Journal of Critical Care 31 (2016) 139–143

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Journal of Critical Care

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Risk factor analysis of postoperative acute respiratory distress syndrome

in valvular heart surgery
Shao-Wei Chen, MD a,b,1, Chih-Hsiang Chang, MD b,c,1, Pao-Hsien Chu, MD d, Tien-Hsing Chen, MD d,
Victor Chien-Chia Wu, MD d, Yao-Kuang Huang, MD a, Chien-Hung Liao, MD e, Shang-Yu Wang, MD b,e,
Pyng-Jing Lin, MD a, Feng-Chun Tsai, MD a,⁎
a
Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan
b
Graduate Institute of Clinical Medical Sciences, College of medicine, Chang Gung University, Taoyuan City, Taiwan
c
Kidney research center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan
d
Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan
e
Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan

a r t i c l e i n f o a b s t r a c t

Keywords: Purpose: The aim of this study is to investigate the incidence, severity, and outcome of postoperative
Valvular heart surgery acute respiratory distress syndrome (ARDS), according to the Berlin definition, in isolated valvular heart surgery.
Acute respiratory distress syndrome The preoperative and perioperative predisposing factors of this complication were also identified.
Methods: A retrospective chart review was conducted on 457 patients who underwent isolated valvular
heart surgery between January 2010 and December 2012. Clinical characteristics and outcomes were collected.
The primary outcome was postoperative ARDS, according to the 2012 Berlin definition for ARDS.
Results: A total of 37 patients (8.1%) developed postoperative ARDS, with a mortality rate of 29.7%. The multivar-
iate analysis identified that age (odds ratios [ORs], 1.067, P ≤ .001), liver cirrhosis (OR, 7.159; P = .001), massive
blood transfusion (OR, 2.980; P = .005), and tricuspid valve replacement (OR, 5.197; P = .012) were indepen-
dent risk factors of postoperative ARDS. Furthermore, we have determined that the increased severity stages of
ARDS were associated with decreased postoperative survival.
Conclusions: In conclusion, postoperative ARDS, according to Berlin definition, in valvular surgery, was associated
with high in-hospital mortality. The severity of ARDS was associated with patient midterm mortality. In multivar-
iate analysis, age, liver cirrhosis, massive blood transfusion, and tricuspid valve replacement were identified as
independent risk factors of ARDS.
© 2015 Elsevier Inc. All rights reserved.

1. Introduction or new worsening respiratory symptoms. It is associated with bilateral

Acute respiratory distress syndrome (ARDS) is a leading cause of
postoperative hypoxemic respiratory failure and is associated with mor-
tality rates of approximately 40% [1,2]. Cardiac surgery is a known risk
factor for ARDS, which affects 0.4% to 20% of patients who underwent
cardiac surgery, with a mortality even approaching 80% [3–6]. The
statistical variations among the studies are depended on the different
classifications and study populations. Postoperative ARDS not only
contributes to increased in-hospital mortality and decreased long-
term survival but also results in high medical expenditures [7,8].
The recently published 2012 Berlin definition of ARDS [9] describes
ARDS as a hypoxemia that occurs within 1 week of a known clinical insult
opacities on chest images that cannot be fully explained by pleural effu-
sions, atelectasis, nodules, or clinical outcomes that are not fully explained
by cardiac failure or fluid overload [3]. The updated and revised Berlin def-
inition was determined to have better mortality prediction validity and also
addressed some of the limitations of the previous ARDS definition that was
defined by the American-European Consensus Conference. However, there
exist few literatures that have applied this new definition in their cardiac
surgery population, and no previous study has ever analyzed the risk factors
of ARDS after isolated valvular surgery. The aim of this study is to retrospec-
tively investigate the incidence, severity, and outcome of ARDS in valvular
surgery, as well as to identify their corresponding risk factors.
2. Materials and methods

