Elevated oxidative stress in patients with congenital heart disease and the effect of cyanosis: a meta-analysis

Figures & data

Table 1. In- and exclusion criteria for papers in this meta-analysis.

Category	Inclusion criteria	Exclusion criteria
Design	Controlled studies: – CHD vs. healthy, or – cCHD vs. aCHD	No full-text or abstract available in English Comments on articles, editorial comments Studies regarding oxidative stress during and shortly after surgery without baseline comparison of groups
Population	Infants, children and adults with CHD	Syndromic patients Preterm infants with PDA Research performed in animals
Assessment method	Assessment of oxidative stress in peripheral blood	Assessment of oxidative stress in other tissues (e.g. urine, cardiac muscle, aortic tissue, …) Only genetic analysis without oxidative stress maker in blood

Abbreviations: (a/c)CHD: (acyanotic/cyanotic) congenital heart disease; PDA: persistent ductus arteriosus.

Figure 1. Flow diagram of the systematic reviewing process following PRISMA guidelines. Abbreviations: (a/c)CHD: (acyanotic/cyanotic) congenital heart disease.

Figure 2. Protocol followed to convert data to mean ± standard deviation. Abbreviations: m: median; max: maximum; min: minimum; p5: 5th percentile; p95: 95th percentile; Q1: 1st quartile; Q3: 3rd quartile; var: variance; µ: mean; σ: standard deviation [26–28].

Table 2. Summary of studies on the presence of oxidative stress in peripheral blood of patients with CHD (grouped by congenital pathology).

