Rubén A Quintero

Jackson Memorial Hospital, Miami, Florida, United States

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Publications (110)411.38 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: A recent randomized clinical trial (MOMS trial) showed that prenatal correction of open spina bifida (OSB) via open fetal surgery was associated with improved infant neurological outcomes relative to postnatal repair, but at the expense of increased maternal morbidity. Objective: To report the final results of our phase I trial (the CECAM trial) on the feasibility, safety, potential benefits and side effects of the fetoscopic treatment of open spina bifida using our unique surgical technique. Study design: Ten consecutive pregnancies with lumbo-sacral OSB were enrolled in the study. Surgeries were performed percutaneously under general anesthesia with three ports and partial CO2 insufflation. After appropriate surgical positioning of the fetus, the neuroplacode was released with scissors and the skin was undermined to place a biocellulose patch over the lesion. The skin was closed over the patch using a single running stitch. Pre-operative, post-operative and postnatal MRI were performed to assess hindbrain herniation. Neurodevelopmental evaluation was performed before discharge and at 3, 6 and 12 months. All cases were delivered by cesarean section, at which time the uterus was assessed for evidence of thinning or dehiscence. Results: The median gestational age at the time of surgery was 27 weeks (range 25 to 28 weeks). Endoscopic repair was completed in 8/10 fetuses. Two cases were unsuccessful due to loss of uterine access. The mean gestational age at birth was 32.4 weeks with a mean latency of 5.6 weeks between surgery and delivery (range 2-8 weeks). There was one fetal and one neonatal demise, and one unsuccessful case underwent postnatal repair. Of the 7 infants available for analysis, complete reversal of hindbrain herniation occurred in 6/7 babies. Three babies required ventriculoperitoneal shunting or third ventriculostomy. Functional motor level was the same or better than the anatomical level in 6/7 cases. There was no significant maternal morbidity and no evidence of myometrial thinning or dehiscence. However, surgeries were complicated by premature rupture of membrane and prematurity. Conclusions: Our study suggests that the antenatal treatment of OSB using a fetoscopic approach and our unique surgical technique can result in a watertight seal, reversal of the hindbrain herniation, and a better than expected motor function. Our technique differs substantially from the classic repair of OSB used in prior open fetal surgery and fetoscopic studies, in which the dura mater is dissected and the defect is closed in multiple layers. Instead, we use a biocellulose patch placed over the lesion and simple closure of the skin. As such, our technique is an alternative to the current paradigms in the antenatal treatment of OSB. Our clinical outcomes are in line with the results of our extensive prior animal work. Maternal benefits of our approach and technique include minimal morbidity and no myometrial legacy. Current limitations of the approach include potential loss of access, premature rupture of membranes and attendant prematurity. Phase II trials are needed to prevent these complications and to further assess the risks and benefits of our distinct surgical approach and technique.
    American journal of obstetrics and gynecology 09/2015; DOI:10.1016/j.ajog.2015.09.065 · 4.70 Impact Factor
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    ABSTRACT: Objective: To assess fetal growth after laser surgery for TTTS at the time of prenatal diagnosis, birth, and at 2years of age. Design/methods: Growth data were collected from surviving children treated between 2007 and 2010 as part of a study to assess neurodevelopment at 24months (±6weeks) corrected age. Fetal weights were obtained via ultrasound using Hadlock's formula at the time of preoperative assessment for laser surgery. Birth weights were recorded by the staff at the delivering institutions. Weights at 2years corrected age were recorded at the time of neurodevelopmental testing. Weights were converted into percentiles according to standard growth curves. Growth restriction was defined as <10th percentile for given age. Multilevel latent growth curve models in Mplus (twins nested in families) examined weight change over time as a function of donor status, and repeated measures ANOVA was utilized to assess in donor-recipient weight discordance over time for twin pairs. Results: 99 of 206 children (56 of 130 families) were studied. There were no differences between enrolled and non-enrolled patients in donor/recipient status and survival rates, fetal demise, intrauterine growth restriction, Quintero stage, and gestational age of surgery or delivery. 48.5% were donors. The median fetal, birth, and 2-year weights for all twins were 288g, 1.9kg, and 11.8kg, respectively, and the overall prevalence of growth restriction was 28%, 22%, and 3%, respectively. Growth restriction rates at prenatal diagnosis were 56% in donors vs. 2% in recipients (OR=64.3, p<0.001); at birth, 35% vs. 10% (OR=5.0, p<0.01); and at 2years, 6% vs. 0%. Donors showed significant gains in weight percentile (B=13.1, p<0.001) and a significant decrease in growth restriction rates over time (B=-1.6, p<0.001). Weight discordance between donor and recipient pairs also significantly decreased over time (linear F(1,42)=54.34, p<0.001). Conclusions: After laser surgery for TTTS, donor twins exhibit significant catch-up growth by two years of age.
    Early human development 09/2015; DOI:10.1016/j.earlhumdev.2015.08.006 · 1.79 Impact Factor

