Papers by ALEJANDRO TORRES
Seminars in Thoracic and Cardiovascular Surgery, 2020
Objective: Despite improvements in operative and perioperative care, the risk of significant morb... more Objective: Despite improvements in operative and perioperative care, the risk of significant morbidity and mortality for children undergoing Fontan procedures persists. Previous investigations have identified peri-Fontan characteristics that may predict early adverse events. The purpose of this study was to identify characteristics from throughout a patient's lifespan, including all perioperative stages, that might predict early Fontan failure-defined as death, Fontan takedown, or listing for cardiac transplantation before hospital discharge or within 30 postoperative days. Methods: A single-center retrospective study of all patients undergoing a Fontan procedure was performed. Patient and intervention-related characteristics were examined from birth through Fontan. Data were described using standard summary statistics. Univariable, logistic regression was used to examine associations with early Fontan failure. Results: In total, 191 patients met inclusion criteria. The incidence of early Fontan failure was 4% (n = 8: six deaths, two Fontan takedowns). Neonatal balloon atrial septostomy was the only patient characteristic significantly associated with Fontan failure. Patients who underwent balloon septostomy had 8.5-times higher odds of Fontan failure (CI 2.6-28.1, p < 0.001) than those who did not. Conclusions: Children who require balloon septostomy as neonates remain at higher risk of Fontan takedown, listing for heart transplantation, or death in the early post-Fontan period.
The Journal of thoracic and cardiovascular surgery, Jan 11, 2018
Surgical options for children with irreparable mitral valve (MV) disease are limited, consisting ... more Surgical options for children with irreparable mitral valve (MV) disease are limited, consisting primarily of fixeddiameter valves or homografts that cannot grow, have poor longevity, or require anticoagulation. To avoid these problems, multiple groups have reported surgically implanting transcatheter valves in the mitral position. 1-4 The most widely used is the Melody valve (Medtronic Inc, Parsippany, NJ), a stented, valved bovine jugular vein graft. Because of its design, specifically its length, the Melody valve presents unique challenges when used for MV replacement, including left ventricular outflow tract (LVOT) and pulmonary vein (PV) obstruction. We present a modified technique for Melody valve implantation in the mitral position that simplifies previous techniques and minimizes these complications.
The Journal of thoracic and cardiovascular surgery, Jan 16, 2018
Video clip is available online. We present a case of hepatic venous baffle obstruction in left at... more Video clip is available online. We present a case of hepatic venous baffle obstruction in left atrial isomerism and dextrocardia in which surgical revision was complicated by atrial size discrepancy and portal hypertension-related varices. A suprahepatic to innominate vein conduit was used to provide hepatic venous egress.
Pediatric cardiology, Jan 15, 2017
Recurrence of subaortic stenosis (SAS) after surgery is common in children. The effects of patien... more Recurrence of subaortic stenosis (SAS) after surgery is common in children. The effects of patient characteristics and surgical timing on disease recurrence are largely unknown. We performed a retrospective study, assessing the relative effects of patient age and left ventricular outflow tract (LVOT) gradient on the need for reoperation for recurrent SAS. We included all children <20 years of age who underwent initial surgical resection of SAS at our center, January 2003-December 2013. Stratified logistic regression was performed, considering the effects of patient demographics, clinical characteristics, echocardiographic parameters, and operative technique, and clustering standard errors by surgeon. The multivariable model was used to simulate predicted probabilities of recurrent SAS for children at varying ages and baseline LVOT gradients. Sixty-three patients (38 males) underwent initial operation for SAS. Patients were followed for a median of 3.7 years (IQR 1.2-7.1). Twenty-...