⁎ Corresponding author at: Department of Cardiothoracic and Vascular Surgery, Chang 2.1. Study design and patient population
Gung Memorial Hospital, Linkou Medical Center, No. 5 Fuxing St, Guishan District,
Taoyuan City 33305, Taiwan. Tel.: +886 3 3281200; fax: +886 3 3285818.
E-mail address: josephchen0939@yahoo.com.tw (F.-C. Tsai). This post hoc analysis of a prospective collected database was
1
Shao-Wei Chen and Chih-Hsiang Chang contributed equally to this work. approved by the instructional review board of Chang Gung Memorial

http://dx.doi.org/10.1016/j.jcrc.2015.11.002
0883-9441/© 2015 Elsevier Inc. All rights reserved.
140 S.-W. Chen et al. / Journal of Critical Care 31 (2016) 139–143
Hospital. Between January 2010 and December 2012, medical records of
506 consecutive patients, who received isolated valvular heart surgery
in a tertiary referral hospital, were reviewed. All patient records were
anonymized and de-identified prior to analysis. We excluded patients
who received emergent operation or perioperative extracorporeal
membrane oxygenation support, or those patients who died on the
day of surgery. In order to appraise respiratory outcomes, patients
who underwent preoperative mechanical ventilator support were also
excluded. The final cohort comprised a total of 457 patients, where
their detailed demographic information is listed in Fig. 1.
2.2. Data collection and definitions
Clinical characteristics and demographic data were extracted from a
prospectively collected database. The primary outcome was the
incidence, severity, and risk factors of postoperative ARDS. Based
on the Berlin definition [9], ARDS was described as the following:
(1) hypoxemia, occurring within 1 week of a known clinical insult or
new or worsening respiratory symptoms; (2) chest image with bilateral
opacities that cannot be fully explained by pleural effusions, atelectasis,
or nodules; and (3) clinical outcomes that are not fully explained by
cardiac failure or fluid overload. Also, ARDS is divided into 3 categories
that included the following: (1) mild ARDS (200 mm Hg b PaO2/FiO2
≤300 mm Hg with PEEP [positive end-expiratory pressure] or continu-
ous positive airway pressure ≥ 5 cm H2O), (2) moderate ARDS
(100 mm Hg b PaO2/FiO2 ≤ 200 mm Hg with PEEP ≥ 5 cm H2O), and
(3) severe ARDS (PaO2/FiO2 ≤100 mm Hg with PEEP ≥5 cm H2O). Patient
diagnoses were independently confirmed by 2 physicians with who
have reviewed the medical records.
2.3. Statistical analysis
Continuous variables were summarized by mean and SE unless
otherwise stated. The primary end point was the comparison of postop-
erative outcome between ARDS and non-ARDS groups. Kolmogorov-
Smirnov test was used to determine the normal distribution of each
variable. Student t test was used to compare the means of continuous
variables and normally distributed data; otherwise, Mann-Whitney U
test was used. Categorical data were tested using the χ 2 test or Fisher
exact test. Furthermore, risk factors of ARDS were assessed using
univariate analysis. Variables that were statistically significant in the
univariate analysis were included in the multivariate analysis with
logistic regression. Discrimination was assessed using the area under a
receiver operating characteristic curve (AUROC), which was compared
Fig. 1. Study design. ECMO indicates extracorporeal membrane oxygenation.
with a nonparametric approach. Categorical data were tested by χ 2
test. P value less than .05 was considered statistically significant.
3. Results
3.1. Characteristics of the study population: ARDS vs non-ARDS group
A total of 457 adult patients, with a mean age of 58.0 ± 0.7 years and
48.6% (235 men and 222 women) female, were investigated in this
study. A total of 37 (8.1%) patients developed postoperative ARDS (10
[27.0%] mild, 18 [48.6%] moderate, and 9 [24.3%] severe) in our cohort.
All patient characteristic are listed in Table 1. Compared with non-
ARDS patients, the ARDS group is older and have more diabetes mellitus,
more congestive heart failure (CHF) functional class (Fc) III/IV, more liver
cirrhosis, and higher preoperative risk score. The mean values of
EuroSCORE and Society of Thoracic Surgeons score on mortality risk
were 6.6% ± 0.4% and 4.9% ± 0.4% for the ARDS and non-ARDS group, re-
spectively. The observed in-hospital mortality rate of this study was 5.0%.
Aortic valve replacement was performed in 163 (36.8%) patients.
The mitral procedures such as mitral valve repair and replacement
were performed in 195 (42.7%) and 112 (24.5%) patients, respectively.
Tricuspid valve repair was also performed in 151 (33%) patients.
The mean cardiopulmonary bypass and aortic clamping time were
160 ± 3.0 and 109.3 ± 2.1 minutes, respectively. The detailed surgical
information and perioperative data are listed in Table 2. Operative char-
acteristics, including the type of surgery performed, type of valve re-
placement, concomitant procedures, duration of cardiopulmonary
bypass time, and aortic cross-clamping time, were similar between the
2 groups. However, the ARDS group had more cases of tricuspid valve
replacement and tissue valve tricuspid replacement. Compared with
the non-ARDS group, the ARDS group had more patients who had mas-
sive blood transfusions (18.3% and 4.9%; ARDS vs non-ARDS, P b .001),
defined by the transfusion of more than 4 units of packed red blood
cells (PRBCs). Furthermore, the scoring system results, determined
when patients were admitted into the intensive care unit (ICU), which
included Acute Physiology, Age and Chronic Health Evaluation III
(APACHE III) and the Sequential Organ Failure Assessment (SOFA),
were significantly higher in the ARDS group than in the non-ARDS
group (all P b .001).
3.2. Postoperative outcomes
There were 23 (5.0%) in-hospital mortalities, where the ARDS
group had higher in-hospital mortality than did the non-ARDS group
(29.7% and 2.9%; ARDS vs non-ARDS, P b .001). Postoperative morbidity
analysis showed that when compared with the non-ARDS group, the
ARDS group had more patients who underwent tracheostomy (16.2%
and 0.5%; ARDS vs non-ARDS, P b .001), more acute renal failures
(24.3% and 1.2%; ARDS vs non-ARDS, P b .001), and more postoperative
cerebral vascular accidents (13.5% and 1.2%; ARDS vs non-ARDS, P =
.045). Furthermore, the patients in the ARDS group also had longer ven-
tilator time, ICU, and hospital stay durations. The detailed comparison of
the different postoperative outcomes is listed in Table 3. In the subse-
quent analysis, where the patients ARDS severities were classified ac-
cording to the Berlin definition, 24%, 49%, and 27% of the patients met
the criteria of mild, moderate, and severe stages of ARDS, respectively.
The mortality rate was determined to correspond with increased sever-
ity stages of ARDS from mild (11%), moderate (27.8%), to severe (50%).
3.3. Logistic regression analysis for ARDS according to preoperative and
perioperative variables
The logistic regression model was applied to the ARDS patients
according to the preoperative and perioperative factors. Although age,
liver cirrhosis, CHF Fc III/IV, diabetes mellitus, tricuspid valve replace-
ment, and blood transfusion greater than 4 units were associated with
 S.-W. Chen et al. / Journal of Critical Care 31 (2016) 139–143 141

