Papers by Christian Brizard
Heart Lung and Circulation, 2018
The Annals of Thoracic Surgery, Aug 1, 2020
This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
The Annals of Thoracic Surgery, Sep 1, 2022
Objective: This study evaluated the results of arterial switch operation and closure of ventricul... more Objective: This study evaluated the results of arterial switch operation and closure of ventricular defects (ASO + VSDc) for double outlet right ventricle with sub-pulmonary ventricular septal defect (Taussig-Bing anomaly). Methods: Between 1988 and 2003, 33 patients (25 male, 76%) with Taussig-Bing anomaly underwent ASO + VSDc (median age 39 days, 1 day-2.1 years). The relationship of the great arteries was anteroposterior (Group I, n = 19) or side-by-side (Group II, n = 14). Coronary anatomy (Yacoub's classification) was exclusively type A or D in Group I and predominantly type D or E in Group II (64%). Incidence of sub-aortic obstruction and aortic arch obstruction was similar in Group I and II (37% vs 57%, p = 0.25 and 84% vs 79%, p = 0.98, respectively). Twenty-five patients (76%) had one-stage total correction. Risk factors were analysed using multivariable analysis. Follow-up was complete (median interval of 6.2 years; range, 0.6-15.2 years). Results: There were three early (9%) and one late death. Actuarial survival was 88 AE 6% at 1 and 10 years. There were two early and four late re-operations. Freedom from re-operation was 90 AE 5% and 75 AE 9% at 1 and 10 years. Four patients required cardiological re-interventions. Freedom from re-intervention at 5 and 10 years was 79 AE 9%. On multivariable analysis, complex coronary anatomy (type B and C) was a risk for early mortality (p < 0.001) but all other anatomical variables and staged strategy did not influence early or actuarial survival. Conclusions: The ASO + VSDc approach can be applied to Taussig-Bing anomaly with acceptable mortality and morbidity and it is the procedure of choice at our institution. Anatomical variables did not influence outcomes with this strategy. A staged strategy is still appropriate in complex cases.
Interactive Cardiovascular and Thoracic Surgery, Oct 6, 2019
OBJECTIVES: To date, few studies have assessed the quality of life following congenital cardiac s... more OBJECTIVES: To date, few studies have assessed the quality of life following congenital cardiac surgery. In this study, we aimed at determining the quality of life after truncus arteriosus (TA) repair using the Short Form 36 questionnaire in adult survivors. METHODS: Seventy-three patients (age >18 years) who underwent TA repair at the Royal Children's Hospital, Australia were identified for the study. Of these, 42 patients (58%, 42/73) participated in the study and completed the Short Form 36 questionnaire. The results of the 8 domains and the derived health state summary score (Short Form Six Dimension, SF-6D) were compared with age-matched Australian population controls, and with patients who underwent the arterial switch operation (ASO).
The Annals of Thoracic Surgery, 2018
Background. In 2005 the Department of Cardiothoracic Surgery at The Royal Children's Hospital sta... more Background. In 2005 the Department of Cardiothoracic Surgery at The Royal Children's Hospital started an early academic mentoring program for medical students and junior doctors with the aim of fostering an interest in academic surgery. Methods. Between 2005 and 2015, 37 medical students and junior doctors participated in research in the Department of Cardiothoracic Surgery at The Royal Children's Hospital. Each was given an initial project on which to obtain ethics approval, perform a literature review, data collection, statistical analysis, and prepare a manuscript for publication. A search of the names of these former students and doctors was conducted on PubMed to identify publications. Results. A total of 113 journal articles were published in peer-reviewed journals with an average impact factor of 4.1 (range, 1.1 to 19.9). Thirty (30 of 37, 81%
European Journal of Cardio-Thoracic Surgery, Feb 25, 2016
OBJECTIVES: Partial atrioventricular septal defect (pAVSD) is repaired with excellent long-term s... more OBJECTIVES: Partial atrioventricular septal defect (pAVSD) is repaired with excellent long-term survival. However, up to 25% of patients require reoperations. This study reviews results of reoperation following pAVSD repair at a single institution. METHODS: From 1975 to 2012, 40 patients (16%, 40/246) underwent reoperation following pAVSD repair at the study institution. The data were retrospectively reviewed. RESULTS: The mean time to reoperation was 5.4 ± 5.8 years. The most common reoperations were left atrioventricular valve (LAVV) surgery (78%, 31/40) and resection of left ventricular outflow tract obstruction (20%, 8/40). The most common cause for LAVV surgery was regurgitation through the cleft (58%, 18/31), followed by central regurgitation (29%, 9/31). Most cases of LAVV regurgitation were treated by repair (77%, 24/31), rather than replacement (23%, 7/31). Since the introduction of a patch augmentation technique for LAVV repair in 1998, the rate of repair has increased from 54 to 94% (P = 0.012). The early mortality rate was 2.5% (1/40). The survival rate was 90% (95% CI: 76-96) at 10 years and 83% (95% CI: 60-94) at 20 years. The rate of freedom from further reoperation was 66% (95% CI: 46-80) at 10-and 20-year follow-up. CONCLUSIONS: The most common cause for reoperation following pAVSD repair was LAVV regurgitation through the LAVV cleft. Reoperation is performed with survival comparable to that of primary pAVSD repair, yet the rate of further reoperations remains high. The patch augmentation technique for LAVVR has significantly increased the rate of successful LAVV repair.