  • Ultrasound in Obstetrics and Gynecology 09/2015; 46(S1):30-30. DOI:10.1002/uog.15039 · 3.85 Impact Factor
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    ABSTRACT: Invasive fetal cardiac intervention (FCI) has been reported in single-institution series, promoting technical and physiologic success. This study describes the creation of an international registry of cases presenting for FCI, intended to compile technical and outcome data from a multicenter cohort. For this initial analysis, the entire database of the International Fetal Cardiac Intervention Registry (IFCIR) was queried for details of diagnoses, procedures, and outcomes. Maternal-fetal dyads from January 2001 through June 2014 were included. Eighteen institutions submitted data by data harvest. Of 370 cases entered, 245 underwent FCI: 100 aortic valvuloplasties from a previous single-center report (excluded from additional reporting here), an additional 86 aortic and 16 pulmonary valvuloplasties, 37 atrial septal cases, and 6 unclassified cases. FCI did not appear to affect overall survival to hospital discharge. Among live-born infants with a fetal diagnosis of aortic stenosis/evolving hypoplastic left heart syndrome, more than twice as many were discharged with biventricular circulation after successful FCI versus those meeting institutional criteria but without any or successful FCI (42.8% vs. 19.4%, respectively). When fetal deaths were counted as treatment failures, the percentages were similar: biventricular circulation at discharge was 31.3% versus 18.5% for those discharged with univentricular palliation. Survival to discharge for live-born fetuses with atrial restriction was similar to that of those undergoing technically successful versus unsuccessful FCI (63.6% vs. 46.7%, respectively), although criteria for diagnosis were nonuniform. We describe the contents of the IFCIR and present post-natal data to suggest potential benefit to fetal therapy among pregnancies considered for possible intervention and support proposals for additional work. Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
    Journal of the American College of Cardiology 07/2015; 66(4):388-99. DOI:10.1016/j.jacc.2015.05.037 · 16.50 Impact Factor
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    ABSTRACT: Selective reduction (SR) via intravascular potassium chloride (KCl) injection is contraindicated in monochorionic twins due to the presence of placental vascular communications, which may serve as a conduit for inter-twin passage of KCl or allow exsanguination of the living twin into the demised twin. After successful selective laser photocoagulation of communicating vessels (SLPCV) for twin-twin transfusion syndrome (TTTS), the twins' circulatory systems are rendered independent. Theoretically, intravascular KCl injection into one twin after successful SLPCV should not result in passage of the feticidal agent nor cause hemodynamic alterations in the co-twin. We describe 3 cases of 1,069 patients (0.3%) that underwent SLPCV for TTTS between 2003 and 2013 and subsequent SR. SLPCV was successfully completed at 18(0), 22(6), and 23(0) weeks' gestational age for Quintero stages III, IV, and III TTTS, respectively. SR via intravascular KCl injection was later performed at maternal request due to the risk of neurological compromise in one twin at 22(6), 25(4), and 23(6) weeks' gestational age. All co-twins survived after SR, and no neurological sequelae were suspected after birth. Further study is necessary before SR can be routinely considered after laser surgery for TTTS. © 2015 S. Karger AG, Basel.
    Fetal Diagnosis and Therapy 06/2015; DOI:10.1159/000431255 · 2.94 Impact Factor
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    ABSTRACT: In twin-twin transfusion syndrome (TTTS), persistent absent or reversed end-diastolic flow in the umbilical artery is a rare finding in the recipient twin, and the clinical implications of this finding are not well characterized. We sought to study the clinical importance of abnormal umbilical artery Doppler waveforms in recipient twins and determine the perinatal survival of these twins after laser surgery. A retrospective study of patients with TTTS treated with laser surgery between 2006 and 2012 was conducted. Recipient twins with absent or reversed umbilical artery end-diastolic flow on preoperative sonography were identified, and clinical and perinatal outcomes were compared to the remaining cohort. Statistical analyses were performed with Fisher exact and χ(2) tests. Of 369 consecutive TTTS cases, 14 (3.8%) had absent or reversed umbilical artery end-diastolic flow in the recipient twin. The rate of hydrops was higher in this group compared to those without absent or reversed flow (35.7% [5 of 14] versus 10.1% [36 of 355]; P = .0125). The rate of recipient twin growth restriction was also higher in the absent or reversed flow group (28.6% [4 of 14] versus 3.9% [14 of 355]; P = .0029). There was an increased rate of recipient fetal demise within 24 hours after surgery in those with absent or reversed flow (21.4% [3 of 14] versus 2.5% [9 of 355]; P = .0078), although there was no statistical difference in 30-day survival between the groups (78.6% [11 of 14] versus 89.9% [319 of 355]; P = .1751). Doppler findings of absent or reversed umbilical artery end-diastolic flow are rare in recipient twins. Although immediate post-laser surgery survival is relatively decreased in this group, overall perinatal survival rates appear to be favorable. © 2015 by the American Institute of Ultrasound in Medicine.
    Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine 05/2015; 34(5):843-846. DOI:10.7863/ultra.34.5.843 · 1.54 Impact Factor
  • Eftichia Kontopoulos · Jon Barrett · Ramen Chmait · Ruben Quintero ·
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    ABSTRACT: We propose that twins be labeled at birth by birth order ("1" or "2"), while keeping their antenatal label as "A" or "B." Copyright © 2015 Elsevier Inc. All rights reserved.
    American journal of obstetrics and gynecology 03/2015; 213(2). DOI:10.1016/j.ajog.2015.03.050 · 4.70 Impact Factor
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    ABSTRACT: Introduction: Twin-twin transfusion syndrome (TTTS) and twin anemia-polycythemia sequence (TAPS) are classified as distinct clinical disorders associated with unbalanced blood flow through placental vascular communications. Typically, TAPS placentas demonstrate few <1 mm arteriovenous (AV) communications, and at fetoscopy the twins are visibly pale and plethoric. Materials and methods: In a cohort of TTTS patients who underwent laser surgery, those with preoperative findings suggestive of anemia/polycythemia (AP) were compared to those with TTTS alone. AP was defined as middle cerebral artery peak systolic velocity in one twin >1.5 multiples of the median (MoM), and <1.0 MoM in the other. Results: Of 369 TTTS patients, 9 (2.4%) met criteria for preoperative AP. The mean number (±SD) of AV communications in the TTTS + AP group was 5.6 ± 5.7, compared with 8.8 ± 4.8 in the TTTS-alone group (p = 0.013). Five TTTS + AP patients (56%) had a few thin AV communications (mean 2.8 ± 1.6); all 5 had visibly pale and plethoric twins. The remaining 4 (44%) had large or numerous anastomoses (mean 10.5 ± 6.8); none had fetal skin color discordance. Discussion: Preoperative AP affected 2% of TTTS patients. Of these, approximately half had placental and skin color findings typically reported with isolated TAPS.
    Fetal Diagnosis and Therapy 02/2015; 37(4). DOI:10.1159/000365919 · 2.94 Impact Factor