Table 1
Preoperative demographic data and clinical characteristics between the ARDS and non-ARDS groups (expressed as mean ± SE)

All patients (n = 457) Non-ARDS (n = 420) ARDS (n = 37) P

Preoperative demographic data

Age (y) 58.0 ± 0.7 57.3 ± 0.7 66.1 ± 1.8 b.001
Sex, female (%) 222 (48.6) 206 (49.0) 16 (43.2) NS (.998)
BMI (kg/m2) 23.3 ± 0.2 23.3 ± 0.2 23.0 ± 0.6 NS (.377)
b20 kg/m2 82 (17.9) 72 (17.1) 10 (27) NS (.133)
N30 kg/m2 26 (5.7) 25 (6.0) 1 (2.7) NS (.413)
Diabetes mellitus, n (%) 78 (17.1) 67 (16.0) 11 (29.7) .033
Hypertension, n (%) 181 (39.6) 165 (39.3) 16 (43.2) NS (.637)
Old stroke, n (%) 54 (11.8) 49 (11.7) 5 (13.5) NS (.739)
CHF Fc III/IV (%) 210 (46) 186 (44.3) 24 (64.9) .016
Ejective fraction (%) 60.8 ± 0.7 60.8 ± 0.7 61.4 ± 2.3 NS (.797)
Systolic PA pressure (mm Hg) 53.3 ± 1.1 52.8 ± 1.1 58.3 ± 4.1 NS (.152)
Pulmonary hypertension, n (%) 270 (60.8) 246 (58.6) 24 (64.9) NS (.455)
Current smoking, n (%) 143 (31.3) 133 (31.7) 10 (27.0) NS (.56)
COPD, n (%) 18 (3.9) 16 (3.8) 2 (5.4) NS (.632)
ESRD, n (%) 16 (3.5) 13 (3.1) 3 (8.1) NS (.112)
Infective endocarditis, n (%) 49 (10.1) 45 (10.7) 4 (10.8) NS (.985)
Liver cirrhosis, n (%) 23 (5.0) 16 (3.8) 7 (18.9) b.001
HbA1c (%) 6.1 ± 0.1 6.1 ± 0.1 6.2 ± 0.3 NS (.525)
Serum creatinine (mg/dL) 1.2 ± 0.1 1.1 ± 0.7 1.6 ± 0.3 NS (.096)
Hemoglobin (g/dL) 12.3 ± 0.1 12.4 ± 0.1 11.1 ± 0.4 NS (.189)
Leukocytes (×103/μL) 6.8 ± 0.1 6.8 ± 0.1 7.0 ± 0.5 NS (.079)
hs-CRP (mg/L) 18.6 ± 1.9 18.32 ± 2.1 20.6 ± 4.1 NS (.715)
Preoperative risk scores
STS score 4.9 ± 0.4 4.2 ± 0.4 12.7 ± 2.9 b.001
EuroSCORE 6.6 ± 0.4 6.1 ± 0.3 11.8 ± 2.4 b.001

