Dear Sir,
I read with great interest the article by Rampengan et al.[1] On determining the optimal timing for tetralogy of Fallot (TOF) management. I would like to appraise the authors for such a comprehensive meta-analysis involving a large sample size of 28,968 patients, making a significant contribution to the aim of determining the correct time. However, I would like to highlight and comment on additional points to be discussed.
First, the studies included patients of different TOF subtypes and associated anomalies such as pulmonary atresia, absent pulmonary valve, and additional septal defects. Use of various surgical techniques, approaches, and management protocols can impact the outcomes independent of the age of repair. This heterogeneity can confound the outcomes between the two groups, and their inclusion without stratification can confound the results.[2]
While the absence of data on pulmonary artery size was acknowledged, variables such as the influence of genetic syndromes, patient weight, comorbidity, and baseline oxygen saturation were not taken into account. These are established determinants in congenital cardiac repair.[3] The cutoff ages for categorizing repairs as neonatal (<30 days to 0–1 months) or postneonatal vary across studies. Such inconsistencies may impact comparisons and overall results among the two groups, leading to blurring the effect of timing. Long-term measures, including neurodevelopment, quality of life, and exercise capacity, were not given much attention, despite being crucial for surgical timing in children.[4]
In addition to that, the outcomes of congenital cardiac surgery (TOF) are highly sensitive to institutional and geographical variation and surgeon volume. These factors, significantly affecting morbidity and mortality,[5] were not explored, although the meta-analysis included retrospective data.
To conclude, the meta-analysis strengthened and reinforced the postneonatal repair as the one yielding better perioperative outcomes. However, stratified and subgroup analyses, perioperative risk factors, long-term functional outcomes, and outcomes such as hospital costs, resource utilization, and patient-reported quality of life are critical for guiding future studies to yield more robust findings and results. It will surely contribute to future research projects.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
REFERENCES
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