Interactive Cardiovascular and Thoracic Surgery, Mar 23, 2018
OBJECTIVES: When drainage of an anomalous pulmonary vein is high into the superior vena cava (SVC... more OBJECTIVES: When drainage of an anomalous pulmonary vein is high into the superior vena cava (SVC), traditional techniques of 1-patch or 2-patch repair may be challenging. The cavoatrial anastomosis technique (the Warden procedure) was developed to reduce the risk of sinus node dysfunction and SVC obstruction. Herein, we describe the outcomes of the Warden procedure in children at a single institution. METHODS: A retrospective study was conducted on all children with partial anomalous pulmonary venous drainage (PAPVD) undergoing the Warden procedure from 1996 to 2015. RESULTS: There were 42 PAPVD patients with a right upper pulmonary vein entering into the SVC undergoing the Warden procedure. The mean age of the patients at surgery was 5.5 years (71 days to 15.4 years). There was no operative mortality. Median hospital stay was 5 (3-25) days. One (2.4%) patient developed cavoatrial (SVC) obstruction. This patient required percutaneous intervention (stenting and balloon dilatation). There was 1 (2.4%) late death in a patient with PAPVD and pulmonary atresia due to a hypoxic brain injury following catheter intervention for a stenotic conduit. Survival was 97 ± 3% (95% confidence interval 83-100%) at 5 and 7 years. All patients were asymptomatic at a mean follow-up of 6 years (range 1 month to 21 years) after surgery. No patient had sick sinus syndrome, sinus node dysfunction or required permanent pacemaker at follow-up. CONCLUSIONS: The Warden procedure for repair of PAPVD to the SVC can be performed with no operative mortality or permanent pacemaker requirement. Mid-term outcomes are excellent with a low occurrence of SVC obstruction.
The Journal of Thoracic and Cardiovascular Surgery, Jul 1, 2011
Objective: Systemic cooling for cardiopulmonary bypass is widely used to attenuate the systemic i... more Objective: Systemic cooling for cardiopulmonary bypass is widely used to attenuate the systemic inflammatory response syndrome and organ injury in children after open surgery. We compared the effects of moderate (24 C) and mild (34 C) hypothermia during bypass on markers of the systemic inflammatory response syndrome and organ injury, and on clinical outcome after corrective surgery for congenital heart disease. Methods: Sixty-six children (mean age, 6.8 AE 5.7 months; mean weight, 6.2 AE 2.3 kg) were randomized to 24 C or 34 C bypass temperature during cardiac surgery. Perfusion strategies were otherwise strictly identical. Clinical data and blood samples were collected before bypass, 5 minutes after aortic crossclamp release, and 4, 24, and 48 hours after bypass. Patients were followed up until discharge from the hospital. Results: In the 54 children with outcome data, bypass temperature did not influence the duration of mechanical ventilation between the 24 C group and the 34 C group (median [interquartile range] 22 [13-40] hours vs 14 [8-40] hours, P ¼ .14), intensive care unit stay (43 [24-49] hours vs 29 [23-47] hours, P ¼ .79), blood loss (29 [20-38] mL/kg vs 23 [13-38] mL/kg, P ¼ .36), or incidence of postoperative infection (9% vs 11%, P ¼ 1.0). There was no evidence of an influence of bypass temperature on the markers of acute inflammation, innate immune response, organ injury, coagulation, or hemodynamics. Conclusions: There is no evidence that the systemic inflammatory response syndrome and organ injury after pediatric open surgery are influenced by bypass temperature. The routine use of hypothermic bypass may not be warranted in the pediatric population. (J Thorac Cardiovasc Surg 2011;142:174-80) Cardiopulmonary bypass (CPB) used for adult cardiac surgery is now uniformly carried out under normothermic conditions. The temperatures applied in pediatric CPB vary significantly, ranging from deep hypothermia to normothermia. The lack of a consistent approach to CPB temperature in pediatric practice is related to a lack of supportive evidence from well-designed randomized trials. 1,2 This prospective, randomized, blinded study compared the effects of mild (34 C) and moderate hypothermia (24 C) during CPB on the clinical outcome, markers of systemic inflammatory response syndrome (SIRS), and the development of postoperative organ injury in a group of infants and children undergoing open surgery.
