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Ann Thorac Surg 2006;82:1643-1648
© 2006 The Society of Thoracic Surgeons

Original Articles: Cardiovascular

Cardiac Troponin T Levels for Risk Stratification in Pediatric Open Heart Surgery

Leena H. Mildh, MDa,*, Ville Pettilä, MD, PhDb, Heikki I. Sairanen, MD, PhDc, Paula H. Rautiainen, MD, PhDa

a Department of Anesthesiology and Intensive Care, Hospital for Children and Adolescents, Finland
c Department of Cardiac Surgery, Hospital for Children and Adolescents, Finland
b Division of Intensive Care, Department of Anesthesiology and Intensive Care, Helsinki University Hospital, Helsinki, Finland

Accepted for publication May 4, 2006.

* Address correspondence to Dr Mildh, Helsinki University Hospital, Hospital for Children and Adolescents, PO Box 281, 00029 HUS, Helsinki, Finland. (Email: leena.mildh{at}hus.fi).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 References
 
BACKGROUND: Cardiac troponin T has been found to be accurate predictor of complications and adverse clinical events after pediatric cardiac surgery. Contrary to adult cardiac surgery, the relationship of troponin T to patient survival after pediatric heart surgery has not been previously studied. The purpose of this study was to determine whether troponin T could predict death after pediatric open cardiac surgery.

METHODS: This was a retrospective cohort study in which data from 1001 consecutive children having cardiac surgery during a 5-year period were studied. Perioperative variables that could influence death at 30 postoperative days were evaluated.

RESULTS: Multivariate analysis, using a forward stepwise logistic regression, showed that troponin T measured on the first postoperative day was a strong independent predictor of death at 30 days. Level of troponin T greater than 5.9 µg/L on the first postoperative day predicted death (odds ratio, 10.7; 95% confidence interval: 5.2 to 22.1) as did admission lactate level greater than 5.2 mmol/L (odds ratio, 22.2; 95% confidence interval: 9.7 to 50.8) No other variable, including postoperative creatine kinase-MB mass concentration, age, diagnosis, surgical procedure, presence of cyanosis, chromosomal anomaly or ventriculotomy, duration of cardiopulmonary bypass, or aortic cross-clamp, had any independent effect on 30-day survival.

CONCLUSIONS: Cardiac troponin T level on the first postoperative day is a powerful independent risk marker of death in pediatric cardiac surgery.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 Acknowledgments
 References
 
In cardiac surgery, intraoperative myocardial damage is a major determinant of postoperative cardiac dysfunction associated with morbidity and mortality. Cardiac troponin T and troponin I are well documented in previous literature to reflect myocardial damage and clinical outcome after adult and pediatric cardiac surgery (1–8) as well as myocardial infarction [9]). In adult cardiac surgery, the predictive value of postoperative troponins are shown to predict in-hospital clinical outcome variables: death, shock, myocardial infarction, and arrhythmias [1, 2, 6, 10]). However, similar risk stratification using postoperative troponin levels in terms of survival is lacking after pediatric heart surgery. In previous pediatric literature, postoperative serum lactate and operative risk scoring according to the Risk Adjustment for Congenital Heart Surgery-1 (RACHS-1) scoring system were shown to predict outcome after pediatric heart surgery [11–15].

Troponin T is a specific and sensitive marker of myocardial cell injury after pediatric open-heart surgery. Numerous factors can explain an increase in troponin T in this situation: the type of surgery, the choice of cardioplegia, the choice of perfusion strategy, and the presence of cyanosis or ventriculotomy [3, 16–19]). The absolute levels have been shown to depend on diagnosis, to correlate with the extent of myocardial damage, and to allow anticipation of the postoperative course [5, 20–24]). Although some authors have suggested prognostic implications [5, 25–27]), they have not evaluated whether troponin T or any other variable is an independent risk factor. Even highly statistically significant differences between survivors and nonsurvivors may not reflect the discriminant power of a single variable when predicting mortality [28, 29].

In past years, the immature heart was thought to be more resistant to hypoxia, but recent rsearch has questioned this hypothesis. More myocardial damage is reported in younger patients, causing higher troponin levels [3, 17, 19, 20].