European heart journal. Acute cardiovascular care, Jan 14, 2016
Transcatheter techniques are emerging for left atrial (LA) decompression under venoarterial extra... more Transcatheter techniques are emerging for left atrial (LA) decompression under venoarterial extracorporeal membrane oxygenation (VA-ECMO). We aimed to assess whether balloon atrioseptostomy (BAS) is a safe and efficient strategy. All patients who underwent percutaneous static BAS under VA-ECMO at four tertiary institutions were retrospectively reviewed. From 2000 to 2014, BAS was performed in 64 patients (32 adults and 32 children). Indications for ECMO support included acute myocarditis (31.3%) and non-myocarditis cardiac disease, mostly end-stage dilated cardiomyopathy (32.8%). BAS was required because of pulmonary oedema/haemorrhage and left ventricular (LV) distension. The mean balloon diameter was 21.8 ± 8.4mm. Adequate LA decompression was achieved in all patients. Mean LA pressure fell from 24.2 ± 6.9 mmHg to 7.8 ± 2.6 mmHg (p < 0.001). The left-to-right atrial pressure gradient fell from 17.2 ± 7.1 mmHg to 0.09 ± 0.5 mmHg (p < 0.001). Echocardiography showed an unrestr...
Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions, Jan 16, 2016
To describe our experience, at a large pediatric heart transplant center, with percutaneous coron... more To describe our experience, at a large pediatric heart transplant center, with percutaneous coronary interventions (PCI) for cardiac allograft vasculopathy (CAV). CAV is a leading cause of late graft failure, mortality, and re-transplantation in pediatric heart transplant (HTx) recipients. Studies of PCI in adult patients have shown some short-term improvements, but no significant change in long-term outcomes. There are limited data on PCI for CAV in pediatric patients. We describe the largest single-center experience to date. We performed a retrospective chart review of all pediatric HTx recipients who underwent PCI for a diagnosis of CAV from 2005 to 2014. Twenty-three procedures were performed in 13 patients, at a median age of 16.4 years (range 5.6-21.2) and median time from HTx to first PCI of 8.3 years (range 2.9-20.3). Three cases consisted of angioplasty alone, two cases had bare metal stents implanted, and the remaining 18 had drug-eluting stents implanted. There was acute ...
Journal of the American College of Cardiology, Jan 22, 2016
Risk factors associated with outcomes for pulmonary artery (PA) stenting remain poorly defined. T... more Risk factors associated with outcomes for pulmonary artery (PA) stenting remain poorly defined. The goal of this study was to determine the effect of patient and procedural characteristics on rates of adverse events and procedural success. Registry data were collected, and 2 definitions of procedural success were pre-specified for patients with biventricular circulation: 1) 20% reduction in right ventricular pressure or 50% increase in PA diameter; and 2) 25% reduction in right ventricular pressure or 50% decrease in PA gradient or post-procedure ratio of in-stent minimum to pre-stent distal diameter >80%. A separate definition of procedural success based on normalization of PA diameter was pre-specified for patients with single ventricle palliation. Between January 2011 and January 2014, a total of 1,183 PA stenting procedures were performed at 59 institutions across 1,001 admissions; 262 (22%) procedures were performed in patients with a single ventricle. The rate of procedural...
Journal of Interventional Cardiology, 2016
Objective: To describe the significance of aortic root distortion (AD) and/or aortic valve insuff... more Objective: To describe the significance of aortic root distortion (AD) and/or aortic valve insufficiency (AI) during balloon angioplasty of the right ventricular outflow tract (RVOT) performed to rule out coronary artery compression prior to transcatheter pulmonary valve (TPV) implantation. Methods: AD/AI was assessed by retrospective review of all procedural aortographies performed to evaluate coronary anatomy prior to TPV implantation. AD/AI was also reviewed in all pre-post MPV implant echocardiograms to assess for progression. Results: From 04/2007 to 3/2015, 118 pts underwent catheterization with intent for TPV implant. Mean age and weight were 24.5 AE 12 years and 64.3 AE 20 kg, respectively. Diagnoses were: TOF (53%), D-TGA/DORV (18%), s/p Ross (15%), and Truncus (9%). Types of RV-PA connections were: conduits (96), bioprosthetic valves (14), and other (7). Successful TPV implant occurred in 91 pts (77%). RVOT balloon angioplasty was performed in 43/118 pts (36%). Aortography was performed in 18/43 pts with AD/AI noted in 6/18 (33%); 2 with D-TGA (1 s/p Lecompte, 1 s/p Rastelli), 2 with TOF, 1 Truncus and 1 s/p Ross. Procedure was aborted in the 2 who developed severe AD/AI. TPV was implanted in 3/4 patients with mild AD/AI. Review of pre-post TPV implantation echocardiograms in 83/91 pts (91%) revealed no new/worsened AI in any patient. Conclusion: AD/AI is relatively common on aortography during simultaneous RVOT balloon angioplasty. Lack of AI progression by echocardiography post-TPV implant suggests these may be benign findings in most cases. However, AD/AI should be carefully evaluated in certain anatomic subtypes with close RVOT/aortic alignments.