Archives of Disease in Childhood, Jun 6, 2016
Objective Historical cohort studies have reported adverse neurodevelopment following cardiac surg... more Objective Historical cohort studies have reported adverse neurodevelopment following cardiac surgery during early infancy. Advances in surgical techniques and perioperative care have coincided with updating of neurodevelopmental assessment tools. We aimed to determine perioperative risk factors for impaired neurodevelopment at 2 years following surgery for congenital heart disease (CHD) in early infancy. Design and patients We undertook a prospective longitudinal study of 153 full-term infants undergoing surgery for CHD before 2 months of age. Infants were excluded if they had a genetic syndrome associated with neurodevelopmental impairment. Outcome measures Predefined perioperative parameters were recorded and infants were classified according to cardiac anatomy. At 2 years, survivors were assessed using the Bayley Scales of Infant Development-III. Results At 2 years, 130 children (98% of survivors) were assessed. Mean cognitive, language and motor scores were 93.4±13.6, 93.6±16.1 and 96.8±12.5 respectively (100±15 norm). Twenty (13%) died and 12 (9%) survivors had severe impairment (score <70), mostly language (8%). The lowest scores were in infants born with single ventricle physiology with obstruction to the pulmonary circulation who required a neonatal systemic-to-pulmonary artery shunt. Additional risk factors for impairment included reduced gestational age, postoperative elevation of lactate or S100B and repeat cardiac surgery. Conclusions In the modern era of infant cardiac surgery and perioperative care, children continue to demonstrate neurodevelopmental delays. The use of updated assessment tools has revealed early language dysfunction and relative sparing of motor function. Ongoing follow-up is critical in this high-risk population.
Heart Lung and Circulation, 2014
Background: Giant left atrium (GLA) is often associated with mitral valve disease. The etiology i... more Background: Giant left atrium (GLA) is often associated with mitral valve disease. The etiology is unclear, but likely related to LA wall stretching under volume or pressure overload. The increase in diameter generates increase in wall tension and may further promote atrial fibrillation. Several procedures have been described to reduce the size of the LA [1–7]. We describe a simple technique for LA reduction that involves isolation of pulmonary veins and excision of the LA appendage. We believe that our reduction technique permits safe resection of excessive LA wall, and yet it is a simple and reproducible approach compared to more complex plications [2,3], resections [5–7] or auto transplantation [4]. There have been several definitions of GLA ranging from 60 to more than 100 mm in diameter. GLA is a risk factor for pre and post operative complications. Increased size of the LA is a substrate for atrial fibrillation. With increasing volume, there is increased risk of thrombus formation, thromboembolic events and arrhythmia (AF). GLA may impair venous return and distort the postero-lateral wall of the left ventricle. Other rare complications may occur due to compression of the bronchial tree, basal segments of lower lobes and oesophagus. GLA can be asymptomatic or present with symptoms of the above mentioned complications, manifesting as arrhythmia, palpitations, chest pain, dyspnoea and thromboembolic events [1]. There is no consensus regarding management of GLA during mitral valve surgery in contemporary practice. Themain indication for surgicalmanagement is compression of the heart or adjacent structures by the GLA. These are usually managed at the time of mitral valve surgery. The literature suggests that the LA should be reduced in size during concomitant mitral valve surgery as well as in casesofmazeprocedure forchronic atrial fibrillation [1].Mortality rate afterGLA reduction during mitral valve repair has been reported up to 8–23% [1,3]. We believe that our reduction technique permits safe resection of excessive LAwall.
Interactive Cardiovascular and Thoracic Surgery, Nov 9, 2021
OBJECTIVES: Left ventricular outflow tract obstruction (LVOTO) is a recognized complication after... more OBJECTIVES: Left ventricular outflow tract obstruction (LVOTO) is a recognized complication after complete repair of atrioventricular septal defect (AVSD). This study reviewed the incidence and management of LVOTO following AVSD repair at a single institution. METHODS: From 1975 to 2019, 24 patients (3.3%, 24/730) underwent reoperation due to LVOTO following partial AVSD (pAVSD) and complete AVSD (cAVSD) repair. The data were retrospectively reviewed.