This study was performed to evaluate preoperative and postoperative variables related to 30-day outcome after pediatric open heart surgery.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 Acknowledgments
 References
 
This retrospective cohort study was performed in Helsinki University Hospital for Children and Adolescents, where all pediatric heart surgery is performed in Finland (population 5.2 million) without any patient selection. The study was reviewed and approved by the local Human Investigation Committee, which waived the need to obtain informed consent.

Subjects and Data Collection
Data from all patients under 18 years having heart surgery necessitating cardiopulmonary bypass (CPB) between January 1, 2000, and December 31, 2004, were included in the study. Primary outcome measure was death within the first 30 days (day 30) after surgery. Information describing patients' surgical procedure, diagnosis, duration of CPB, aortic cross-clamp, and survival at day 30 postoperatively were recorded in specific pediatric heart surgery database (ProCardio, Melba Group, Finland), which obtains its information from the Finnish Population Registry Center [30]). Patients were given one primary diagnosis to facilitate comparison. Heart defects were sorted hierarchically; patients with more than one defect were given the diagnosis highest on the list. The hierarchy was based on hierarchies published previously [30, 31]. Patients diagnoses and surgical procedures were grouped according to the international congenital heart surgery nomenclature [31–33]. Information on patient demographics (sex, weight, age), intubation time, length of stay in intensive care unit (ICU), as well as on troponin T and creatine kinase MB mass concentration (CK-MBm) values were obtained from the intensive care database (Centricity Critical Care Clinisoft; GE Healthcare, Helsinki, Finland). Data tables were exported from the intensive care database, imported into a relational database (Microsoft Access; Microsoft, Seattle, Washington), and combined with the surgical database. Data containing this information have not been previously published.

Surgical Procedures
In hypoplastic left heart patients, the first-stage palliation operation, Norwood I, was done using either a Blalock-Taussig or Sano shunt with selective low flow perfusion. Bidirectional Glenn operation was used for the second-stage operation. Total cavopulmonary connection was performed with extracardiac (polytetrafluoroethylene) conduit and beating heart. For patients with a RV-PA conduit operation, the procedure was also performed with beating heart.

Myocardial Protection
Intermittent antegrade blood cardioplegia was used for myocardial protection. Patients with solitary atrial septum defect closure received cold blood cardioplegia. All other patients received, in addition to cold cardioplegia, both warm induction cardioplegia immediately after aortic cross-clamp and warm blood cardioplegia before reperfusion.

Postoperative Care
Postoperatively, milrinone was used as first-line inotrope therapy for patients needing such support. If needed, epinephrine or norepinephrine was added to milrinone for sufficient hemodynamic support. Extubation was done when breathing and gas exchange were satisfactory. Patients were discharged from the ICU when hemodynamics were stable with no catecholamine support and gas exchange was normal after extubation.

Blood Sampling and Biochemical Analysis
According to the institutional program, plasma concentrations of troponin T and CK-MBm were determined on the first and second postoperative days (sampling time 6:00 AM). Biochemical analysis was performed with electrochemiluminescence immunoassay (ECLIA) for both troponin T (Elecsys Troponin T STAT; Roche, Mannheim, Germany) and CK-MBm (Elecsys CK-MB STAT; Roche). Postoperative plasma lactate was obtained after arrival to the ICU and was performed with an ABL 700 series analyzer (Radiometer Medical A/S, DK-2700; Bronshoj, Denmark).

Risk Adjustment
Patients were placed into operative risk category groups according to the RACHS-1 scoring system [11, 15]. The RACHS-1 divides the surgeries into six categories, with category 1 being the lowest mortality operations and category 6 being the surgeries associated with the highest mortality. That was done when analyzing the final data. The presence of chromosomal anomaly was included in the analysis as a dichotomous variable.

Clinical Outcome
Primary outcome measure was day 30 all-cause mortality. Variables studied were patient age, presence of chromosomal anomaly, RACHS-1 group, diagnosis, surgical procedure, CPB, aortic cross-clamp, presence of cyanosis preoperatively, ventriculotomy performed, and plasma troponin T and CK-MBm measured on days 1 and 2 postoperatively as well as initial lactate on ICU admission.