Reference	Parameter of oxidative stress (+, − or +/−)	Control group			Patients						Patient characteristics		p-Value (control vs. total patients)	p-Value (control vs. group 1/cCHD)	p-Value (control vs. group 2/aCHD)	p-Value (group 1/cCHD vs. group 2/aCHD)
					cCHD			aCHD
		N	Mean ± SD	Matched	N	Mean ± SD	Pathology	N	Mean ± SD	Pathology	Age group	History of Surgery
Ercan 2009 [17]	TOS (+)	32	9.2 ± 3.5	Healthy	29	20.04 ± 16.7	Mix	30	9.93 ± 3.7	Mix	Children	?	/	<0.0001	NS	<0.001
	TAS (−)		2.1 ± 0.2			2.32 ± 0.14			2.17 ± 0.25				/	<0.0001	NS	<0.01
	OSI (+/−)		4.35 ± 1.47			8.62 ± 7.32			4.63 ± 1.73				/	<0.0001	NS	<0.01
Pirinccioglu 2012 [21]	MDA (+)	30	5.72 ± 1.16	Healthy (age + sex + BMI)	15	12.06 ± 2.08	Mix	28	10.34 ± 2.14	Mix	Children	No	/	<0.001	<0.001	<0.001
	PCO (+)		1.33 ± 0.45			2.9 ± 0.74			2.34 ± 0.45				/	<0.001	<0.001	<0.001
	TAC (−)		1.19 ± 0.13			0.91 ± 0.21			0.98 ± 0.22				/	<0.001	<0.001	NS
Altin 2016 [16]	TOS (+)	30	5.38 ± 2.16	Healthy (demographically)	30	7.15 ± 4.39	Mix	30	6.04 ± 3.05	Mix	Children	No	/	NS	NS	NS
	TAS (−)		1.75 ± 0.27			1.54 ± 0.35			1.53 ± 0.51				/	NS	NS	NS
	OSI (+/−)		3.22 ± 1.65			4.24 ± 2.04			3.93 ± 2.72				/	NS	NS	NS
Manso 2012 [29]	TBARS (+)	/	/	/	27	1.97 ± 2.19*	Mix	28	1.05 ± 1.09*	Mix	Children	No	/	/	/	NS
	Carbonyl Moieties (+)	/	/	/		6.62 ± 7.97*			2.11 ± 2.17*				/	/	/	NS
Martínez-Quintana 2022 [30]	γGT (+)	2745	24.29 ± 15.38*	Healthy (age + sex + AHT + DM +  dyslipidemia)	589				34.06 ± 28.92*	Mix	Adolescents- Adults	?	<0.001	/	/	/
Vanreusel 2022 [10]	Superoxide (+)	36	1.19 ± 0.65	Healthy (age + sex)	15	0.98 ± 0.57	Mix	21	1.04 ± 0.47	Mix	Adults	53%	NS	/	/	NS
	Folic acid (−)		9.48 ± 4.12		14	10.65 ± 3.50			8.92 ± 2.74				NS	/	/	NS
Vidya 2014 [25] + 2015 [31]	Total Comet Length (+)	40	30.33 ± 5.19	Healthy (age + sex)	16	69.91 ± 15.57	TOF	28	66.95 ± 14.28	Mix	Children	?	<0.001	/	/	NS
	Head Diameter (+)		29.5 ± 5.35			47.28 ± 7.57			48.94 ± 10.48				0.602	/	/	NS
	Comet Tail Length (+)		0.89 ± 1.55			22.65 ± 11.34			18.07 ± 11.12				<0.001	/	/	NS
	%DNA in Head (+)		89.02 ± 7.61			84.53 ± 5.45			90.33 ± 12.34				<0.001	/	/	NS
	%DNA in Tail (+)		10.98 ± 7.61			15.47 ± 5.45			11.89 ± 4.22				0.108	/	/	<0.05
Temel 2019 [37]	Native thiol (−)	47	360.6 ± 94.9	Healthy (age + sex + BMI)	24	294.5 ± 64.3	TOF	23	255.1 ± 64.5	VSD	Children	50% of TOF 30% of VSD	/	<0.01	<0.001	NS
	Disulfide (+)		47.6 ± 22.7			61.2 ± 22.9			30.5 ± 15.6				/	<0.05	<0.01	<0.001
	Disulfide/native thiol (+/−)		14.3 ± 8.3			22 ± 10.5			12.2 ± 5.5				/	<0.001	NS	<0.001
	Disulfide/total thiol (+)		11.3 ± 5.1			14.6 ± 4.9			9.5 ± 3.6				/	<0.01	NS	<0.001
	Native thiol/Total thiol (−)		88 ± 21.8			70.8 ± 9.7			81 ± 7.3				/	<0.001	NS	<0.05
Pavlova 2009 [40]	SOD (−)	11	3.45 ± 0.05	Healthy	18	2.95 ± 0.05	TOF	20	3.1 ± 0.05	VSD + HF	Children	No	15% lower in CHD	/	/	NS
	TBARS (+)		0.76 ± 0.01			0.85 ± 0.01			0.84 ± 0.01				10% higher in CHD	/	/	NS
	TAOA (−)		3.98 ± 0.2			3.25 ± 0.175			2.1 ± 0.1				/	20% lower in TOF	50% lower in VSD + HF	/
	Intensity of Chemiluminescence⁁ (+)		26.5 ± 0.375			26 ± 0.25			32.25 ± 0.5				/	NS	/	25% higher in VSD + HF
Sanli 2012 [33]	Homocysteine (+)	20	9.26 ± 2.05	Healthy (age + sex)	/	/	/	20	14.5 ± 2.6	Left-to-right shunt - no PAH	Children –Young Adults	No	/	/	<0.01	/
					9	22.8 ± 4.7	cCHD-PAH	21	19.5 ± 5.2	aCHD-PAH			/	<0.001	<0.001	0.04
	ADMA (+)		17.1 ± 5.6		/	/	/	20	19.6 ± 7.4	Left-to-right shunt - no PAH			/	/	NS	/
					9	26.6 ± 12.1	cCHD-PAH	21	21.6 ± 7.6	aCHD-PAH			/	0.002	<0.01	NS
Srujana 2010 [46]	Comet Tail Length (+)	65	1.28 ± 0.32	Healthy (age + sex)	63	2.57 ± 0.29	TOF	/	/	/	Children	?	/	<0.0001	/	/
Guerra 2007 [39]	LMW − PTP (−)	53	289.9 ± 113.1	Healthy (age)	38	150.1 ± 82.7	TOF	/	/	/	Children	Yes	/	<0.001	/	/
	MHR (−)		22.1 ± 10.6			10.8 ± 3.9		/	/	/			/	<0.001	/	/
Michel 2020 [36]	ADMA (+)	20	0.41 ± 0.05	Healthy (age + sex)	20	0.51 ± 0.12	Fontan	/	/	/	Adults	Yes	/	0.0004	/	/
	Met − SO (+)		0.58 ± 0.23			0.94 ± 0.32		/	/	/			/	0.00008	/	/
	Met − SO/Met (+/−)		0.02 ± 0.01			0.04 ± 0.02		/	/	/			/	<0.00001	/	/
	Methionine (−)		29.4 ± 7.8			27.9 ± 8.3		/	/	/			/	NS	/	/
	Histidine (−)		110.4 ± 24.4			93.1 ± 15		/	/	/			/	0.008	/	/
Pektas 2016 [43]	TOS (+)	40	16.1 ± 4.6	Healthy (age + sex + BMI)	/	/	/	40	35.6 ± 2.8	Left-to-right shunt	Children	?	/	/	0.018	/
	TAS (-)		1.4 ± 0.3		/	/	/		1.1 ± 0.2				/	/	NS	/
	OSI (+/-)		11.5 ± 3.2		/	/	/		32.4 ± 1.4				/	/	0.022	/
Le 2010 [27]	SOD (-)	20	4.13 ± 1.03	Healthy (age)	/	/	/	31	3.12 ± 1.47	Left-to-right shunt	Children	?	/	/	0.04	/
	MDA (+)		0.5 ± 0.2		/	/	/		0.72 ± 0.33				/	/	0.017	/
Tan 2021 [56]	H2S (-)	48	52.65 ± 3.91	Healthy	/	/	/	48	50.28 ± 4.13	Left-to-right shunt	Children	No	/	/	0.005	/
Dervisoglu 2021 [38]	Ischemia-modified albumin (+)	75	0.51 ± 0.09	Healthy (age + sex)	/	/	/	100	0.62 ± 0.17	VSD	Chdildren	No	/	/	<0.001	/
Karatas 2013 [42]	TOS (+)	20	13.78 ± 2.4	Healthy (age + sex)	/	/	/	25	13.64 ± 1.06*	MVP + BAV	Children	?	/	/	NS	/
	TAC (-)		3.91 ± 0.18		/	/	/		3.82 ± 0.28				/	/	NS	/
	OSI (+/-)		3.51 ± 0.54		/	/	/		3.745 ± 0.09*				/	/	NS	/
Drapisz 2013 [41]	ADMA (+)	20	0.43 ± 0.05*	Healthy (age)	/	/	/	20	0.54 ± 0.05*	BAV	Adults	No	/	/	<0.001	/
	SDMA (+)		0.35 ± 0.06*		/	/	/		0.39 ± 0.06*				/	/	<0.001	/
	L-arginine (-)		62.33 ± 12.70*		/	/	/		61.33 ± 7.14*				/	/	NS	/
	Homocysteine (+)		9.37 ± 2.86*		/	/	/		11.53 ± 2.62*				/	/	0.006	/
Coskun 2021[45]	8-OHdG (+)	22	18.8 ± 3.94	Healthy (age + sex)	19				21.48 ± 10.48	PAH	Adults	?	NS	/	/	/