ALT indicates alanine transaminase; BMI, body mass index; COPD, chronic obstructive pulmonary disorder; hs-CRP, high-sensitivity C-reactive protein; NS, not significant; STS, Society of
Thoracic Surgeons.

ARDS in the univariate analysis, only age (odds ratios [ORs], 1.067; P ≤ had adequate discriminatory power for predicting ARDS in valvular
.001), liver cirrhosis (OR, 6.641; P = .005), massive blood transfusion heart surgery.
(OR, 2.980; P = .005), and tricuspid valve replacement (OR, 5.197;
P = .012) were shown to be independently associated with postopera-
tive ARDS in the multivariate analysis (Table 4). 3.5. Midterm outcome based on severity of ARDS

3.4. Scoring systems and ARDS prediction
Using Hosmer-Lemeshow analysis, the SOFA and APACHE III scores,
determined during ICU admission, were tested for their discriminatory
power for predicting postoperative ARDS (Fig. 2). For ARDS risk predic-
tion, AUROC analysis verified that both the APACHE III (AUROC: 0.779 ±
0.036, P b .001) and the SOFA (AUROC: 0.767 ± 0.033, P b .001) scores
A follow-up was conducted for 380 (87.6%) surviving patients, with
a mean follow-up duration of 35.7 ± 0.8 months. Fig. 3 illustrates the
cumulative survival rate of 457 isolated valvular heart surgery patients,
stratified by ARDS severity. Patient who experienced ARDS exhibited
significantly lower survival rate as expected (log rank, P b .001), and
the increasing severity stages of ARDS were associated with decreased
postoperative survival.

Table 2
Operative and perioperative data between the ARDS and non-ARDS groups (expressed as mean ± SE)

All patients (n = 457) Non-ARDS (n = 420) ARDS (n = 37) P

Surgical procedure
Aortic valve replacement, n (%) 163 (36.8) 156 (37.1) 12 (32.4) NS (.569)
Mechanical valve, n (%) 32 (7.0) 30 (7.1) 2 (5.4) NS (.619)
Tissue valve, n (%) 136 (29.8) 126 (30.0) 10 (27.0) NS (.705)
Aortic valve repair, n (%) 14 (3.1) 14 (3.3) 0 (0) NS (.259)
Mitral valve replacement, n (%) 112 (24.5) 100 (23.8) 12 (32.4) NS (.242)
Mechanical valve, n (%) 27 (5.9) 25 (6.0) 2 (5.4) NS (.892)
Tissue valve, n (%) 85 (18.6) 75 (17.9) 10 (27) NS (.169)
Mitral valve repair, n (%) 195 (42.7) 180 (42.9) 15 (40.5) NS (.785)
Tricuspid valve replacement, n (%) 21 (4.6) 16 (3.8) 5 (13.5) .007
Mechanical valve, n (%) 4 (0.9) 4 (1.0) 0 (0) NS (.551)
Tissue valve, n (%) 17 (3.7) 12 (2.9) 5 (13.5) .001
Tricuspid valve repair, n (%) 151 (33) 135 (32.1) 16 (43.2) NS (.169)
Concomitant procedures
Maze procedure, n (%) 134 (29.3) 122 (29.0) 12 (32.4) NS (.665)
Cardiopulmonary bypass time (min) 160.5 ± 3.0 159.0 ± 3.1 177.0 ± 11.5 NS (.104)
Aortic cross-clamping time (min) 109.3 ± 2.1 109.1 ± 2.2 112.1 ± 7.9 NS (.78)
Redo operation, n (%) 89 (19.5) 79 (8.8) 10 (27.0) NS (.226)
Postoperative massive transfusion (red blood cell transfusion N4 units), n (%) 37 (8.1) 17 (4.9) 20 (18.3) b.001
Postoperative IABP support, n (%) 8 (1.8) 6 (1.4) 2 (5.4) NS (.077)
Postoperative score
APACHE III 37.9 ± 0.7 36.6 ± 0.7 52.3 ± 2.5 b.001
SOFA 6.8 ± 0.1 6.7 ± 0.1 8.4 ± 0.3 b.001