The Journal of Thoracic and Cardiovascular Surgery, 2016
Disclosures: M.B.L. is an unpaid member of the PARTNER Trial executive committee. J.A.V. is a pro... more Disclosures: M.B.L. is an unpaid member of the PARTNER Trial executive committee. J.A.V. is a proctor and consultant for Medtronic and investigator of Edwards Sapien for pulmonary position (COMPASSION trial). T.M.N. is a consultant for Edwards Lifesciences and Medtronic. Authors have nothing additional to disclose with regard to commercial support.
Journal of the American College of Cardiology, 2015
Background: Hypoplastic left heart syndrome (HLHS) with intact or highly restrictive atrial septu... more Background: Hypoplastic left heart syndrome (HLHS) with intact or highly restrictive atrial septum (RS) is a rare and potentially lethal diagnosis that comprises 5-10% of all cases of HLHS. Immediate postnatal creation of an atrial communication is often necessary to decompress the left atrium (LA) and relieve pulmonary venous hypertension. Prenatal diagnosis and delivery planning enables the coordinated multidisciplinary care required for survival after birth. case: A 22-year-old woman presented for fetal evaluation of HLHS. Fetal echocardiography performed at 28 weeks gestation at our institution demonstrated HLHS with a pinhole patent foramen ovale. The atrial septum was thickened with severe bowing into the right atrium. Pulmonary venous Doppler tracings were abnormal and suggestive of RS. decision Making: A maternal hyperoxygenation test to assess pulmonary vascular resistance variability was performed at 38 weeks gestation. Values before and after hyperoxygenation showed no significant increase in pulmonary artery blood flow by Doppler interrogation. This finding predicted the high likelihood of postnatal LA hypertension due to RS and severe hemodynamic compromise soon after birth. Following consultation with the family and the maternal fetal medicine, neonatology, interventional cardiology, and surgical teams, the decision was made to plan for a timed vaginal delivery via induction and for a cesarean section if birth was delayed. Immediately after birth, O2 saturation was <30%. The infant was brought into the waiting cardiac catheterization laboratory at 13 minutes of life. After transseptal LA access, a stent was placed across the thick septum under echocardiographic guidance. Mean LA pressure decreased from 29 to 9 mmHg and O2 saturation increased to 90%. The infant underwent an uncomplicated Norwood-Sano procedure at 19 days old and is currently awaiting the second stage palliation surgery. conclusion: Immediate postnatal intervention is required in some patients with HLHS-RS. Fetal echocardiography and maternal hyperoxygenation testing are crucial in providing clinical prenatal information that allows for the coordination of multidisciplinary care after birth.
Journal of the American College of Cardiology, 2015
Background: Because risk factors associated with outcomes for pulmonary artery (PA) stenting rema... more Background: Because risk factors associated with outcomes for pulmonary artery (PA) stenting remain poorly defined, we sought to determine the effect of patient and procedural characteristics on complication rates and procedural success. methods: Demographic, procedural and lesion specific data was collected through the Improving Pediatric and Adult Congenital Treatment (IMPACT) registry. Two definitions of procedural success were pre-specified for patients with biventricular (BV) circulation: 1) 20% reduction in right ventricular pressure (RV) or 50% increase in PA diameter; 2) 25% reduction in RV pressure or 50% decrease in PA gradient or post procedure ratio of in-stent minimum to pre-stent distal diameter >80%. A separate definition of procedural success based on normalization of PA diameter was pre-specified for patients with single ventricle (SV) palliation. Complications were classified as life-threatening based on expert consensus. results: Between 1/2011 and 1/2014, 1183 PA stenting procedures were performed at 59 institutions. 262 (22%) procedures were performed in patients with a SV. Mean age and weight were 9 (+/-9) years and 29 (+/-26) kg respectively. The rate of procedural success was 76% for definition 1, 86% for definition 2, and 75% for SV patients. By multivariate analysis, ostial stenosis was significantly associated with procedural success for BV patients by both definitions. No variable was associated with procedural success for SV patients. The overall complication rate was 14% with 9% of patients having a life-threatening complication. By multivariate analysis, weight <4 kg, SV, and emergency status were significantly associated with life-threatening complications. Procedure indication was not associated with procedural success or complication. Conclusion: In our analysis of 1183 PA stenting procedures, success was 75% across all definitions and complications were relatively common. BV patients with an ostial stenosis had a higher probability of a successful outcome. Patients who had a SV, weight <4 kg, or emergency procedure had a higher risk of having a life-threatening complication. These findings may help inform patient selection for PA stenting.
