Rubén A Quintero

Jackson Memorial Hospital, Miami, Florida, United States

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Publications (190)814.07 Total impact

  • [Show abstract] [Hide abstract]
    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 · 1.53 Impact Factor
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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; DOI:10.1016/j.ajog.2015.03.050 · 3.97 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. © 2015 S. Karger AG, Basel.
    Fetal Diagnosis and Therapy 02/2015; 37(4). DOI:10.1159/000365919 · 2.30 Impact Factor
  • American Journal of Obstetrics and Gynecology 01/2015; 212(1):S104. DOI:10.1016/j.ajog.2014.10.225 · 3.97 Impact Factor
  • American Journal of Obstetrics and Gynecology 01/2015; 212(1):S162-S163. DOI:10.1016/j.ajog.2014.10.348 · 3.97 Impact Factor
  • American Journal of Obstetrics and Gynecology 01/2015; 212(1):S91-S92. DOI:10.1016/j.ajog.2014.10.196 · 3.97 Impact Factor
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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 · 3.14 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 · 3.97 Impact Factor
  • Ultrasound in Obstetrics and Gynecology 08/2014; 44(2). DOI:10.1002/uog.13425 · 3.14 Impact Factor
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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. DOI:10.1055/s-0034-1382774 · 1.60 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 01/2014; 210(1). DOI:10.1002/pd.4353 · 2.51 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; DOI:10.3109/14767058.2013.871701 · 1.21 Impact Factor
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    Ultrasound in Obstetrics and Gynecology 10/2013; 42(s1). DOI:10.1002/uog.13037 · 3.14 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 · 3.97 Impact Factor
  • Ruben A Quintero, Eftichia V Kontopoulos
    01/2013; 7:415-425. DOI:10.5005/jp-journals-10009-1312
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    ABSTRACT: Abstract Objectives: To assess whether the observed vs. expected lung-to-head ratio (o/e LHR) corrects for the dependence of the LHR on gestational age. Study Design: Published data on right lung area (LA) and LHR were used to plot the 50(th) percentile and different fixed values of the o/e LHR (e.g., 30%) against gestational age from 16-32 weeks. The Z-scores for various fixed o/e LHR values and similar percent value of lung area were calculated. The effect of using a fixed LHR or a fixed o/e LHR were tested against gestational age. The o/e LHR- equivalent to a fixed LHR of 1.0 was assessed against gestational age. Results: The LHR and the o/e LHR both increase with gestational age. The Z-scores of a given fixed value of the o/e LHR (e.g., 30%) is not similar to the Z-score of the same percent (e.g., 30%) of the expected LA, and thus identify different proportions of subjects. A fixed o/e LHR (e.g., 30%) results in different populations, depending on the gestational age. The o/e LHR equivalent to an LHR value of 1.0 decreases from 80% at 16 weeks to 30% at 32 weeks. Conclusions: The o/e LHR is not independent of gestational age. Studies using this parameter should be interpreted with caution.
    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 10/2012; DOI:10.3109/14767058.2012.736000 · 1.21 Impact Factor
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    ABSTRACT: The purpose of this study was to evaluate the phenomenon of vascular ischemic limb necrosis in twin-twin transfusion syndrome (TTTS). This was a multicenter retrospective review of ischemic limb necrosis in patients with TTTS. Twenty cases of fetal ischemic limb necrosis in association with TTTS were identified from 10 fetal medicine centers. The recipient was affected in 19 cases, and the lower limb was affected in 17 cases. The extent of the damage correlated with TTTS severity. Eighty percent of limb defects (16/20) clearly were unrelated to laser treatment (3 cases untreated, 7 cases after amnioreduction, 6 cases present at time of laser). The recipient was relatively polycythemic in 5 of 7 cases in which neonatal or fetal hemoglobin/hematocrit levels were available. Ischemic limb necrosis is a rare complication of TTTS. The lesion is unrelated to therapy and may be the result of polycythemia, hypertension, and vasoconstriction.
    American journal of obstetrics and gynecology 08/2012; 207(2):131.e1-10. DOI:10.1016/j.ajog.2012.06.005 · 3.97 Impact Factor
  • Paediatric respiratory reviews 06/2012; 13:S1. DOI:10.1016/S1526-0542(12)70003-9 · 2.22 Impact Factor
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    ABSTRACT: Objective: To evaluate pulmonary growth and development after fetoscopic intraluminal tracheal occlusion (FITO) using a modified 8-mm Z-stent in an ovine model of congenital left-sided diaphragmatic hernia (CDH). Methods: Thirty-three time-dated ewes were studied: Group I: healthy controls; Group II: CDH controls (untreated); Group III: CDH treated with FITO. CDH was created in Groups II and III at 70-80 days' gestation. FITO was performed at 100-110 days. Left lung histological, morphometric, immunohistochemical and biochemical studies were conducted after delivery and euthanasia at 138 days. Results: Fifteen (45%) animals (Group I: 3; Group II: 5; Group III: 7) were available for analysis. The left lung parenchymal volume to fetal weight ratios were similar between Groups I and III (p = 0.24), and higher than Group II (p < 0.05III (79 versus 75%, p = 0.26), compared to 41% in Group II (p < 0.05). Pulmonary hypoplasia occurred in 1/7 (16%) in the FITO group, compared to 100% in Group II and 0% in Group I (p = .003). DNA and protein were significantly increased in Group III (p < 0.001). The concentration of type II pneumocytes was similar between healthy controls and the FITO group, and was paradoxically increased in untreated hernia fetuses. There was no histological evidence of tracheal injury. Conclusion: FITO with a modified 8-mm Z-stent is associated with lung growth and maturation similar to controls without obvious deleterious effects. A phase I clinical trial of FITO with the modified 8-mm Z-stent in severe CDH patients seems warranted.
    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 05/2012; 25(11):2346-53. DOI:10.3109/14767058.2012.695825 · 1.21 Impact Factor
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    ABSTRACT: Objective: To report the performance of fetal bronchoscopy in a case of pulmonary sequestration. Materials and Methods: A 24 year-old female, Gravida 2, Para 1, was referred at 27.5 weeks with a large fetal left lung mass with marked right mediastinal shift and no visible normal left lung. Differential diagnosis included possible bronchial atresia. Results: The patient underwent fetal laryngoscopy and fetal bronchoscopy at 31.5 weeks. The right lung and a portion of the left lung expanded during surgery as a result of bronchial lavage. Bronchial atresia or bronchogenic cyst were not found. Pregnancy continued uneventfully, with continuous growth of the right lung and a small amount of left lung. The patient delivered vaginally at term. The baby underwent thoracoscopic resection of a pulmonary sequestration at 10.5 months of age and did well. Conclusion: Fetal bronchoscopy is feasible. The procedure may prove useful in the differential diagnosis and in the potential treatment of different fetal lung lesions, as well as aid in the understanding of the role of bronchial obstruction as a common pathophysiologic mechanism for different fetal lung masses. Risks and benefits of fetal bronchoscopy warrant further experience.
    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 05/2012; 25(11):2354-8. DOI:10.3109/14767058.2012.695826 · 1.21 Impact Factor