CT indicates chest tube; IABP, intra-aortic balloon pump; NS, not significant.
142 S.-W. Chen et al. / Journal of Critical Care 31 (2016) 139–143

Table 3
Postoperative outcomes between the ARDS and non-ARDS groups (expressed as mean ± SE)

All patients (n = 457) Non-ARDS (n = 420) ARDS (n = 37) P

In-hospital mortality, n (%) 23 (5.0) 12 (2.9) 11 (29.7) b.001

Ventilator time (h) 33.1 ± 3.2 21.5 ± 1.9 164.5 ± 25.2 b.001
ICU stay (d) 4.0 ± 0.2 3.21 ± 0.1 13.0 ± 1.5 b.001
Hospital stay (d) 20.4 ± 0.8 19.1 ± 0.8 35.3 ± 4.0 b.001
Cerebral vascular accident, n (%) 7 (1.5) 2 (1.2) 5 (13.5) .045
Acute renal failure, n (%) 11 (2.4) 2 (1.2) 9 (24.3) b.001
Tracheostomy, n (%) 8 (1.8) 2 (0.5) 6 (16.2) b.001

4. Discussion independently associated with postoperative ARDS in the multivariate

Postoperative ARDS is a clinical devastating pulmonary syndrome
that is associated with acute hypoxemic respiratory failure and high
mortality. It is a common cause of postoperative respiratory failure for
patients who underwent cardiac surgeries [10]. The recently published
Berlin definition has reinforced and revised the ARDS definition by the
1994 American-European Consensus Conference [9,11]. The new defini-
tion was demonstrated to have improved predictive validity for mortal-
ity with its corresponding severities [9]. This improved definition can
facilitate early-case recognition and better-matched treatment options
to severity in both research trials and clinical practices [12]. Further-
more, according to an autopsy study, where histopathologic findings
were correlated with severity and duration of ARDS, severe ARDS of
more than 72 hours was identified in a homogeneous group of patients
who were characterized by a high proportion of diffuse alveolar damage
[13]. However, there exist few literatures that apply this new definition
in a cardiac surgery population, and no previous study has ever
analyzed the risk factors of postvalvular surgery ARDS.
The incidence rate of ARDS in cardiac surgery varied from 0.4% to
20% based on previous literatures [3–6,14–16]. The statistical variations
were attributed to different study populations, design methodology,
and varied ARDS definitions. Recent studies that aimed to predict the
risk of postoperative acute lung injury (ALI) and ARDS, with ARDS
defined based on the American-European Consensus Conference defini-
tion, demonstrated that cardiac surgery was a risk factor for postopera-
tive ALI/ARDS. The incidence rate of ALI/ARDS in high-risk cardiac
surgery such as valve replacement and multiple vale repair was 6%
[10] and 9% [6], respectively. In our investigation, we aimed to evaluate
the incidence, severity, and outcome of ARDS, according to the Berlin
definition, after valvular heart surgery. Our study demonstrated that
the incidence of ARDS was 8.1% and the mortality is approximately
29.7%. The ARDS of mild, moderate, and severe stages was determined
to associate with increased mortality (mild, 11.1%; moderate, 27.8%;
severe, 50%). These results were compatible with those results presented
by another previous study [12]. Furthermore, we demonstrated that
patients who experienced ARDS had significantly lower midterm
survival rate (log rank, P b .001), and the increase in severity stages of
ARDS was associated with decreased postoperative survival.
Targeted preventative measures may decrease ARDS development
if at-risk patients can be identified and diagnosed early. In this
study, factors such as age, liver cirrhosis, massive blood transfusion
(PRBC N4 units), and tricuspid valve replacement were shown to be
analysis. Unsurprisingly, patients with old age carry higher risks of sur-
gical mortality and morbidity, which can be attributed to the lower
organ reserves in older individuals. For liver cirrhosis, previous study
demonstrated that liver-lung interaction is plausible because liver inju-
ry can induce host inflammatory response and thus increase lung mi-
crovascular permeability [17]. Furthermore, patients who underwent
cardiac surgery with advanced liver disease are at risk for blood transfu-
sion, which is a known risk factor for ALI and ARDS [4]. Blood transfu-
sion in cardiac surgery patients is associated with ALI, and the effect
was dose dependent for red blood cell products [18]. An interesting
finding in this study is that tricuspid valve replacement was determined
as an independent risk factor for ARDS. Patients who required tricuspid
valve replacement was known as a high-risk group in cardiac surgery.
Tricuspid valve replacement was associated with poor perioperative
and long-term outcome than tricuspid valve repair [19,20], which was
determined to be associated with postoperative ARDS in our study.
The possible explanation for this observation is that the high proportion
of reoperation and delay intervention due to high surgical risk often
correlates with right ventricular dysfunction and cardiac cirrhosis [21].
Recent publications have outlined risk-prediction scoring models
such as lung injury prediction score and surgical lung injury prediction
score that have specifically targeted mixed medical and surgical popula-
tions with acute illness [5,10]. The specific etiologies and risk factors of
postoperative ARDS in cardiac surgery are unique. Cardiopulmonary by-
pass can induce pulmonary ischemia-reperfusion injury and systemic
inflammation, where both complications have been associated with
ARDS. Furthermore, the frequent requirement of blood transfusion
was determined to induce transfusion-related ALI [13]. However, the
risk of postoperative ARDS in elective cardiac surgery has not been ade-
quately addressed. In our study, we demonstrated that postoperative
ICU score has high discrimination power for predicting ARDS. Further
investigation of different cardiac surgery-specific preoperative risk-
prediction scores is crucial for early ARDS prediction and prevention.
5. Study limitation
Despite the favorable results obtained in this study, many important
limitations should be noted. First, our study is limited by its post hoc
analysis nature and all of its inherent limitations. Second, this investiga-
tion also shared limitations with other clinical studies that were associ-
ated with the reproducibility of ARDS diagnosis. Reproducibility may be
difficult when studying postoperative ARDS after cardiac surgery

