ALFREDO INACIO FIORELLI
Projetos de Pesquisa
Unidades Organizacionais
Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina
LIM/11 - Laboratório de Cirurgia Cardiovascular e Fisiopatologia da Circulação, Hospital das Clínicas, Faculdade de Medicina
LIM/11 - Laboratório de Cirurgia Cardiovascular e Fisiopatologia da Circulação, Hospital das Clínicas, Faculdade de Medicina
11 resultados
Resultados de Busca
Agora exibindo 1 - 10 de 11
- Comparative Analysis of the Complications of 5347 Endomyocardial Biopsies Applied to Patients After Heart Transplantation and With Cardiomyopathies: A Single-center Study(2012) FIORELLI, A. I.; BENVENUTI, L.; AIELO, V.; COELHO, A. Q.; PALAZZO, J. F.; ROSSENER, R.; BARRETO, A. C. P.; MADY, C.; BACAL, F.; BOCCHI, E.; STOLF, N. A. G.Introduction. Endomyocardial biopsy (EMB) plays an important role in allograft surveillance to screen an acute rejection episode after heart transplantation (HT), to diagnose an unknown cause of cardiomyopathies (CMP) or to reveal a cardiac tumor. However, the procedure is not risk free. Objective. The main objective of this research was to describe our experience with EMB during the last 33 years comparing surgical risk between FIT versus no-HT patients. Method. We analyzed retrospectively the data of 5347 EMBs performed from 1978 to 2011 (33 years). For surveillance of acute rejection episodes after HT we performed 3564 (66.7%), whereas 1777 (33.2%) for CMP diagnosis, and 6 (1.0%) for cardiac tumor identification. Results. The main complications due to EMB were divided into 2 groups to facilitate analysis: major complications associated with potential death risk, and minor complications. The variables that showed a significant difference in the HT group were as follows: tricuspid Injury (.0490) and coronary fistula (.0000). Among the no-HT cohort they were insufficient fragment (.0000), major complications (.0000) and total complications (.0000). Conclusions. EMB can be accomplished with a low risk of complications and high effectiveness to diagnose CMP and rejection after HT. However, the risk is great among patients with CMP due to their anatomic characteristics. Children also constitute a risk group for EMB due to their small size in addition to the heart disease. The risk of injury to the tricuspid valve was higher among the HT group.
- Comparative experimental study of myocardial protection with crystalloid solutions for heart transplantation(2012) LIMA, Melchior Luiz; FIORELLI, Alfredo Inacio; VASSALLO, Dalton Valentim; PINHEIRO, Bruno Botelho; STOLF, Noedir Antonio Groppo; GOMES, Otoni MoreiraBackground: There is a growing need to improve myocardial protection, which will lead to better performance of cardiac operations and reduce morbidity and mortality. Therefore, the objective of this study was to compare the efficacy of myocardial protection solution using both intracellular and extracellular crystalloid type regarding the performance of the electrical conduction system, left ventricular contractility and edema, after being subjected to ischemic arrest and reperfusion. Methods: Hearts isolated from male Wistar (n=32) rats were prepared using Langendorff method and randomly divided equally into four groups according the cardioprotective solutions used Krebs-Henseleit-Buffer (KHB), Bretschneider-HTK (HTK), St. Thomas-1 (STH-1) and Celsior (CEL). After stabilization with KHB at 37 degrees C, baseline values (control) were collected for heart rate (HR), left ventricle systolic pressure (LVSP), maximum first derivate of rise left ventricular pressure (+dP/dt), maximum first derivate of fall left ventricular pressure (-dP/dt) and coronary flow (CF). The hearts were then perfused at 10 degrees C for 5 min and kept for 2 h in static ischemia at 20 degrees C in each cardioprotective solution. Data evaluation was done using analysis of variance in completely randomized One-Way ANOVA and Tukey's test for multiple comparisons. The level of statistical significance chosen was P<0.05. Results: HR was restored with all the solutions used. The evaluation of left ventricular contractility (LVSP, +dP/dt and -dP/dt) showed that treatment with CEL solution was better compared to other solutions. When analyzing the CF, the HTK solution showed better protection against edema. Conclusion: Despite the cardioprotective crystalloid solutions studied are not fully able to suppress the deleterious effects of ischemia and reperfusion in the rat heart, the CEL solution had significantly higher results followed by HTK>KHB>STH-1.