The Annals of Thoracic Surgery, 2014
Background. We investigated the influence of coronary artery abnormalities on outcome in patients... more Background. We investigated the influence of coronary artery abnormalities on outcome in patients with pulmonary atresia/intact ventricular septum (PA-IVS) for planned single-ventricle palliation. Methods. Catheterization and medical records were reviewed in patients with PA-IVS for planned singleventricle palliation at our institution between 2000 and 2012. Primary outcome was death or transplantation. Patients with confirmed or strong suspicion of stenosis in 2 or more main coronary arteries or coronary ostial atresia were defined as having right ventricle-dependent coronary circulation (RVDCC); those with stenosis of 1 main vessel or normal anatomy were defined as having non-RVDCC. Results. Of 58 patients with PA-IVS, 17 (30%) underwent single-ventricle palliation. Ten (59%) had RVDCC (3 with ostial atresia) and 7 (41%) had non-RVDCC. Median followup time was 8.2 years (0 months-11.3 years), with 1 patient in each group lost to follow-up. Five patients with RVDCC died, including the 3 patients with ostial atresia, and 1 underwent transplantation at 6 months of life. No deaths occurred after second-stage palliation. Three of the 4 surviving patients with RVDCC completed a Fontan operation, and 2 of these patients had evidence of cardiac ischemia on follow-up. No deaths occurred among patients with non-RVDCC. Kaplan-Meier analysis demonstrated significantly better survival in patients with non-RVDCC (100%) than in patients with RVDCC (40%) (p [ 0.026). Conclusions. In patients with PA-IVS undergoing single-ventricle palliation, RVDCC is associated with high early mortality, especially with coronary ostial atresia. There should be early consideration of transplantation in neonates with RVDCC. Patients with non-RVDCC undergoing single-ventricle palliation have excellent longterm outcomes, with no mortality seen in this series.
Pulmonary Circulation, 2013
Cardiac catheterization is important for the management of patients with pulmonary arterial hyper... more Cardiac catheterization is important for the management of patients with pulmonary arterial hypertension (PAH). It is used for diagnosis, assessment, and monitoring of PAH patients, as well as to perform interventions such as balloon atrial septostomy and coil embolization of collateral vessels. Although reports on the risks of catheterization in PAH patients are scarce, many centers hesitate to perform these procedures in such fragile patients. We performed a retrospective chart review of all cardiac catheterizations performed in PAH patients over 10 years at our pulmonary hypertension center. Demographic, hemodynamic, and outcome data were collected. Complication rates were determined, and multivariate proportional hazards modeling was performed to identify predictors of catheterization‐related complications. There were 1,637 catheterizations performed in 607 patients over 10 years. Pediatric patients accounted for 50% of these cases, 48% were performed in patients with idiopathic...