  • American Journal of Obstetrics and Gynecology 01/2015; 212(1):S91-S92. DOI:10.1016/j.ajog.2014.10.196 · 4.70 Impact Factor

  • American Journal of Obstetrics and Gynecology 01/2015; 212(1):S104. DOI:10.1016/j.ajog.2014.10.225 · 4.70 Impact Factor
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    American Journal of Obstetrics and Gynecology; 01/2015
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    ABSTRACT: Objective To determine expert consensus on substeps of fetoscopic laser surgery (FLS) for twin-to-twin transfusion syndrome (TTTS) required for an authority-based curriculum for fetal medicine specialists in training for this procedure.MethodsA Delphi survey was conducted among an international panel of experts (n = 98) in fetoscopic laser surgery. Experts rated the substeps of laser surgery on a 5-point Likert-type scale and were able to comment on each substep using a dedicated online platform, accessed by invited tertiary care facilities specialized in fetal therapy. Responses were returned to the panel until consensus was reached. (Crohnbach's α ≥ .80). All substeps that 80% of experts rated as ≥4 were included in the evaluation instrument.ResultsAfter the first iteration of the Delphi procedure, a response rate of 74% (73/98) was reached, in the second and the third iteration response rates of respectively 90% (66/73) and 81% (59/73) were reached. Of the total of 81 substeps rated in the first round, 20 substeps had to be rerated in the second round. Finally, the initial list of substeps was reduced to 55 on which experts agreed to be essential. In the third round the substeps were ranked in order of importance; with ‘coagulation of all anastomoses that cross equator’ and ‘determine fetoscope insertion site’ as most important.ConclusionsA list of 55 essential substeps of FLS for TTTS was defined. This list is the first authority-based evidence to be used for a final training model for future fetal surgeons.
    Ultrasound in Obstetrics and Gynecology 12/2014; 45(4). DOI:10.1002/uog.14761 · 3.85 Impact Factor
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    ABSTRACT: Abstract Objective: To evaluate the impact of selective intrauterine growth restriction (SIUGR) on monochorionic multiples treated with selective laser photocoagulation of communicating vessels (SLPCV) for twin-twin transfusion syndrome (TTTS). Methods: Perinatal survival was compared among TTTS patients with and without SIUGR. The TTTS+SIUGR group was defined as TTTS patients with donor twin weight <10(th) percentile. Multivariable logistic regression analyses identified factors associated with 30-day survival. Results: Of 369 patients, 65% (N=241) had TTTS+SIUGR. 30-day donor twin survival for the TTTS-only group was 84% vs. 75% in the TTTS+SIUGR group (p=0.0348). Stage III Donor-involved (Stage III Donor, Donor/Recipient) TTTS+SIUGR patients (N=110) had 66% 30-day donor survival. Multivariable logistic regression demonstrated that the TTTS-only group was twice as likely to achieve donor survival compared to the TTTS+SIUGR group (OR 2.01, 95%CI 1.11-3.66, p = 0.0214). In the TTTS+SIUGR group, patients not classified as Stage III Donor-involved were twice as likely to achieve donor survival as Stage III Donor-involved patients (OR 2.02, 95%CI 1.10-3.71, p = 0.0226). Conclusions: SIUGR, present in two-thirds of TTTS patients, was a risk factor for decreased donor survival. Patients with donor SIUGR and umbilical artery persistent or reversed end-diastolic flow (Quintero Stage III Donor-involved) were especially at risk.
    American Journal of Obstetrics and Gynecology 09/2014; 210(1):1-17. DOI:10.3109/14767058.2014.960834 · 4.70 Impact Factor
  • R. H. Chmait · E. Kontopoulos · R. Quintero ·

    Ultrasound in Obstetrics and Gynecology 08/2014; 44(2). DOI:10.1002/uog.13425 · 3.85 Impact Factor
  • Ramen H Chmait · Eftichia V Kontopoulos · Rubén A Quintero ·
