：

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Objective To develop and validate a nomogram prediction model for pulmonary infection in patients following cardiac valve replacement surgery, providing a reference for early screening of high-risk populations and implementing targeted preventive measures. Methods Clinical data of patients who underwent cardiac valve replacement surgery at the Second Affiliated Hospital of Anhui Medical University from January 2020 to October 2023 were collected. Patients were randomly assigned to a modeling group and a validation group in a 7 : 3 ratio. Based on the occurrence of pulmonary infection post-surgery, patients were divided into a pulmonary infection group and a non-pulmonary infection group. Risk factors for pulmonary infection after cardiac valve replacement were analyzed using least absolute shrinkage and selection operator (LASSO) regression and logistic regression to establish a risk prediction model, which was subsequently validated. Model evaluation was conducted using the area under the receiver operating characteristic curve (AUC), calibration curves, and decision curve analysis. Results A total of 689 patients were included, comprising 354 males and 335 females, with a median age of 58.0 (50.0, 68.0) years. The incidence of pulmonary infection was 16.0% (110/689). Independent risk factors for pulmonary infection following cardiac valve replacement included emergency admission, smoking history, chronic obstructive pulmonary disease, duration of cardiopulmonary bypass, duration of tracheal intubation, and postoperative renal injury. The AUC for the modeling group was 0.911 [95%CI (0.877, 0.946) ], with a Hosmer-Lemeshow χ²-value of 6.577 (P=0.583) in the modeling group. The AUC value was 0.891 [95%CI (0.840, 0.941) ], with a Hosmer-Lemeshow χ²-value of 5.486 (P=0.705) in the validation group. The model demonstrated good discrimination, calibration, and net benefit. Conclusion The established nomogram prediction model has significant predictive value and can be applied to risk assessment and individualized treatment for pulmonary infection in patients following cardiac valve replacement surgery.

Citation： CAI Wenqian, WU Dequan, Lü Wenjing, LIU Bo, SUN Yue. Analysis of risk factors for pulmonary infection after heart valve replacement and construction of nomogram prediction model. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2025, 32(9): 1302-1311. doi: 10.7507/1007-4848.202411031 Copy

1.	Roth GA, Mensah GA, Johnson CO, et al. Global burden of cardiovascular diseases and risk factors, 1990-2019: update from the GBD 2019 study. J Am Coll Cardiol, 2020, 76(25): 2982-3021.
2.	Writing Committee Members, Otto CM, Nishimura RA, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2021, 77(4): 450-500.
3.	楊書強, 康娜, 王俊生, 等. 心臟瓣膜置換術后肺部感染的影響因素及其與TNF-α基因多態性的關聯. 中華醫院感染學雜志, 2023, 33(11): 1650-1654.Yang SQ, Kang N, Wang JS, et al. Influencing factors for postoperative pulmonary infection in heart valve replacement patients and their association with TNF-α gene polymonrphisms. Chin J Nosocomiol, 2023, 33(11): 1650-1654.
4.	Passos LSA, Nunes MCP, Aikawa E. Rheumatic heart valve disease pathophysiology and underlying mechanisms. Fronti Cardiovasc Med, 2021, 7: 612716.
5.	Yao X, Li N, Lu R, et al. Development of a nomogram for predicting nosocomial infections among patients after cardiac valve replacement surgery. J Clin Nurs, 2023, 32(7-8): 1466-1475.
6.	Zhou Y, Yu F, Yu Y, et al. Clinical significance of MDRO screening and infection risk factor analysis in the ICU. Am J Transl Res, 2021, 13(4): 3717-3723.
7.	Wang D, Lu Y, Sun M, et al. Pneumonia after cardiovascular surgery: incidence, risk factors and interventions. Front Cardiovasc Med, 2022, 9: 911878.
8.	Papazian L, Klompas M, Luyt CE. Ventilator-associated pneumonia in adults: a narrative review. Intensive Care Med, 2020, 46(5): 888-906.