Pediatric Cardiology, 2013
Continued advancements in congenital cardiac catheterization and interventions have resulted in i... more Continued advancements in congenital cardiac catheterization and interventions have resulted in increased patient and procedural complexity. Anticipation of lifethreatening events and required rescue measures is a critical component to preprocedural preparation. We sought to determine the incidence and nature of life-threatening adverse events in congenital and pediatric cardiac catheterization, risk factors, and resources necessary to anticipate and manage events. Data from 8905 cases performed at the 8 participating institutions of the Congenital Cardiac Catheterization Project on Outcomes were captured between 2007 and 2010 [median 1,095/site (range 133-3,802)]. The incidence of all life-threatening events was 2.1 % [95 % confidence interval (CI) 1.8-2.4 %], whereas mortality was 0.28 % (95 % CI 0.18-0.41 %). Fifty-seven life-threatening events required cardiopulmonary resuscitation, whereas 9 % required extracorporeal membrane oxygenation. Use of a risk adjustment model showed that age \1 year [odd ratio (OR) 1.9, 95 % CI 1.4-2.7, p \ 0.001], hemodynamic vulnerability (OR 1.6, 95 % CI 1.1-2.3, p \ 0.01), and procedure risk (category 3: OR 2.3, 95 % CI 1.3-4.1; category 4: OR 4.2, 95 % CI 2.4-7.4) were predictors of life-threatening events. Using this model, standardized life-threatening event ratios were calculated, thus showing that one institution had a lifethreatening event rate greater than expected. Congenital cardiac catheterization and intervention can be performed safely with a low rate of life-threatening events and mortality; preprocedural evaluation of risk may optimize preparation of emergency rescue and bailout procedures. Risk predictors (age \ 1, hemodynamic vulnerability, and procedure risk category) can enhance preprocedural patient risk stratification and planning.
The Journal of Heart and Lung Transplantation, 2014
used for palliation and as a bridge to lung transplantation (LT) by permitting right to left atri... more used for palliation and as a bridge to lung transplantation (LT) by permitting right to left atrial-level shunting to improve cardiac output, at the expense of cyanosis. In PAH patients (pts), there is survival benefit with the presence of an atrial shunt. We report our contemporary institutional BAS experience in pediatric and adult pts with severe PAH. Methods: We performed a retrospective analysis of 46 BAS performed in 32 pts with PAH from 2002-2013. Pt characteristics obtained prior to initial BAS, at 1 year (yr) and most recent follow-up included hemodynamics (rightsided pressures and cardiac index), biomarkers (B-type natriuretic peptide, troponin, renal and hepatic function), and echocardiographic (echo) findings (presence/degree of tricuspid regurgitation, right ventricular function, pericardial effusion). LT-and re-BAS-free survival were analyzed. Results: Median age at BAS was 23 yrs (range 1-56). The most common indications for BAS were symptomatic RHF (21/46) and presyncope/syncope (19/46); 69% of pts were WHO functional class III or IV pre-BAS. There were no procedural complications or deaths. Survival at 30 days was 96%. There was an immediate decrease in systemic saturation from 94 to 91% (p< 0.001). Of the biomarkers, only AST improved post-BAS from 26 to 20 U/L (p< 0.05). Of the 19 presyncope/syncope pts, at 1 yr follow-up, 5 experienced LT (1), re-BAS (2), or death (2); 1 was lost to follow-up; 2 had further syncope; and 11 had no further syncope. Of the 21 symptomatic RHF pts, at 1 yr follow-up, 9 experienced LT (3) or death (6); 2 were lost to follow-up; 1 had worsening symptoms; and 9 had symptomatic improvement. There were no significant differences in echo or hemodynamic findings between pre-BAS and 1 yr or latest follow-up. LT-and re-BAS-free survival at 1 and 5 yrs was 60.9 and 31.7%. Conclusion: At our institution, BAS is utilized for palliation of refractory RHF in PAH patients when maximal medical therapy fails, and was shown to be safe in these very ill patients. BAS may be utilized as a bridge to LT or to alleviate signs of RHF including syncope. Other potential benefits of BAS on end-organ function and overall survival remain to be determined.