Abbreviations: 8-OHdG: 8-hydroxy-2'-deoxyguanosine; ADMA: asymmetric dimethylarginine; AHT: arterial hypertension; BAV: bicuspid aortic valve; BMI: body mass index; (a/c)CHD: (acyanotic/cyanotic) congenital heart disease; DM: diabetes mellitus; γGT: gamma-glutamyl transferase; H₂S: hydrogen sulfide; HF: heart failure; LMW-PTP: low-molecular-weight protein tyrosine phosphatase; MDA: malondialdehyde; Met(-SO): methionine (sulfoxide); MHR: methemoglobin reductase; MVP: mitral valve prolapse; OSI: oxidative stress index (TOS/TAC); PAH: pulmonary arterial hypertension; PCO: protein carbonyl; SDMA: symmetric dimethylarginine; SOD: superoxide dismutase; TAC/S: total antioxidant capacity/status; TAOA: total antioxidant activity; TBARS: thiobarbituric acid reactive substances; TOF: tetralogy of Fallot; TOS: total oxidant status; VSD: ventricular septal defect.

+: pro-oxidative stress markers, -: anti-oxidative stress markers, +/-: ratio of pro-to-anti oxidative stress markers, ?: not specified; NS: not statistically significant (statistical significance level was established at p < 0.05 or ≤0.05); *median (min-max)/(IQR)/(5th–95th perc) converted to mean ± SD; ^Lucigenin enhanced chemiluminescence registers the concentration of superoxide.

Table 3. Methodologic quality of each included article, scored with the quality assessment tool for observational cohort and cross-sectional studies from the National heart, Lung, and blood Institute.