9.	張靜, 李娟, 朱鑫灜, 等. 心臟外科術后肺部并發癥發生風險的列線圖預測模型構建. 安徽醫學, 2022, 43(9): 1012-1017.Zhang J, Li J, Zhu XY, et al. Construction of a nomogram prediction model for risk of pulmonary complications after cardiac surgery. Anhui Med J, 2022, 43(9): 1012-1017.
10.	高翠平, 孫淑玲, 肖茹, 等. 中老年心臟瓣膜置換術肺部感染危險因素調查. 中國消毒學雜志, 2023, 40(4): 284-286, 290.Gao CP, Sun SL, Xiao R, et al. Study on risk factors of pulmonary infection in middle aged and elderly patients undergoing cardiac valve replacement. Chin J Dis, 2023, 40(4): 284-286, 290.
11.	方萍, 金平, 霍佳佳, 等. 急性腦卒中患者肺部感染風險預測模型的構建及驗證. 護理學雜志, 2023, 38(16): 30-33.Fang P, Jin P, Huo JJ, et al. Construction and verification of a risk prediction model for pulmonary infection in patients with acute stroke. J Nurs Sci, 2023, 40(4): 284-286, 290.
12.	Wang DS, Huang XF, Wang HF, et al. Clinical risk score for postoperative pneumonia following heart valve surgery. Chin Med J, 2021, 134(20): 2447-2456.
13.	費蕾, 高明昕, 吳曙華, 等. 老年冠心病并發心力衰竭患者院內肺部感染影響因素及風險預測模型構建. 中華老年心腦血管病雜志, 2024, 26(11): 1277-1280.Fei L, Gao MX, Wu SH, et al. Influencing factors of pulmonary infection in elderly CHD patients with HF and construction on a risk prediction model for the infection. Chin J Geriatr Heart Brain Vessel Dis, 2024, 26(11): 1277-1280.
14.	Wang D, Huang X, Wang H, et al. Risk factors for postoperative pneumonia after cardiac surgery: a prediction model. J Thorac Dis, 2021, 13(4): 2351-2362.
15.	金茜, 劉永花, 楊艷, 等. 老年急性左心衰并發肺部感染病原菌與危險因素及其預測模型的預測價值. 中華醫院感染學雜志, 2024(3): 346-350.Jin X, Liu YH, Yang Y, et al. Pathogenic bacteria and risk factors for pulmonary infections complicating acute left heart failure in the elderly and the predictive value of their predictive model. Chin J Nosocomiol, 2024(3): 346-350.
16.	Hua L, Kong L, Hu J, et al. Perioperative risk factors for post-operative pneumonia after type A acute aortic dissection surgery. Curr Med Sci, 2022, 43(1): 69-79.
17.	Cursino de Moura JF, Oliveira CB, Coelho Figueira Freire AP, et al. Preoperative respiratory muscle training reduces the risk of pulmonary complications and the length of hospital stay after cardiac surgery: a systematic review. J Physiother, 2024, 70(1): 16-24.
18.	劉興紅, 王慧華, 胡玉婷, 等. 冠狀動脈旁路移植患者術后肺部并發癥預防及管理的證據總結. 護理學雜志, 2023, 38(16): 46-52.Liu XH, Wang HH, Hu YT, et al. Summary of evidence on prevention and management of postoperative pulmonary complications in patients undergoing coronary artery bypass grafting. J Nurs Sci, 2023, 38(16): 46-52.
19.	林希, 黃娜. 慢性阻塞性肺疾病急性加重期繼發肺部真菌感染的列線圖預測模型. 中國呼吸與危重監護雜志, 2024, 23(2): 77-85.Lin X, Huang N. A nomogram for predicting secondary pulmonary fungal infection in patients with acute exacerbations of chronic obstructive pulmonary disease. Chin J Respir Crit Care Med, 2024, 23(2): 77-85.
20.	Mali S, Haghaninejad H. Pulmonary complications following cardiac surgery. Arch Med Sci Atheroscler Dis, 2019, 4: e280-e285.