Journal of Cardiac Failure, 2009
analyzed retrospectively. Pts indicated for ICD or CRT-D were implanted and followed for 3 months... more analyzed retrospectively. Pts indicated for ICD or CRT-D were implanted and followed for 3 months. Pts were divided into 3 groups: A e pts with a HF hosp; B e pts with other patient-condition related events; C e none of the above. Daily maximum (max), median (med) and minimum (min) RRs before an event (4-, 2-, 1-week before and on the day of the event) were compared to those at baseline (8 weeks prior). Last day of study was taken as event day for group C. Only the 1 st event per patient contributed to analysis. For each group, one-way repeated-measures ANOVA with patient random intercept was used to separately assess the difference in daily trends over time. Dunnett's test was used to assess the difference compared to the baseline if ANOVA resulted in p!0.05. Pts with insufficent data were excluded from the analysis. Results: Of the 216 pts implanted, 179 pts had sufficient data for this analysis (5/18/156 pts in group A/B/C respectively). In group A, daily max and med RRs became significantly elevated 2 weeks before the event, compared to baseline (max RR 25.6 6 2.4 vs. 30.2 6 2.9 breaths/minute (bpm) p!0.05, med RR 18.2 6 2.6 vs. 21.2 6 3.9 bpm p!0.05). There was a statistically significant change in max RR 2 weeks before the event compared to baseline in group C (27.2 6 4.1 vs. 26.7 6 3.6 bpm, p!0.05), but might not be clinically significant. Other comparisons did not show statistical significance. Conclusions: In this study, daily max and med RRs became elevated several weeks before HF hospitalization compared to a baseline 8 weeks prior in patients with implantable devices. Similar levels of changes were not observed in patients without HF hospitalization. A larger study is warranted to demonstrate the clinical relevance of RR trends in HF patient management.
Catheterization and Cardiovascular Interventions, 2008
To report our experience with transcatheter occlusion of antegrade pulmonary blood flow (APF) for... more To report our experience with transcatheter occlusion of antegrade pulmonary blood flow (APF) for postoperative complications of cavopulmonary anastomosis (BCPA). Background: It has been suggested that limited APF enhances pulmonary arterial growth in patients undergoing BCPA. However, APF may result in suboptimal postoperative hemodynamics and sequelae such as SVC syndrome or prolonged chest tube drainage. For this subgroup, closure of APF may alleviate these problems. Methods: All BCPA procedures where APF was left open from 1995-2005 were reviewed. Symptomatic patients with APF who underwent a cardiac catheterization in the postoperative period comprised the study cohort. Results: 179 BCPA procedures were performed during the study period. APF was left patent in 29/179. 6/29 patients (age 10-28 months, median 14 months) presented 12 to 130 day; (median 31 days) with persistent pleural effusions (5) or SVC syndrome (1, Five had a history of a previous pulmonary arterial band (PAB) and one pulmonary stenosis. PA pressure was elevated in all (range 17-27 mmHg; median 22 mmHg). Hemodynamic evaluation with temporary APF occlusion was repeated in all patients. APF was successfully closed in 4/6 patients. The Amplatzer POA occluder was used in 3 and the Amplatzer ASD occluder in 1. Pulmonary effusions resolved in all the patients who had transcatheter APF closure as did the case of SVC syndrome. There were no complications. Conclusion: Transcatheter APF occlusion seems both safe and feasible in patients with hemodynamic compromise following BCPA with residual APF. Temporary occlusion testing prior to permanent device closure is recommended.
La construccion es una de las actividades de la industria que genera mayor impacto ambiental. Est... more La construccion es una de las actividades de la industria que genera mayor impacto ambiental. Esta se ha regido por materiales convencionales y metodos constructivos desde hace decadas. La infraestructura de las ciudades genera cambios en el relieve de cada region y con ellos, cambios climaticos que, cada vez, son mas agresivos. Un modo de reducir la contaminacion producida por las edificaciones y viviendas es a traves el uso de materiales bioclimaticos que, segun caracteristicas termicas de la region evaluada, contribuyen a mantener los lugares frescos o calurosos. El clima en el Departamento del Valle del Cauca es calido y con un alto contenido de humedad. Debido a esto, se investigaron materiales bioclimaticos con caracteristicas aislantes termicas producidas o distribuidas en el Departamento, para recubrimientos exteriores e interiores en los muros de las viviendas, con el fin de evaluar el comportamiento termico de dichos materiales. Los materiales encontrados fueron corcho, es...
To solve the thermal control problems of modern spacecraft with complex payloads and configuratio... more To solve the thermal control problems of modern spacecraft with complex payloads and configurations, there is an increasing demand for multiple evaporator and/or multiple condenser loop heat pipes (LHPs). As a result, several initiatives, including flight ...
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Papers by ALEJANDRO TORRES