Statistical Methods
Data are presented as mean ± SD or median (interquartile range). Statistical analyses were performed with SPSS 10.1.3 for Windows (SPSS, Chicago, Illinois). Differences in continuous variables between groups were compared using the nonparametric Mann-Whitney test. A p value less than 0.05 was considered significant.

Thereafter, univariate analysis regarding 30-day mortality and relevant variables (day 1 troponin T [troponin T-1], RACHS-1, blood lactate on admission, age, CK-MBm, CPB, aortic cross-clamp, diagnosis, surgical procedure, and presence of ventriculotomy, cyanosis, or chromosomal anomalies) was performed. Second, analysis of an independent effect of variables (troponin T-1, RACHS-1, blood lactate on admission, age, CPB, diagnosis, surgical procedure, cyanosis) on 30-day death was performed using forward stepwise logistic regression analysis with p less than 0.20 to include and p greater than 0.10 to exclude covariates from the model. Lactate and troponin T-1 were analyzed as a continuous variables. Thereafter cut-off values for lactate and troponin T-1 were calculated based on 95% specificity for death. Third, the result of forward logistic regression analysis was confirmed using direct enter method for adjustment for procedure, age and RACHS-1, and separately using lactate and troponin T-1 as dichotomous variables. Owing to the lack of separation of development and validation sets, the performance of the model was evaluated using cross-validation by the leave-one-out method.

The discriminative power of independent predictors regarding 30-day mortality underwent evaluation by producing receiver operating characteristic curves (ROCs) and by calculating areas under the curves (AUCs) with 95% confidence intervals [34].


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 Acknowledgments
 References
 
Data are presented as mean ± SD or median (interquartile range).

Patient Characteristics
During the study period, a total of 1,026 consecutive patients had open heart surgery necessitating CPB. Patients with heart transplantation, application of ventricular assist device, or age more than 18 years were excluded, which left 1,001 patients for further analysis. The median age of these patients was 0.56 years (range, 0.19 to 2.86), and median weight was 6.7 kg (range, 4.0 to 12.8). Six hundred and one patients (60%) were infants and 400 (40%) were older than 1 year; 572 (57%) were male and 429 (43%) were female. Forty-two patients (4.2%) died within 30 days of operation. In postmortem examination, the cause of death of these patients was considered cardiac in 39 cases and unrelated to cardiac procedures in 3 cases. The number of procedures performed on each patient is shown in Table 1. Patient characteristics according to RACHS-1 and mortality in each group is depicted in Table 2. Of the 1,001 patients included in the study, 970 (97%) had troponin T measured on the first postoperative day. Outcome data at day 30 postoperatively were available from all patients, as well as information about procedure, diagnosis, length of stay, age, cyanosis, ventriculotomy, and RACHS-1.


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  		Table 1. Number of Procedures Performed on Each Patient
 

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  		Table 2. Mortality Related to RACHS-1 Categories
 
Variables Affecting Primary Outcome
Among each of the multivariable analyses performed for the prediction of survival at day 30, a TnT level >5.9 µg/L at first postoperative day as well as initial lactate level and RACHS-1 were the strongest predictors of death (Fig 1). Results of the univariate and multiple forward logistic regression analysis of all explanatory variables tested are presented in Table 3. If troponin T-1 was greater than 5.9 µg/L, univariate odds ratio for death was 10.7 (95% confidence interval: 5.2 to 22.1; deaths, 14 of 62 versus 24 of 908), and if admission lactate was greater than 5.25 mmol/L, univariate odds ratio for death was 22.2 (95% confidence interval: 9.7 to 50.8; deaths, 14 of 58 versus 12 of 850). In the multiple forward regression analysis, only troponin T-1 (p < 0.001) and initial lactate (p < 0.001) were independent predictors of death at day 30. In contrast to the troponin T-1 results, troponin T levels measured at postoperative day 2 or any postoperative CK-MBm level measured added no prognostic information. Nor did the change in troponin T levels affect outcome. No correlation to survival was noted with age, duration of CPB or aortic cross-clamp, diagnosis or surgical procedure, presence of cyanosis or ventriculotomy or chromosomal anomaly. Troponin T-1 (p < 0.001) and lactate (p < 0.001) remained the only independent predictive covariates for 30-day death when entering RACHS (p = 0.61), age (p = 0.44), and procedure (p = 0.77) directly into logistic regression model. Using troponin T-1 and lactate as dichotomous variables according to their cut-off values, or using backward selection for all variables, did not change the result. Performance of the model using only troponin T-1 and lactate by leave-one-out cross-validation revealed that 92.2% of patients could be correctly classified regarding 30-day mortality.