21.	胡凱利, 楊斯鈺, 吳前勝, 等. 心臟術后患者機械通氣時間延長風險預測模型的構建及驗證. 護理學報, 2022, 29(20): 60-64.Hu KL, Yang SY, Wu QS, et al. Construction of risk prediction model for prolonged mechanical ventilation in patients after cardiac surgery. J Nurs, 2022, 29(20): 60-64.
22.	Liu J, Li X, Xie W, et al. Risk factors and short-term outcomes of postoperative pulmonary complications in elderly patients after cardiopulmonary bypass. Clin Interv Aging, 2024, 19: 31-39.
23.	den Os MM, van den Brom CE, van Leeuwen ALI, et al. Microcirculatory perfusion disturbances following cardiopulmonary bypass: a systematic review. Crit Care, 2020, 24(1): 218.
24.	趙映, 劉蘇, 劉淑芳, 等. 心臟大血管術后肺部感染病原學及危險因素. 中華醫院感染學雜志, 2021, 31(7): 1039-1042.Zhao Y, Liu S, Liu SF, et al. Etiological characteristice and risk factors for postoperative pulmonary infcetion in cardio-macrovascular surgery patients. Chin J Nosocomiol, 2021, 31(7): 1039-1042.
25.	Gao Y, Wang C, Wang Y, et al. Establishment and validation of a nomogram to predict hospital-acquired infection in elderly patients after cardiac surgery. Clin Interv Aging, 2022, 17: 141-150.
26.	Pozuelo-Carrascosa DP, Herráiz-Adillo á, Alvarez-Bueno C, et al. Subglottic secretion drainage for preventing ventilator-associated pneumonia: an overview of systematic reviews and an updated meta-analysis. Eur Respir Rev, 2020, 29(155): 190107.
27.	劉霞, 郭絲雨, 張紫薇. 長期臥床老年病人并發肺炎的危險因素及Nomogram預測模型構建. 護理研究, 2023, 37(16): 2909-2914.Liu X, Guo SY, Zhang ZW. Risk factors and nomogram prediction model construction for complications of pneumonia in long-term bedridden elderly patients. Chin Nurs Res, 2023, 37(16): 2909-2914.
28.	Mertes PM, Kindo M, Amour J, et al. Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump. Anaesth Crit Care Pain Med, 2022, 41(3): 101059.
29.	Küllmar M, Zarbock A, Engelman DT, et al. Prevention of acute kidney injury. Crit Care Clin, 2020, 36(4): 691-704.
30.	羅丹, 陳晶晶, 胡忠, 等. 慢性阻塞性肺疾病急性加重期合并肺部感染患者腎損傷的危險因素及預測模型建立. 中華醫院感染學雜志, 2023, 33(12): 1800-1803.Luo D, Chen JJ, Hu Z, et al. Risk factors of renal injury and construction of prediction model in patients with acute exacerbation of choric obstructive pulmonary disease and pulmonary infection. Chin J Nosocomiol, 2023, 33(12): 1800-1803.

1. Roth GA, Mensah GA, Johnson CO, et al. Global burden of cardiovascular diseases and risk factors, 1990-2019: update from the GBD 2019 study. J Am Coll Cardiol, 2020, 76(25): 2982-3021.
2. Writing Committee Members, Otto CM, Nishimura RA, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2021, 77(4): 450-500.
3. 楊書強, 康娜, 王俊生, 等. 心臟瓣膜置換術后肺部感染的影響因素及其與TNF-α基因多態性的關聯. 中華醫院感染學雜志, 2023, 33(11): 1650-1654.Yang SQ, Kang N, Wang JS, et al. Influencing factors for postoperative pulmonary infection in heart valve replacement patients and their association with TNF-α gene polymonrphisms. Chin J Nosocomiol, 2023, 33(11): 1650-1654.
4. Passos LSA, Nunes MCP, Aikawa E. Rheumatic heart valve disease pathophysiology and underlying mechanisms. Fronti Cardiovasc Med, 2021, 7: 612716.