TopicRef.	Altin 2016 [16]		Coskun 2021 [45]		Dervisoglu 2021 [33]			Drapisz 2012 [41]		Ercan 2009 [17]		Guerra 2007 [39]		Karatas 2013 [34]		Le 2010 [27]		Manso 2012 [29]	Martinez 2021 [30]	Michel 2020[36]	Pavlova 2009 [40]
1. Research question/objective	Yes		Yes		Yes			Yes		Yes		Yes		Yes		Yes		Yes	Yes	Yes	Yes
2. Study population	Yes		Yes		Yes			Yes		Yes		Yes		Yes		Yes		Yes	Yes	Yes	Yes
3. Participation rate	NR		NR		NR			CD		NR		NR		NR		CD		NR	Yes	Yes	NR
4. Subject selection, in- and exclusion criteria	Yes		Yes		Yes			Yes		Yes		Yes		Yes		CD		Yes	Yes	Yes	Yes
5. Sample size/power description	Yes		No		No			Yes		No		No		No		CD		Yes	No	No	No
6. Exposure measured prior to outcome(s)?	Yes		Yes		Yes			Yes		Yes		Yes		Yes		Yes		Yes	Yes	Yes	Yes
7. Timeframe exposure – outcome	Yes		Yes		Yes			Yes		Yes		Yes		Yes		Yes		Yes	Yes	Yes	Yes
8. Different levels of exposure	Yes		Yes		Yes			Yes		Yes		No		Yes		Yes		Yes	Yes	Yes	Yes
9. Exposure measures	No		No		Yes			Yes		No		Yes		Yes		Yes		No	No	Yes	Yes
10. Exposure assessed over time	NA		NA		NA			NA		NA		NA		NA		NA		NA	NA	NA	NA
11. Outcome measures	Yes		Yes		Yes			Yes		Yes		Yes		Yes		CD		Yes	Yes	Yes	Yes
12. Blinding of assessors	No		No		No			Yes		No		No		No		CD		No	No	No	No
13. Lost to follow-up	NA		NA		NA			NA		NA		NA		NA		NA		NA	NA	NA	NA
14. Potential confounding variables	Yes		No		No			No		No		Yes		No		Yes		No	Yes	Yes	Yes
TopicRef.		Pektas 2016 [43]		Pirinccioglu 2011 [21]		Sanli 2012 [33]	Srujana 2010 [46]		Tan 2021 [56]		Temel 2019 [35]		Vanreusel 2022 [10]		Vidya 2014 [25]		Vidya 2015 [31]
1. Research question/objective		Yes		Yes		Yes	No		Yes		Yes		Yes		Yes		Yes
2. Study population		Yes		Yes		Yes	Yes		Yes		Yes		Yes		Yes		No
3. Participation rate		NR		NR		NR	NR		NR		NR		NR		NR		NR
4. Subject selection, in- and exclusion criteria		Yes		Yes		Yes	Yes		Yes		Yes		Yes		Yes		No
5. Sample size/power description		Yes		No		No	No		No		No		No		No		No
6. Exposure measured prior to outcome(s)?		Yes		Yes		Yes	Yes		Yes		Yes		Yes		Yes		Yes
7. Timeframe exposure – outcome		Yes		Yes		Yes	Yes		Yes		Yes		Yes		Yes		Yes
8. Different levels of exposure		No		Yes		Yes	No		Yes		Yes		Yes		No		Yes
9. Exposure measures		Yes		No		No	Yes		Yes		Yes		No		No		No
10. Exposure assessed over time		NA		NA		NA	NA		NA		NA		NA		NA		NA
11. Outcome measures		No		Yes		Yes	Yes		Yes		Yes		Yes		Yes		Yes
12. Blinding of assessors		No		No		Yes	No		No		No		No		No		No
13. Lost to follow-up		NA		NA		NA	NA		NA		NA		NA		NA		NA
14. Potential confounding variables		No		Yes		No	No		No		Yes		Yes		No		No

Abbreviations: CD: cannot determine; NA: not applicable; NR: not reported.

Figure 3. Schematic figure of the used methods to assess oxidative stress in blood of patients with CHD. Abbreviations: 8-OHdG: 8-hydroxy-2'-deoxyguanosine; ADMA: asymmetric dimethylarginine; eNOS: endothelial nitric oxide synthase; FA: folic acid; γGT: gammaglutamyl transferase; GSH: glutathione; GSSG: glutathione disulfide; GP: glutathione peroxidase; H₂O_: water; H₂O₂: hydrogen peroxide; H₂S: hydrogen sulfide; (Met-)Hb: (met)hemoglobin; Hcy: homocysteine; HO^•: hydroxyl radical; im: ischemia-modified; LMW-PTP: low-molecular-weight protein tyrosine phosphatase; Met(-SO): methionine (sulfoxide); MHR: methemoglobin reductase; NO: nitric oxide; O₂: oxygen; O₂^•−= superoxide anion radical; ONOO^-: peroxynitrite; PCO: protein carbonyl; ROS: reactive oxygen species; SDMA: symmetric dimethylarginine; SOD: superoxide dismutase; TBARS: thiobarbituric acid reactive substances.

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