Figure 1
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  		Fig 1. Receiver operating characteristic curves for day 1 troponin T (dashed black line; area under curve 0.768, 95% confidence interval (CI): 0.664 to 0.872]), initial blood lactate level (solid black line; area under curve 0.857, 95% CI: 0.760 to 0.953), and relative mortality risk (dashed gray line; Risk Adjustment for Congenital Heart Surgery-1, area under curve 0.733, 95% CI: 0.624 to 0.841]).

 

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  		Table 3. Complete List of Forward Logistic Regression Analysis of Variables Affecting Survival at Day 30 Postoperatively
 
Troponin T Concentrations and Surgical Procedure
A troponin T concentration greater than 5.9 µg/L on the first postoperative day (troponin T-1) predicted death with 95% specifity and 30% sensitivity. The troponin T-1 of the whole group was mean 2.22 ± 4.30 µg/L and median 1.38 µg/L (25th to 75th percentiles: 0.52 to 2.83); and CK-MBm was mean 49 ± 64 µg/L and median 32 µg/L (25th to 75th percentiles: 18 to 57). Surgical procedures were associated with different troponin T-1-concentrations (Table 4). Procedures necessitating ventriculotomy produced higher levels of troponin T-1 (median [interquartile range]) compared with procedures that did not require ventriculotomy (3.22 µg/L [2.06 to 4.82] versus 1.25 µg/L [0.48-2.64], p < 0.001). Patients with preoperative cyanosis had also higher troponin T-1 compared with noncyanotic patients (1.86 µg/L [0.71 to 3.36] versus 0.91 µg/L [0.40 to 2.20], p < 0.001). Infants had higher troponin T-1 than children (2.18 µg/L [1.25 to 3.70] versus 0.53 µg/L [0.29 to 1.01], p < 0.001).


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  		Table 4. Median (Interquartile Range) First Postoperative Troponin T (TnT)-Values and Mortality in Surgical Groups
 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
Acknowledgments
 References
 
The main result of this study is that troponin T level greater than 5.9 µg/L measured on the first postoperative day after pediatric cardiac surgery is associated with a significant increase in risk of death at day 30 postoperatively. Also postoperative lactate, measured at admission to ICU, was even more strongly associated with survival at day 30, as known from previous literature [12–14]. No other clinical variable had any statistical significance in predicting outcome at day 30. This is the first study evaluating the prognostic value of troponin T on survival after pediatric cardiac surgery. This finding, troponin T being a prognostic marker, is in accordance with studies of adults in which it has been shown to predict poor outcome both after cardiac surgery and myocardial infarction [1, 2, 6, 9, 10].

Corrective congenital heart surgery can involve significant ventricular incisions or myocardial resection. In such patients, postoperative troponin release is likely to be due to reperfusion injury as well as to surgical trauma. In this study, troponin T-1 was affected by different variables, as reported in many previous studies. Cyanotic patients had higher troponin T, and procedures necessitating ventriculotomy increased troponin T more than procedures without ventriculotomy. That is reflected in the procedure subgroups of tetralogy of Fallot repair and pulmonary atresia repair, which produced high troponin T-1 and often required ventriculotomy. Infants seem to have higher troponin T, which can be due to procedures performed at a younger age producing high troponin T (tetralogy of Fallot repair and interrupted aortic arch repair), although the vulnerability of young myocardium by surgery or CPB cannot be ruled out. The association of elevated troponin levels and adverse clinical outcome has been widely studied in pediatric heart surgery. Elevated troponin T has been shown to relate with surgical severity [5], younger age, aortic cross-clamp time [19], and presence of ventriculotomy [17] or cyanosis [3, 16]. Elevated troponin I levels have been shown to relate to surgical procedure (ventricular septal defect, tetralogy of Fallot), duration of ventilation, ICU stay [4], aortic cross-clamp time [8], and duration of inotropic support [8]. None of these studies evaluated which of these variables correlate with death. Also, the number of patients selected to these studies is relatively small (50 to 200 patients) compared with our study of 1,001 patients and an unselected patient population.