5. Yao X, Li N, Lu R, et al. Development of a nomogram for predicting nosocomial infections among patients after cardiac valve replacement surgery. J Clin Nurs, 2023, 32(7-8): 1466-1475.
6. Zhou Y, Yu F, Yu Y, et al. Clinical significance of MDRO screening and infection risk factor analysis in the ICU. Am J Transl Res, 2021, 13(4): 3717-3723.
7. Wang D, Lu Y, Sun M, et al. Pneumonia after cardiovascular surgery: incidence, risk factors and interventions. Front Cardiovasc Med, 2022, 9: 911878.
8. Papazian L, Klompas M, Luyt CE. Ventilator-associated pneumonia in adults: a narrative review. Intensive Care Med, 2020, 46(5): 888-906.
9. 張靜, 李娟, 朱鑫灜, 等. 心臟外科術后肺部并發癥發生風險的列線圖預測模型構建. 安徽醫學, 2022, 43(9): 1012-1017.Zhang J, Li J, Zhu XY, et al. Construction of a nomogram prediction model for risk of pulmonary complications after cardiac surgery. Anhui Med J, 2022, 43(9): 1012-1017.
10. 高翠平, 孫淑玲, 肖茹, 等. 中老年心臟瓣膜置換術肺部感染危險因素調查. 中國消毒學雜志, 2023, 40(4): 284-286, 290.Gao CP, Sun SL, Xiao R, et al. Study on risk factors of pulmonary infection in middle aged and elderly patients undergoing cardiac valve replacement. Chin J Dis, 2023, 40(4): 284-286, 290.
11. 方萍, 金平, 霍佳佳, 等. 急性腦卒中患者肺部感染風險預測模型的構建及驗證. 護理學雜志, 2023, 38(16): 30-33.Fang P, Jin P, Huo JJ, et al. Construction and verification of a risk prediction model for pulmonary infection in patients with acute stroke. J Nurs Sci, 2023, 40(4): 284-286, 290.
12. Wang DS, Huang XF, Wang HF, et al. Clinical risk score for postoperative pneumonia following heart valve surgery. Chin Med J, 2021, 134(20): 2447-2456.
13. 費蕾, 高明昕, 吳曙華, 等. 老年冠心病并發心力衰竭患者院內肺部感染影響因素及風險預測模型構建. 中華老年心腦血管病雜志, 2024, 26(11): 1277-1280.Fei L, Gao MX, Wu SH, et al. Influencing factors of pulmonary infection in elderly CHD patients with HF and construction on a risk prediction model for the infection. Chin J Geriatr Heart Brain Vessel Dis, 2024, 26(11): 1277-1280.
14. Wang D, Huang X, Wang H, et al. Risk factors for postoperative pneumonia after cardiac surgery: a prediction model. J Thorac Dis, 2021, 13(4): 2351-2362.
15. 金茜, 劉永花, 楊艷, 等. 老年急性左心衰并發肺部感染病原菌與危險因素及其預測模型的預測價值. 中華醫院感染學雜志, 2024(3): 346-350.Jin X, Liu YH, Yang Y, et al. Pathogenic bacteria and risk factors for pulmonary infections complicating acute left heart failure in the elderly and the predictive value of their predictive model. Chin J Nosocomiol, 2024(3): 346-350.
16. Hua L, Kong L, Hu J, et al. Perioperative risk factors for post-operative pneumonia after type A acute aortic dissection surgery. Curr Med Sci, 2022, 43(1): 69-79.
17. Cursino de Moura JF, Oliveira CB, Coelho Figueira Freire AP, et al. Preoperative respiratory muscle training reduces the risk of pulmonary complications and the length of hospital stay after cardiac surgery: a systematic review. J Physiother, 2024, 70(1): 16-24.