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    ABSTRACT: Treatment of twin-twin transfusion syndrome (TTTS) via the sequential selective laser photocoagulation of communicating vessels (SQLPCV) technique involves lasering the arteriovenous communications from the donor twin to the recipient twin first, followed by the arteriovenous communications from the recipient twin to the donor. Occluding the vascular communications in this particular order may result in transient intraoperative net transfusion to the donor twin and facilitate hemodynamic equilibrium, particularly to the volume depleted donor twin. Preliminary evidence suggests that the SQLPCV technique may result in improved perinatal outcomes compared with the standard selective (SLPCV) laser surgical approach. In this article, we describe the pathophysiological basis for this surgical approach, delineate the surgical technique, review the literature, and elaborate on the outstanding questions of the SQLPCV treatment of TTTS.
    American Journal of Perinatology 06/2014; 31(S 01). DOI:10.1055/s-0034-1382774 · 1.91 Impact Factor
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    ABSTRACT: Objective To analyze perinatal outcome in monoamniotic (MA) pregnancies that underwent antenatal surgical interventions for fetal complications. Methods Review of all MA pregnancies treated with antenatal surgical interventions in 3 Fetal Treatment Centers between 2000 and 2013. Indications were twin-twin transfusion syndrome, twin reversed arterial perfusion sequence, discordant anomalies or elective reduction. We analyzed associations between indication, type of intervention, perinatal survival and gestational age (GA) at birth, and compared our results with a systematic review of the literature. ResultsFifty-eight MA pregnancies were included. Median GA at treatment was 18.0 weeks (range: 13.1 - 33.0). Procedures included cord coagulation plus transection (n = 42), cord coagulation without transection (n = 7), laser coagulation of placental anastomoses (n = 7), and one case each with interstitial laser and radiofrequency ablation. Median GA at birth was 34 weeks (range 16.0 - 41.0) and 75% (53/71) of fetuses intended to survive indeed survived. Literature review: 20 articles, reporting on a total of 45 cases of surgically treated MA pregnancies, showing similar outcome results. Conclusion We present the largest series concerning surgical interventions in complicated MA pregnancies. Despite being rare in experienced hands, a 75% survival is achieved. Collaboration between centers, data-sharing and benchmarking may further improve outcome. This article is protected by copyright. All rights reserved.
    Prenatal Diagnosis 06/2014; 210(1). DOI:10.1002/pd.4353 · 3.27 Impact Factor
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    ABSTRACT: Abstract Objective: To report our preliminary clinical experience in the antenatal correction of open spina bifida using a fetoscopic approach and a simplified closure technique. Methods: Four fetuses with lumbar-sacral defects were operated in utero from 25 to 27 weeks. Surgeries were performed percutaneously under general anesthesia using three trocars and partial carbon dioxide insufflation. After dissection of the neural placode, the surrounding skin was closed over a cellulose patch using a single continuous stitch. Results: Surgical closure was successful in three of the 4 cases. All successful cases showed improvement of the hindbrain herniation and no neurosurgical repair was required in two cases. Delivery occurred between 31 to 33 weeks, and no fetal or neonatal deaths occurred. Ventriculoperitoneal shunting was not needed in 2/3 successful cases. Conclusions: Our preliminary experience suggests that definitive fetoscopic repair of open spina bifida is feasible using our innovative surgical technique. A phase I trial for the fetoscopic correction of OSB with this technique is currently being conducted.
    The journal of maternal-fetal & neonatal medicine: the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians 12/2013; 27(16). DOI:10.3109/14767058.2013.871701 · 1.37 Impact Factor
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    Ultrasound in Obstetrics and Gynecology 10/2013; 42(s1). DOI:10.1002/uog.13037 · 3.85 Impact Factor
  • Ruben A. Quintero · Ramen Chmait · Eftichia Kontopoulos ·