Troponin T and troponin I are regarded as the most cardiac specific of currently available biochemical markers for myocardial damage [22–24]. Several studies confirm the diagnostic accuracy of both troponins in children [7, 19–21]. These two troponins differ somewhat from each other: troponin T may remain raised for a longer period [7, 19, 23], probably because of its kinetics with biphasic release both from cytoplasmic pool and structural proteins. That might explain why the difference in troponin T measurements between day 1 and day 2 in our study had no independent effect on outcome. Troponin T is also shown to be affected by renal insufficiency and to give false positive values [22, 23]. Renal insufficiency was not chosen as a variable in the present study, because it was difficult to set a cutoff point of renal markers that would suit all age groups of patients from newborns to adolescents. However, whatever the reason why troponin T-1 was raised, it was a powerful determinant of survival. The timing of troponin T-1 measurement (6:00 AM) is in accordance to previous reports, in which troponin T peaked 8 to 36 hours after perioperative ischemia [3, 18, 23, 24]. Because troponin T-1 is measured at fixed time point of day, the interval between perioperative ischemia and troponin T-1 is not same in all patients. However, a fixed time point mostly reflects clinical practice in the ICU.

Troponin T-1 measured in our material matches well with previous studies, in which peak postoperative troponin T after pediatric open heart surgery is reported to rise to 4 µg/L [19], 2.7 µg/L [18], 4.06 µg/L [21], and 2.82 µg/L [3], depending on patient selection and type of surgery. Type of anesthesia [18], perfusion, and cardioplegia techniques [3, 35] can also affect postoperative troponin T, which could explain these small differences in postoperative troponin T.

Creatinine kinase-MBm is a poor indicator of survival after adult cardiac surgery [6]. This is in accordance with other pediatric studies evaluating various clinical variables and their correlation to CK-MBm [5, 7, 17, 20]. Our results confirm CK-MBm to be a poor marker for outcome after pediatric heart surgery. After surgical injury, CK-MBm reaches a peak earlier than troponins, reflecting differences in molecular weights, cellular distribution, and plasma clearance. Also, being a quite nonspecific marker of myocardial damage diminishes its value as a prognostic marker. Thus, our results suggest that measurement of CK-MBm may not be advantageous in postoperative pediatric cardiac patients.

There are some limitations in the present study. First, as a retrospective cohort study, no perfect standardizing of anesthesia, cardioplegia, CPB, or postoperative care could be done, which all could influence postoperative troponin T levels. However, the patients were treated according to institutional written protocol, which minimizes the variability in patient care. An ideal study protocol to investigate the predictive value of a variable would be a prospective cohort study. However, we believe that owing to the large and unselected patient population, routine laboratory data, and the computerized data management system, our results can be considered representative for all pediatric open heart surgery patients. Second, no preoperative values of troponin T or CK-MBm were obtained from the patients, and thus the first postoperative troponin T could be elevated not only because of surgical trauma, but also because of preoperative ischemia. Third, renal failure was not evaluated in this study, even though it can itself elevate troponin T without cardiac injury [22, 23].

In conclusion, we have demonstrated that elevated cardiac troponin T measured on the first postoperative day is a strong independent risk factor for death after pediatric cardiac surgery. Postoperative cardiac troponin T concentrations reflect the extent of myocardial injury and is therefore an independent predictor of survival after pediatric open heart surgery. Also, elevated postoperative lactate is an even stronger predictor of death, as shown earlier in previous studies. On the other hand, measuring CK-MBm seems not to be advantageous in these patients.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
References
 
We would like to thank Sirpa Savolainen, RN, for her expertise and help in collecting the data from electronic data bases. This study was supported in part by Helsinki University Central Hospital, Finland (EVO grant).


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 References
 

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