The Annals of Thoracic Surgery, Jun 1, 2021
This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
European Journal of Cardio-Thoracic Surgery, Oct 23, 2017
OBJECTIVES: Late hypertension after coarctation repair is associated with high mortality, but its... more OBJECTIVES: Late hypertension after coarctation repair is associated with high mortality, but its risk factors remain unclear. This study aims to determine early and late postoperative risk factors for late hypertension after coarctation repair. METHODS: A cross-sectional study including transthoracic echocardiogram and 24-h blood pressure (BP) monitoring was performed in 144 patients aged > _10 years with previous coarctation repair. Median age at repair was 39 days (interquartile range 0-3 years). Early postoperative hypertension was evaluated by calculating the mean of BP measurements taken on the same day before hospital discharge or the need for antihypertensives prior to discharge. Multivariable analyses were performed to adjust for gender, surgical age, and followup age. RESULTS: After a mean follow-up period of 22 ± 7 years, 59% (84/142) of patients were hypertensive: 58% (82/142) on 24-h BP monitoring and 1% (2/142) on antihypertensives. Early postoperative hypertension was present in 58% (73/126): 39% (49/126) on BP measurements and 19% (24/126) on antihypertensives. Early and late arch reobstruction (transthoracic echocardiogram peak gradient > _25 mmHg) was present in 37% (23/62) and 23% (33/144), respectively. On multivariable logistic analysis, early postoperative hypertension and maximum descending arch velocity on echocardiography were associated with late hypertension on 24-h BP monitoring (odds ratio 2.21, 95% confidence interval 1.05-4.66, P = 0.04; and odds ratio 2.28, 95% confidence interval 1.08-4.81, P = 0.03; respectively). CONCLUSIONS: There is a high prevalence of late hypertension after coarctation repair. Arch reobstruction may be a major determinant of late hypertension. Early postoperative hypertension may identify very early in life those at risk of developing late hypertension.
The Journal of Thoracic and Cardiovascular Surgery, Oct 1, 2012
Aortic root dilatation is uncommon in children, with most cases related to congenital heart disea... more Aortic root dilatation is uncommon in children, with most cases related to congenital heart disease and its repair or to connective tissue disorders. 1-3 It rarely causes severe aortic insufficiency or dissection. 4 There are no clear indications for aortic root replacement in asymptomatic children. However, many clinicians would suggest replacing a significantly dilated root when an adult size graft can be implanted. The valve-sparing aortic root replacement has obvious advantages over composite graft and homograft root replacement and is progressively being introduced for pediatric root replacement. The long-term durability of this technique in children has not been defined, and the current literature has suggested that the valve-sparing procedures, especially root remodeling, may have a high failure rate. 1-3
The Journal of Thoracic and Cardiovascular Surgery, May 1, 2021
Objectives: Complete atrioventricular septal defect (cAVSD) repair is usually performed between 3... more Objectives: Complete atrioventricular septal defect (cAVSD) repair is usually performed between 3 and 6 months of age. However, some children present with early heart failure requiring intervention. It is unclear whether primary complete repair or initial pulmonary artery banding (PAB) provides better outcomes. Methods: All patients (n ¼ 194) who underwent surgery for cAVSD younger than 3 months of age between 1990 and 2019 were included. Propensity score matching was performed on risk factors for mortality. Results: Primary complete repair was performed in 77.8% (151/194), whereas PAB was performed in 22.2% (43/194). Children who had PAB were younger (P < .01), had lower weight (P < .001), and less trisomy 21 (P ¼ .04). Interstage mortality for PAB was 18.6% (8/43), whereas early mortality for primary repair was 3.3% (5/151). Survival at 20 years was 92.0% (95% confidence interval [CI], 85.6%-95.7%) for primary repair and 63.2% (95% CI, 42.5%-78.1%) for PAB (P<.001). There was no difference in left atrioventricular valve (LAVV) reoperation rates (P ¼ .94). Propensity score matching produced 2 well-matched groups. Survival at 20 years was 94.2% (95% CI, 85.1%-98.8%) for primary repair, and 58.4% (95% CI, 33.5%-76.7%) for PAB (P ¼ .001). There was no difference in LAVV reoperation rates (P ¼ .71). Neonatal repair was achieved with no early deaths and 100% survival at 10 years. Conclusions: In children younger than 3 months of age, complete repair of cAVSD is associated with better survival than PAB. Both strategies have similar rates of LAVV reoperation. Neonatal repair of cAVSD can be achieved with excellent results. Primary repair of cAVSD should be the preferred strategy in children younger than 3 months of age.