- Sildenafil vs. Sodium Nitroprusside for the Pulmonary Hypertension Reversibility Test Before Cardiac Transplantation(2012) FREITAS JR., Aguinaldo Figueiredo; BACAL, Fernando; OLIVEIRA JUNIOR, Jose de Lima; FIORELLI, Alfredo Inacio; SANTOS, Ronaldo Honorato; MOREIRA, Luiz Felipe Pinho; SILVA, Christiano Pereira; MANGINI, Sandrigo; TSUTSUI, Jeane Mike; BOCCHI, Edimar AlcidesBackground: Pulmonary hypertension is associated with a worse prognosis after cardiac transplantation. The pulmonary hypertension reversibility test with sodium nitroprusside (SNP) is associated with a high rate of systemic arterial hypotension, ventricular dysfunction of the transplanted graft and high rates of disqualification from transplantation. Objective: This study was aimed at comparing the effects of sildenafil (SIL) and SNP on hemodynamic, neurohormonal and echocardiographic variables during the pulmonary reversibility test. Methods: The patients underwent simultaneously right cardiac catheterization, echocardiography, BNP measurement, and venous blood gas analysis before and after receiving either SNP (1 - 2 mu g/kg/min) or SIL (100 mg, single dose). Results: Both drugs reduced pulmonary hypertension, but SNP caused a significant systemic hypotension (mean blood pressure - MBP: 85.2 vs. 69.8 mm Hg; p < 0.001). Both drugs reduced cardiac dimensions and improved left cardiac function (SNP: 23.5 vs. 24.8%, p = 0.02; SIL: 23.8 vs. 26%, p < 0.001) and right cardiac function (SIL: 6.57 +/- 2.08 vs. 8.11 +/- 1.81 cm/s, p = 0.002; SNP: 6.64 +/- 1.51 vs. 7.72 +/- 1.44 cm/s, p = 0.003), measured through left ventricular ejection fraction and tissue Doppler, respectively. Sildenafil, contrary to SNP, improved venous oxygen saturation, measured on venous blood gas analysis. Conclusion: Sildenafil and SNP are vasodilators that significantly reduce pulmonary hypertension and cardiac geometry, in addition to improving biventricular function. Sodium nitroprusside, contrary to SIL, was associated with systemic arterial hypotension and worsening of venous oxygen saturation. (Arq Bras Cardiol 2012;99(3):848-856)
- Risk Factor Analysis of Late Survival After Heart Transplantation According to Donor Profile: A Multi-Institutional Retrospective Study of 512 Transplants(2012) FIORELLI, A. I.; BRANCO, J. N.; DINKHUYSEN, J. J.; OLIVEIRA JUNIOR, J. L.; PEREIRA, T. V.; DINARDI, L. F. L.; SANTOS, M. M.; DIAS, R. R.; PEREIRA, L. A.; STOLF, N. A. G.Introduction. Patients with terminal heart failure have increased more than the available organs leading to a high mortality rate on the waiting list. Use of Marginal and expanded criteria donors has increased due to the heart shortage. Objective. We analyzed all heart transplantations (HTx) in Sao Paulo state over 8 years for donor profile and recipient risk factors. Method. This multi-institutional review collected HTx data from all institutions in the state of Sao Paulo, Brazil. From 2002 to 2008 (6 years), only 512 (28.8%) of 1777 available heart donors were accepted for transplantation. All medical records were analyzed retrospectively; none of the used donors was excluded, even those considered to be nonstandard. Results. The hospital mortality rate was 27.9% (n = 143) and the average follow-up time was 29.4 +/- 28.4 months. The survival rate was 55.5% (n = 285) at 6 years after HTx. Univariate analysis showed the following factors to impact survival: age (P = .0004), arterial hypertension (P = .4620), norepinephrine (P = .0450), cardiac arrest (P = .8500), diabetes mellitus (P = .5120), infection (P = .1470), CKMB (creatine kinase MB) (P = .8694), creatinine (P = .7225), and Na+ (P = .3273). On multivariate analysis, only age showed significance; logistic regression showed a significant cut-off at 40 years: organs from donors older than 40 years showed a lower late survival rates (P = .0032). Conclusions. Donor age older than 40 years represents an important risk factor for survival after HTx. Neither donor gender nor norepinephrine use negatively affected early survival.