18. 劉興紅, 王慧華, 胡玉婷, 等. 冠狀動脈旁路移植患者術后肺部并發癥預防及管理的證據總結. 護理學雜志, 2023, 38(16): 46-52.Liu XH, Wang HH, Hu YT, et al. Summary of evidence on prevention and management of postoperative pulmonary complications in patients undergoing coronary artery bypass grafting. J Nurs Sci, 2023, 38(16): 46-52.
19. 林希, 黃娜. 慢性阻塞性肺疾病急性加重期繼發肺部真菌感染的列線圖預測模型. 中國呼吸與危重監護雜志, 2024, 23(2): 77-85.Lin X, Huang N. A nomogram for predicting secondary pulmonary fungal infection in patients with acute exacerbations of chronic obstructive pulmonary disease. Chin J Respir Crit Care Med, 2024, 23(2): 77-85.
20. Mali S, Haghaninejad H. Pulmonary complications following cardiac surgery. Arch Med Sci Atheroscler Dis, 2019, 4: e280-e285.
21. 胡凱利, 楊斯鈺, 吳前勝, 等. 心臟術后患者機械通氣時間延長風險預測模型的構建及驗證. 護理學報, 2022, 29(20): 60-64.Hu KL, Yang SY, Wu QS, et al. Construction of risk prediction model for prolonged mechanical ventilation in patients after cardiac surgery. J Nurs, 2022, 29(20): 60-64.
22. Liu J, Li X, Xie W, et al. Risk factors and short-term outcomes of postoperative pulmonary complications in elderly patients after cardiopulmonary bypass. Clin Interv Aging, 2024, 19: 31-39.
23. den Os MM, van den Brom CE, van Leeuwen ALI, et al. Microcirculatory perfusion disturbances following cardiopulmonary bypass: a systematic review. Crit Care, 2020, 24(1): 218.
24. 趙映, 劉蘇, 劉淑芳, 等. 心臟大血管術后肺部感染病原學及危險因素. 中華醫院感染學雜志, 2021, 31(7): 1039-1042.Zhao Y, Liu S, Liu SF, et al. Etiological characteristice and risk factors for postoperative pulmonary infcetion in cardio-macrovascular surgery patients. Chin J Nosocomiol, 2021, 31(7): 1039-1042.
25. Gao Y, Wang C, Wang Y, et al. Establishment and validation of a nomogram to predict hospital-acquired infection in elderly patients after cardiac surgery. Clin Interv Aging, 2022, 17: 141-150.
26. Pozuelo-Carrascosa DP, Herráiz-Adillo á, Alvarez-Bueno C, et al. Subglottic secretion drainage for preventing ventilator-associated pneumonia: an overview of systematic reviews and an updated meta-analysis. Eur Respir Rev, 2020, 29(155): 190107.
27. 劉霞, 郭絲雨, 張紫薇. 長期臥床老年病人并發肺炎的危險因素及Nomogram預測模型構建. 護理研究, 2023, 37(16): 2909-2914.Liu X, Guo SY, Zhang ZW. Risk factors and nomogram prediction model construction for complications of pneumonia in long-term bedridden elderly patients. Chin Nurs Res, 2023, 37(16): 2909-2914.
28. Mertes PM, Kindo M, Amour J, et al. Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump. Anaesth Crit Care Pain Med, 2022, 41(3): 101059.
29. Küllmar M, Zarbock A, Engelman DT, et al. Prevention of acute kidney injury. Crit Care Clin, 2020, 36(4): 691-704.
30. 羅丹, 陳晶晶, 胡忠, 等. 慢性阻塞性肺疾病急性加重期合并肺部感染患者腎損傷的危險因素及預測模型建立. 中華醫院感染學雜志, 2023, 33(12): 1800-1803.Luo D, Chen JJ, Hu Z, et al. Risk factors of renal injury and construction of prediction model in patients with acute exacerbation of choric obstructive pulmonary disease and pulmonary infection. Chin J Nosocomiol, 2023, 33(12): 1800-1803.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Analysis of risk factors for pulmonary infection after heart valve replacement and construction of nomogram prediction model

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