The Journal of Thoracic and Cardiovascular Surgery, Jun 1, 2011
Journal of the American Heart Association, Mar 12, 2013
Background-The Ross procedure in children carries substantial mortality and reoperation rate. Aor... more Background-The Ross procedure in children carries substantial mortality and reoperation rate. Aortic root dilatation is of concern. To prevent dilatation of the neoaortic root, but permit normal growth, we began to apply an absorbable poly-(pdioxanone)-filaments (PDS) band at the sino-tubular (ST)-junction. Methods and Results-All children (n=100) who underwent Ross procedure during 1995-2012 were studied. Mean age at operation was 8.6AE6.1 years (median 8.3 years, range 3 days to 18 years); 19 patients were younger than 1 year of age. The root replacement (n=91, Ross-Konno procedure in 29 patients), root inclusion (n=6), and subcoronary implantation (n=3) techniques were used. Operative mortality was 6% (6/100, 4 neonates, 2 infants). Age of <1-year at time of operation was a risk factor for early death (P<0.001). Mean follow-up time was 7.0AE4.8 years (median 7.4 years, range 5 days to 16 years). Late mortality was 4.3% (4/94). Freedom from moderate or greater neoaortic valve insufficiency (AI) at 5 and 10 years was 89% and 83%, respectively. Freedom from neoaortic valve reoperation at 5 and 10 years was 96% and 86%, respectively. Aortic dilatation to Z-score >4 was greatest at the ST-junction (23%, 11/48) compared to the aortic annulus (17%, 11/66) and sinuses (14%, 7/50). Since 2001, a PDS band was placed around the ST-junction in 19 patients. Survivors with the PDS band had less AI (0 versus 20%, P=0.043) compared to survivors (n=35) without the PDS at 4.1AE3 years. Conclusions-The Ross procedure in children can be performed with acceptable results. Children younger than 1 year of age have higher mortality, but not an increased autograft reoperation rate. Stabilization of the ST-junction may reduce AI.
The Annals of Thoracic Surgery, May 1, 2014
Background. Absent pulmonary valve syndrome is associated with aneurysmal dilatation of the pulmo... more Background. Absent pulmonary valve syndrome is associated with aneurysmal dilatation of the pulmonary arteries and compression of the tracheobronchial tree and may lead to significant respiratory compromise. We describe the outcomes of surgical correction of absent pulmonary valve syndrome and risk factors for mortality and reoperation. Methods. A review of 52 patients with absent pulmonary valve syndrome who underwent surgical correction between 1975 and 2013 was conducted. The median age and weight at repair were 9 months (range, 4 days to 24.2 years) and 6.9 kg (range, 1.8 to 56 kg). Preoperative intubation was required in 15 patients (29%), and 21 patients (40%) underwent urgent repair. The pulmonary valve was replaced with a valved conduit in 16 patients (31%) or monocusp valve in 16 patients (31%). Valveless repair was performed in 20 patients (38%). Pulmonary artery reduction was performed in 39 patients (75%), and 2 patients (4%) underwent a Lecompte maneuver. Results. The median follow-up time was 13 years (range, 1 month to 35 years). Early mortality was 18.8%
The Annals of Thoracic Surgery, May 1, 2016
Background. Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare congenita... more Background. Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital heart defect with limited data on long-term outcomes after surgical intervention. Methods. We conducted a retrospective review of all children (N [ 42) who underwent surgical repair of ALCAPA between 1980 and 2014 at the Royal Children's Hospital, Melbourne. Results. Twenty-nine (69% [29 of 42]) patients underwent coronary reimplantation, 12 (29% [12 of 42]) had intrapulmonary baffle (Takeuchi) repair, and 1 (2% [1 of 42]) patient had ligation of the anomalous coronary artery. Nine (21%, 9 of 42) patients had concomitant mitral valve (MV) repair at the time of ALCAPA repair. A left ventricular assist device (LVAD) was used in 36% (15 of 42) of patients. Early mortality was 2.4% (1 of 42 patients). Median follow-up was 14 years (mean, 13 years; range, 4 months-31 years). There were no late deaths.
Perfusion, Feb 7, 2023
Peripheral veno-artertial extracorporeal membrane oxygenation (VA-ECMO) is commonly used in the p... more Peripheral veno-artertial extracorporeal membrane oxygenation (VA-ECMO) is commonly used in the paediatric population for intractable respiratory and cardiac failure. One of the devastating complications of VA-ECMO is severe brain damage due to ischemia or haemorrhage. We describe a case of peripheral cervical VA-ECMO complicated by evolving right cerebral ischemia which was rescued with rapid conversion from peripheral to central VA-ECMO support. Notably, the patient had a complete circle of Willis. Following conversion, we observed complete resolution of neurological symptoms with full functional recovery.
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Papers by Christian Brizard