- Tricuspid Valve Injury After Heart Transplantation Due to Endomyocardial Biopsy: An Analysis of 3550 Biopsies(2012) FIORELLI, A. I.; COELHO, G. H. B.; AIELLO, V. D.; BENVENUTI, L. A.; PALAZZO, J. F.; SANTOS JUNIOR, V. P.; CANIZARES, B.; DIAS, R. R.; STOLF, N. A. G.Introduction. Tricuspid regurgitation (TR) is the most commonly valvular dysfunction found after heart transplantation (HTx). It may be related to endomyocardial biopsy (EMB) performed for allograft rejection surveillance. Objective. This investigation evaluated the presence of tricuspid valve tissue fragments obtained during routine EMB performed after HTx and its possible effect on short-term and long-term hemodynamic status. Method. This single-center review included prospectively collected and retrospectively analyzed data. From 1985 to 2010, 417 patients underwent 3550 EMB after HTx. All myocardial specimens were reviewed to identify the presence of tricuspid valve tissue by 2 observers initially and in doubtful cases by a third observer. The echocardiographic and hemodynamic parameters were only considered for valvular functional damage analysis in cases of tricuspid tissue inadvertently removed during EMB. Results. The 417 HTx patients to 3550 EMB, including 17,550 myocardial specimens. Tricuspid valve tissue was observed in 12 (2.9%) patients corresponding to 0.07% of the removed fragments. The echocardiographic and hemodynamic parameters of these patients before versus after the biopsy showed increased TR in 2 cases (2/12; 16.7%) quantified as moderate without progression in the long term. Only the right atrial pressure showed a significant increase (P = .0420) after tricuspid injury; however, the worsening of the functional class was not significant enough in any of the subjects. Thus, surgical intervention was not required. Conclusions. Histological evidence of chordal tissue in EMB specimens is a real-world problem of relatively low frequency. Traumatic tricuspid valve injury due to EMB rarely leads to severe valvular regurgitation; only a minority of patients develop significant clinical symptoms. Hemodynamic and echocardiographic alterations are also less often observed in most patients.
- Myocardial Chemokine Expression and Intensity of Myocarditis in Chagas Cardiomyopathy Are Controlled by Polymorphisms in CXCL9 and CXCL10(2012) NOGUEIRA, Luciana Gabriel; SANTOS, Ronaldo Honorato Barros; IANNI, Barbara Maria; FIORELLI, Alfredo Inacio; MAIRENA, Eliane Conti; BENVENUTI, Luiz Alberto; FRADE, Amanda; DONADI, Eduardo; DIAS, Fabricio; SABA, Bruno; WANG, Hui-Tzu Lin; FRAGATA, Abilio; SAMPAIO, Marcelo; HIRATA, Mario Hiroyuki; BUCK, Paula; MADY, Charles; BOCCHI, Edimar Alcides; STOLF, Noedir Antonio; KALIL, Jorge; CUNHA-NETO, EdecioBackground: Chronic Chagas cardiomyopathy (CCC), a life-threatening inflammatory dilated cardiomyopathy, affects 30% of the approximately 8 million patients infected by Trypanosoma cruzi. Even though the Th1 T cell-rich myocarditis plays a pivotal role in CCC pathogenesis, little is known about the factors controlling inflammatory cell migration to CCC myocardium. Methods and Results: Using confocal immunofluorescence and quantitative PCR, we studied cell surface staining and gene expression of the CXCR3, CCR4, CCR5, CCR7, CCR8 receptors and their chemokine ligands in myocardial samples from end-stage CCC patients. CCR5+, CXCR3+, CCR4+, CCL5+ and CXCL9+ mononuclear cells were observed in CCC myocardium. mRNA expression of the chemokines CCL5, CXCL9, CXCL10, CCL17, CCL19 and their receptors was upregulated in CCC myocardium. CXCL9 mRNA expression directly correlated with the intensity of myocarditis, as well as with mRNA expression of CXCR3, CCR4, CCR5, CCR7, CCR8 and their ligands. We also analyzed single-nucleotide polymorphisms for genes encoding the most highly expressed chemokines and receptors in a cohort of Chagas disease patients. CCC patients with ventricular dysfunction displayed reduced genotypic frequencies of CXCL9 rs10336 CC, CXCL10 rs3921 GG, and increased CCR5 rs1799988CC as compared to those without dysfunction. Significantly, myocardial samples from CCC patients carrying the CXCL9/CXCL10 genotypes associated to a lower risk displayed a 2-6 fold reduction in mRNA expression of CXCL9, CXCL10, and other chemokines and receptors, along with reduced intensity of myocarditis, as compared to those with other CXCL9/CXCL10 genotypes. Conclusions: Results may indicate that genotypes associated to reduced risk in closely linked CXCL9 and CXCL10 genes may modulate local expression of the chemokines themselves, and simultaneously affect myocardial expression of other key chemokines as well as intensity of myocarditis. Taken together our results may suggest that CXCL9 and CXCL10 are master regulators of myocardial inflammatory cell migration, perhaps affecting clinical progression to the life-threatening form of CCC.