Publication Stats

3k Citations
814.07 Total Impact Points

Institutions

  • 2013–2015
    • Jackson Memorial Hospital
      Miami, Florida, United States
    • University of São Paulo
      San Paulo, São Paulo, Brazil
  • 2012
    • Venezuelan Institute for Scientific Research
      Caracas, Distrito Federal, Venezuela
  • 2009–2012
    • University of Miami
      • Department of Obstetrics and Gynecology
      كورال غيبلز، فلوريدا, Florida, United States
  • 2010
    • University of Miami Miller School of Medicine
      Miami, Florida, United States
  • 2008–2009
    • University of Southern California
      • Department of Obstetrics and Gynecology
      Los Angeles, CA, United States
    • Tampa General Hospital
      Tampa, Florida, United States
    • University of Maryland, Baltimore
      Baltimore, Maryland, United States
    • Kaiser Permanente
      Oakland, California, United States
  • 1999–2009
    • University of South Florida
      • • Department of Obstetrics and Gynecology
      • • Morsani College of Medicine
      Tampa, Florida, United States
  • 2007
    • Central University of Venezuela
      Caracas, Distrito Federal, Venezuela
    • Università degli Studi di Siena
      Siena, Tuscany, Italy
  • 1997–2007
    • St. Joseph's Hospital
      Savannah, Georgia, United States
  • 2006
    • University of Pittsburgh
      • Department of Obstetrics, Gynecology and Reproductive Sciences
      Pittsburgh, Pennsylvania, United States
    • University of Washington Seattle
      • Department of Obstetrics and Gynecology
      Seattle, Washington, United States
    • Florida Heart Research Institute
      Miami, Florida, United States
  • 2004
    • University of California, San Diego
      San Diego, California, United States
  • 2003
    • Hospital Universitario de Caracas
      Caracas, Distrito Federal, Venezuela
    • Mater Hospital
      Brisbane, Queensland, Australia
  • 1993–1997
    • Wayne State University
      • Department of Obstetrics and Gynecology
      Detroit, MI, United States