Table 4
Multivariate logistic regression analysis of risk factors for ARDS

Parameter β Coefficient SE OR (95% CI) P

Age 0.065 0.018 1.067 (1.030-1.105) b.001

Liver Cirrhosis 1.968 0.597 7.159 (2.222-23.069) .001
CHF Fc III/IV 0.371 0.395 1.449 (0.668-3.146) NS (.348)
Diabetes mellitus 0.390 0.430 1.476 (0.636-3.429) NS (.365)
Tricuspid valve replacement 1.648 0.659 5.197 (1.428-18.914) .012
Massive blood transfusion 1.092 0.386 2.980 (1.398-6.351) .005
(Red blood cell N4 units)

NS indicates not significant.

 S.-W. Chen et al. / Journal of Critical Care 31 (2016) 139–143
Fig. 2. Receiver operating characteristic curves that compares the ICU scoring systems of
for postoperative ARDS prediction.
because the occurrences of combined cardiogenic pulmonary edema
and ARDS were not uncommon. Finally, this study was conducted at a
single tertiary care medical center in Asia. Regional and ethnic differ-
ences should be considered, and the results may not be directly extrap-
olated to other patient populations. Because the etiology of ARDS after
cardiac surgery is often multifactorial, the exclusion of intraoperative
and postsurgical care factors in this study can result in the inaccurate
prediction of ARDS occurrence.
6. Conclusions
To the best of our knowledge, this is the first assessment of postop-
erative ARDS, according to the Berlin definition, in isolated valvular sur-
gery. The principle findings of current study are as follows. (1) the
incidence rate of ARDS was 8.1%, with a mortality rate that approaches
29.7%, in this study group. (2) The multivariate analysis identified age,
liver cirrhosis, massive blood transfusion (PRBC N4 units), and tricuspid
valve replacement as independent risk factors for postoperative ARDS.
(3) Risk models such as APACHE III and SOFA score can be used for
predicting postoperative ARDS in isolated valvular surgery patients.
(4) We have determined that the increase severity stage of ARDS is
associated with decreased postoperative survival.
In conclusion, postoperative ARDS, based on Berlin definition,
were still exhibiting high mortality rates after isolated valvular
surgery. Age, liver cirrhosis, massive blood transfusion, and tricus-
pid valve replacement were identified as independent risk factors
in the multivariate analysis. Future studies can be performed to
emphasize on the development of preoperative risk model that is
specific for cardiac surgery to guide early ARDS diagnosis and prompt
clinical management.
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