GRAZIELA DOS SANTOS ROCHA FERREIRA

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Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina - Médico

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  • article 8 Citação(ões) na Scopus
    Effect of postoperative goal-directed therapy in cancer patients undergoing high-risk surgery: a randomized clinical trial and meta-analysis
    (2018) GERENT, Aline Rejane Muller; ALMEIDA, Juliano Pinheiro; FOMINSKIY, Evgeny; LANDONI, Giovanni; OLIVEIRA, Gisele Queiroz de; RIZK, Stephanie Itala; FUKUSHIMA, Julia Tizue; SIMOES, Claudia Marques; RIBEIRO JR., Ulysses; PARK, Clarice Lee; NAKAMURA, Rosana Ely; FRANCO, Rafael Alves; CANDIDO, Patricia Ines; TAVARES, Cintia Rosa; CAMARA, Ligia; FERREIRA, Graziela dos Santos Rocha; ALMEIDA, Elisangela Pinto Marinho de; KALIL FILHO, Roberto; GALAS, Filomena Regina Barbosa Gomes; HAJJAR, Ludhmila Abrahao
    Background: Perioperative goal-directed hemodynamic therapy (GDHT) has been advocated in high-risk patients undergoing noncardiac surgery to reduce postoperative morbidity and mortality. We hypothesized that using cardiac index (CI)-guided GDHT in the postoperative period for patients undergoing high-risk surgery for cancer treatment would reduce 30-day mortality and postoperative complications. Methods: A randomized, parallel-group, superiority trial was performed in a tertiary oncology hospital. All adult patients undergoing high-risk cancer surgery who required intensive care unit admission were randomly allocated to a CI-guided GDHT group or to a usual care group. In the GDHT group, postoperative therapy aimed at CI >= 2.5 L/min/m(2) using fluids, inotropes and red blood cells during the first 8 postoperative hours. The primary outcome was a composite endpoint of 30-day all-cause mortality and severe postoperative complications during the hospital stay. A meta-analysis was also conducted including all randomized trials of postoperative GDHT published from 1966 to May 2017. Results: A total of 128 patients (64 in each group) were randomized. The primary outcome occurred in 34 patients of the GDHT group and in 28 patients of the usual care group (53.1% vs 43.8%, absolute difference 9.4 (95% CI, -7.8 to 25.8); p = 0.3). During the 8-h intervention period more patients in the GDHT group received dobutamine when compared to the usual care group (55% vs 16%, p < 0.001). A meta-analysis of nine randomized trials showed no differences in postoperative mortality (risk ratio 0.85, 95% CI 0.59-1.23; p = 0.4; p for heterogeneity = 0.7; I-2 = 0%) and in the overall complications rate (risk ratio 0.88, 95% CI 0.71-1.08; p = 0.2; p for heterogeneity = 0.07; I-2 = 48%), but a reduced hospital length of stay in the GDHT group (mean difference (MD) - 1.6; 95% CI - 2.75 to -0.46; p = 0.006; p for heterogeneity = 0.002; I-2 = 74%). Conclusions: CI-guided hemodynamic therapy in the first 8 postoperative hours does not reduce 30-day mortality and severe complications during hospital stay when compared to usual care in cancer patients undergoing high-risk surgery.
  • article 19 Citação(ões) na Scopus
    Effect of a Perioperative Intra-Aortic Balloon Pump in High-Risk Cardiac Surgery Patients: A Randomized Clinical Trial
    (2018) FERREIRA, Graziela Santos Rocha; ALMEIDA, Juliano Pinheiro de; LANDONI, Giovanni; VINCENT, Jean Louis; FOMINSKIY, Evgeny; GALAS, Filomena Regina Barbosa Gomes; GAIOTTO, Fabio A.; DALLAN, Luis Oliveira; FRANCO, Rafael Alves; LISBOA, Luiz Augusto; DALLAN, Luis Roberto Palma; FUKUSHIMA, Julia Tizue; RIZK, Stephanie Itala; PARK, Clarice Lee; STRABELLI, Tania Mara; LAGE, Silvia Helena Gelas; CAMARA, Ligia; ZEFERINO, Suely; JARDIM, Jaquelline; ARITA, Elisandra Cristina Trevisan Calvo; RIBEIRO, Juliana Caldas; AYUB-FERREIRA, Silvia Moreira; AULER JR., Jose Otavio Costa; KALIL FILHO, Roberto; JATENE, Fabio Biscegli; HAJJAR, Ludhmila Abrahao
