Commentary on: Predictive value of NT-proBNP and hs-TnT for outcomes after pediatric congenital cardiac surgery

Dear Editor,

Recently, the article ‘Predictive value of NT-proBNP and hs-TnT for outcomes after pediatric congenital cardiac surgery¹ published in the International Journal of Surgery has attracted our attention. The study was approved by the hospital ethics committee and the informed consent of the patients. The authors mainly conducted a prospective analysis of 1015 hospitalized children with congenital heart disease (CHD) who needed surgery in a tertiary center. Blood samples were taken 6 h after operation to detect the levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity troponin T (hs-TnT) to predict the occurrence of postoperative adverse events. It is concluded that the level of NT-proBNP within 6 h after operation is a good predictor of postoperative adverse events. Hs-TnT level has a high predictive value for postoperative adverse events in children over 1 year old but limited value in children under 1 year old. The evidence related to the predictive value of NT-proBNP and hs-TnT for early postoperative outcomes in pediatrics is limited and controversial. In this context, the results of that study are of great significance. This paper praises the contribution of that study and puts forward some constructive suggestions at the same time.

First of all, in terms of data collection, that study did not continuously monitor NT-proBNP and hs-TnT during the perioperative period, did not evaluate their peak values and rules of numerical fluctuations, but only measured within 6 h after operation according to the subjective will of doctors, ignored the fluctuation rules of NT-proBNP and hs-TnT and had limited value in predicting the occurrence of perioperative adverse events. There is no baseline comparison, and the results of that study are not comparable. Therefore, we can make up for the deficiency of this study through the continuous detection of perioperative NT-proBNP and hs-TnT levels.

Secondly, only attention was paid to adverse events such as in-hospital death, unscheduled re-intervention (pericardial fenestration, thoracotomy), long-term mechanical ventilation, prolongation of pediatric intensive care unit (PICU) hospitalization, postoperative extracorporeal membrane oxygenation and peritoneal dialysis, ignoring common complications in PICU, such as low cardiac output syndrome (LCOS), pneumonia, renal failure, deep vein thrombosis (DVT)². No follow-up survey was conducted on the subjects, ignoring the occurrence of adverse events after discharge. A previous study by Jacobs et al.³ showed that 96% of patients may experience major diseases after discharge. Therefore, it is necessary to conduct a follow-up survey of discharged patients to increase the prediction of common complications and improve the accuracy of the prediction.

In addition, that study used NT-proBNP and hs-TnT level prediction, respectively, and did not study the correlation between the combination of the two and the occurrence of adverse events. Studies by Mori et al.⁴ have shown that the combination of BNP and hs-TnT can better predict the occurrence of adverse cardiac events than alone. Therefore, through the continuous detection of the level of NT-proBNP and hs-TnT and the joint use, we can find the law of the combination of the two and the occurrence of adverse events and improve the predictive value.

Finally, that study analyzed the predictive value of NT-proBNP and hs-TnT in children over 1 year old and under 1 year old but ignored the law that the level of NT-proBNP decreased with the increase of age in physiological state, and the law that the level of hs-TnT decreased with the increase of age after reaching the highest level in the first month after birth, and the level of hs-TnT was also affected by gender factors^5,6. The research of Palm et al.⁷ showed that zlog-proBNP can overcome the influence of age and has strong predictability for the occurrence of adverse events. Therefore, we can further explore the prediction of zlog-proBNP level on postoperative adverse events in children with congenital heart disease or further study the critical values of age and sex of NT-proBNP and hs-TNT in predicting postoperative adverse events in children with congenital heart disease, so as to improve the accuracy of prediction.

Ethical approval

Not applicable.

Consent

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Sources of funding

The study was funded by the Natural Science Foundation of Fujian Province (2023J0112) and the State Administration of Traditional Chinese Medicine (Chinese Medicine Education letter (2022) No. 1). These funders had no role in the study design, data collection, and analysis, interpretation of data, and writing the manuscript.

Author contribution

S.C.: conception and design of the study; X.H.: collected and analyzed the data; X.F. and S.M.: wrote the paper. All the authors drafted and revised the paper. In addition, all authors read and approved the final manuscript.

Conflicts of interest disclosure

The authors declare no conflict of interest.

Research registration unique identifying number (UIN)

Siwen Chen accepts full responsibility for the work and/or the conduct of the study.

Guarantor

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Data availability statement

The data in this manuscript can be obtained from the public internet.

Provenance and peer review

Not applicable.