    American journal of obstetrics and gynecology 03/2013; 209(2). DOI:10.1016/j.ajog.2013.03.018 · 4.70 Impact Factor
  • Ruben A Quintero · Eftichia V Kontopoulos ·
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    ABSTRACT: The ultrasound diagnosis, management and treatment of twin-twin transfusion syndrome (TTTS) have had a remarkable number of positive developments in the last 20 years. Together, they have resulted in TTTS being the most common condition seen and treated in fetal therapy centers today. This chapter discusses the basic ultrasound assessment of TTTS patients in a step-by-step fashion, to provide a structure to the sonographic examination. This includes review of the diagnostic criteria, the sonographic assessment of disease severity and preoperative ultrasound assessment. The chapter also reviews the rationale for, as well as the fundamental laser technique and its variations, including the nonselective technique, selective laser photocoagulation of communicating vessels (SLPCV), sequential selective laser photocoagulation of the communicating vessels (SQLPCV) and the 'Solomon' technique, and provides potential explanations for the outcome differences of each technique. Future developments in terms of surgical technique and long-term outcome studies are also discussed.
    Donald School Journal of Ultrasound in Obstetrics and Gynecology 01/2013; 7(4):415-425. DOI:10.5005/jp-journals-10009-1312

Publication Stats

2k Citations
411.38 Total Impact Points


  • 2013-2015
    • Jackson Memorial Hospital
      Miami, Florida, United States
  • 2009-2015
    • University of Miami Miller School of Medicine
      • Department of Obstetrics and Gynecology
      Miami, Florida, United States
  • 2009-2012
    • University of Miami
      • Department of Obstetrics and Gynecology
      كورال غيبلز، فلوريدا, Florida, United States
  • 2010
    • Hospitales Angeles
      Ciudad de México, Mexico City, Mexico
  • 1999-2009
    • University of South Florida
      • • Department of Obstetrics and Gynecology
      • • Morsani College of Medicine
      Tampa, Florida, United States
  • 2008
    • University of Maryland, Baltimore
      Baltimore, Maryland, United States
    • Kaiser Permanente
      Oakland, California, United States
    • University of Southern California
      • Department of Obstetrics and Gynecology
      Los Angeles, CA, United States
  • 2006-2008
    • Tampa General Hospital
      Tampa, Florida, United States
    • University of Pittsburgh
      • Department of Obstetrics, Gynecology and Reproductive Sciences
      Pittsburgh, Pennsylvania, United States
  • 2007
    • Università degli Studi di Siena
      Siena, Tuscany, Italy
  • 1998-2007
    • St. Joseph's Hospital
      Savannah, Georgia, United States
  • 2003
    • Mater Hospital
      Brisbane, Queensland, Australia