conferenceObject Heart Transplantation: Main Anatomical Alterations(2012) INACIO, Fiorelli Alfredo; HALTI, Cabral Richard; NELSON, Rodrigues Branco JoaoHeart transplantation is the most effective treatment for well-selected patients with end-stage heart failure, it offers great challenges though. That procedure can be used to exemplify the adaptive capacity of the heart and the integration of the cardiovascular system components after multiple injuries such as ischemia, rejection, pulmonary hypertension, infection, immunosuppression, and so on. New researches about metabolic, molecular and structural remodeling during the development of heart failure due to the brain death consequences on the heart donor and after the transplantation surgical procedure will lead to a better understanding of the heart adaptive capacity which may modify clinical treatment. The inflammatory response and reperfusion injury associated with cardiopulmonary bypass, cardioplegic arrest and immunological factors are key triggers of myocardial injury during heart transplantation. The normal right ventricle has different vulnerability to cardiac insults compared to the left cavity. This occurs due to elevated pulmonary pressure of the recipient and represents the major cause of early allograft dysfunction. This review was addressed to describe some key issues related to anatomical alterations that heart suffers with cardiac failure development with the attempt to react to the systemic responses and also, to the depression of myocardial function observed with dead brain and after the transplantation procedure.conferenceObject Trypanosoma cruzi persistence in the native heart is associated with high-grade myocarditis, but not with Chagas' disease reactivation after heart transplantation(2012) BENVENUTI, L. A.; ROGGERIO, A.; CAMPOS, S. V.; FIORELLI, A. I.; AIELLO, V. D.Introduction: Chagas’ disease is caused by the protozoan Trypanosoma cruzi. Around 20% of infected people develop a chronic, inflammatory cardiomyopathy which may progress to end-stage heart failure. Chagas’ disease reactivation (CDR) may occur after heart transplantation (HT), usually in the first year of follow-up. CDR is a life-threatening complication characterized by relapse of the disease with direct detection of T. cruzi parasites in blood or tissues. We investigated if high-grade myocarditis and/or detection of T. cruzi parasites in the native heart are associated with CDR after HT. Material and Methods: The native heart of 16 chagasic patients who presented CDR after HT (CDR+ group) were compared to the native heart of 11 chagasic patients who never presented CDR in a follow-up of at least 18 months after HT (CDR – group). The intensity of myocarditis was evaluated semi-quantitatively. Parasite persistence was investigated through immunohistochemistry for T. cruzi antigens and qualitative polymerase chain reaction (PCR) for T. cruzi kDNA. Fisher exact test was used to compare data. Results: High-grade myocarditis was present in 15/16 (93.8%) samples of CDR+ group and 9/11 (81.8%) samples of CDR – group (P = 0.549). Parasite persistence, mainly detected through the PCR-based assay, occurred in 13/16 (81.3%) samples of CDR+ group and 7/11 (63.6%) samples of CDR – group (P = 0.391). High-grade myocarditis was present in 20/20 (100%) samples presenting parasite persistence and 4/7 (57.1%) samples without parasite persistence (P = 0.012). Conclusion: Although parasite persistence is associated with high-grade myocarditis in the native heart, neither of them is associated with CDR after HT.- Fatores de risco pré-operatórios para mediastinite após cirurgia cardíaca: análise de 2768 paciente(2012) TIVERON, Marcos Gradim; FIORELLI, Alfredo Inacio; MOTA, Eduardo Moeller; MEJIA, Omar Asdrubal Vilca; BRANDAO, Carlos Manuel de Almeida; DALLAN, Luis A. O.; POMERANTZEFF, Pablo A. M.; STOLF, Noedir A. G.Background: Longitudinal median sternotomy is the most common surgical approach for access to heart disease treatment. The deep wound infections in postoperative period of cardiovascular surgery are a serious complication requiring high costs during treatment. Different studies have indicated some risk factors for the development of mediastinitis and preoperative variables are currently under investigation. Objective: The aim of this study is to identify the preoperative risk factors for postoperative development of mediastinitis in patients undergoing coronary artery bypass grafting and valve replacement. Methods: This observational study represents a cohort of 2768 consecutive operated patients. The period considered for analysis was from May 2007 to May 2009 and there were no exclusion criteria. Analysis was performed by univariate and multivariate logistic regression model of 38 preoperative variables. Results: Thirty-five (1.3%) patients developed mediastinitis and 19 (0.7%) associated with osteomyelitis. The patient age average was 59.9 +/- 13.5 years and the EuroSCORE of 4.5 +/- 3.6. Hospital mortality was 42.8%. The multivariate analysis identified three variables as independent predictors of postoperative mediastinitis: intra-aortic balloon pump (OR 5.41, 95% CI [1.83 -16.01], P = 0.002), hemodialysis (OR 4.87, 95% CI [1.41 to 16.861, P = 0.012) and extracardiac vascular intervention (OR 4.39,95% CI [1.64 to 11.761,P = 0.003). Conclusion: This study showed that necessity of preoperative hemodynamic support with intra-aortic balloon, hemodialysis, and extracardiac vascular intervention were risk factors for development of mediastinitis after cardiac surgery.
- Deleterious Effect of Hypothermia in Myocardial Protection Against Cold Ischemia: A Comparative Study in Isolated Rat Hearts(2012) LIMA, M. L.; FIORELLI, A. I.; VASSALLO, D. V.; BATISTA, P. R.; SIMOES, F. V.; FIORIM, J.; STEFANON, I.; PINHEIRO, B. B.; STOLF, N. A. G.; GOMES, O. M.Background. There is a growing need to improve heart preservation benefit the performance of cardiac operations, decrease morbidity, and more important, increase the donor pool. Therefore, the objective of this study was to evaluate the cardioprotective effects of Krebs-Henseleit buffer (KHB), Bretschneider-HTK (HTK), St. Thomas No. 1 (STH-1), and Celsior (CEL) solutions infused at 10 degrees C and 20 degrees C. Methods. Hearts isolated from male albino Wistar rats and prepared according to Langendorff were randomly divided equally into 8 groups according to the temperature of infusion (10 degrees C or 20 degrees C) and cardioprotective solutions (KHB, HTK, STH-1, and CEL). After stabilization with KHB at 37 degrees C, baseline values were collected (control) for heart rate (HR), left ventricle systolic pressure (LVSP), coronary flow (CF), maximum rate of rise of left ventricular pressure during ventricular contraction (+dP/dt) and maximum rate of fall of left ventricular pressure during left ventricular relaxation (-dP/dt). The hearts were then perfused with cardioprotective solutions for 5 minutes and kept for 2 hours in static ischemia at 20 degrees C. Data evaluation used analysis of variance (ANOVA) in all together randomized 2-way ANOVA and Tukey's test for multiple comparisons. The level of significance chosen was P < .05. Results. We observed that all 4 solutions were able to recover HR, independent of temperature. Interestingly, STH-1 solution at 20 degrees C showed HR above baseline throughout the experiment. An evaluation of the corresponding hemodynamic values (LVSP, +dP/dt, and -dP/dt) indicated that treatment with CEL solution was superior at both temperatures compared with the other solutions, and had better performance at 20 degrees C. When analyzing performance on CF maintenance, we observed that it was temperature dependent. However, when applying both HTK and CEL, at 10 degrees C and 20 degrees C respectively, indicated better protection against development of tissue edema. Multiple comparisons between treatments and hemodynamic variable outcomes showed that using CEL solution resulted in significant improvement compared with the other solutions at both temperatures. Conclusion. The solutions investigated were not able to fully suppress the deleterious effects of ischemia and reperfusion of the heart. However, these results allow us to conclude that temperature and the cardioprotective solution are interdependent as far as myocardial protection. Although CEL solution is the best for in myocardial protection, more studies are needed to understand the interaction between temperature and perfusion solution used. This will lead to development of better and more efficient cardioprotective methods.