    Objectives: The aim of this study was to evaluate the efficacy of perioperative intra-aortic balloon pump use in high-risk cardiac surgery patients. Design: A single-center randomized controlled trial and a meta-analysis of randomized controlled trials. Setting: Heart Institute of SAo Paulo University. Patients: High-risk patients undergoing elective coronary artery bypass surgery. Intervention: Patients were randomized to receive preskin incision intra-aortic balloon pump insertion after anesthesia induction versus no intra-aortic balloon pump use. Measurements and Main Results: The primary outcome was a composite endpoint of 30-day mortality and major morbidity (cardiogenic shock, stroke, acute renal failure, mediastinitis, prolonged mechanical ventilation, and a need for reoperation). A total of 181 patients (mean [sd] age 65.4 [9.4] yr; 32% female) were randomized. The primary outcome was observed in 43 patients (47.8%) in the intra-aortic balloon pump group and 42 patients (46.2%) in the control group (p = 0.46). The median duration of inotrope use (51hr [interquartile range, 32-94 hr] vs 39hr [interquartile range, 25-66 hr]; p = 0.007) and the ICU length of stay (5 d [interquartile range, 3-8 d] vs 4 d [interquartile range, 3-6 d]; p = 0.035) were longer in the intra-aortic balloon pump group than in the control group. A meta-analysis of 11 randomized controlled trials confirmed a lack of survival improvement in high-risk cardiac surgery patients with perioperative intra-aortic balloon pump use. Conclusions: In high-risk patients undergoing cardiac surgery, the perioperative use of an intra-aortic balloon pump did not reduce the occurrence of a composite outcome of 30-day mortality and major complications compared with usual care alone.
  • article 4 Citação(ões) na Scopus
    Cerebral hemodynamics with intra-aortic balloon pump: business as usual?
    (2017) CALDAS, J. R.; PANERAI, R. B.; BOR-SENG-SHU, E.; ALMEIDA, J. P.; FERREIRA, G. S. R.; CAMARA, L.; NOGUEIRA, R. C.; OLIVEIRA, M. L.; JATENE, F. B.; ROBINSON, T. G.; HAJJAR, L. A.
    Objective: Intra-aortic balloon pump (IABP) is commonly used as mechanical support after cardiac surgery or cardiac shock. Although its benefits for cardiac function have been well documented, its effects on cerebral circulation are still controversial. We hypothesized that transfer function analysis (TFA) and continuous estimates of dynamic cerebral autoregulation (CA) provide consistent results in the assessment of cerebral autoregulation in patients with IABP. Approach: Continuous recordings of blood pressure (BP, intra-arterial line), end-tidal CO2, heart rate and cerebral blood flow velocity (CBFV, transcranial Doppler) were obtained (i) 5 min with IABP ratio 1: 3, (ii) 5 min, starting 1 min with the IABP-ON, and continuing for another 4 min without pump assistance (IABP-OFF). Autoregulation index (ARI) was estimated from the CBFV response to a step change in BP derived by TFA and as a function of time using an autoregressive moving-average model during removal of the device (ARI(t)). Critical closing pressure and resistance area-product were also obtained. Main results: ARI with IABP-ON (4.3 +/- 1.2) were not different from corresponding values at IABP-OFF (4.7 +/- 1.4, p = 0.42). Removal of the balloon had no effect on ARIt, CBFV, BP, cerebral critical closing pressure or resistance area-product. Significance: IABP does not disturb cerebral hemodynamics. TFA and continuous estimates of dynamic CA can be used to assess cerebral hemodynamics in patients with IABP. These findings have important implications for the design of studies of critically ill patients requiring the use of different invasive support devices.
  • article 21 Citação(ões) na Scopus
    Dynamic cerebral autoregulation: A marker of post-operative delirium?
    (2019) CALDAS, Juliana R.; PANERAI, Ronney B.; BOR-SENG-SHU, Edson; FERREIRA, Graziela S. R.; CAMARA, Ligia; PASSOS, R. H.; DE-LIMA-OLIVEIRA, Marcelo; GALAS, Filomena R. B. G.; ALMEIDA, Juliano P.; NOGUEIRA, Ricardo C.; MIAN, Natalia; GAIOTTO, Fabio A.; ROBINSON, Thompson G.; HAJJAR, Ludhmila A.
    Objective: We investigated the potential association of cerebral autoregulation (CA) with postoperative delirium (PD), a common complication of cardiac surgery with cardiopulmonary bypass (CPB). Methods: In patients undergoing coronary artery bypass graft (CABG) surgery with CPB, cerebral blood flow velocity (CBFV) and blood pressure (BP) were continuously recorded during 5-min preoperatively (T1), after 24 h (T2), and 7 days after procedure (T3). Prospective multivariate logistic regression analysis was performed to determine the independent risk factors of PD. Autoregulation index (ARI) was calculated from the CBFV response to a step change in BP derived by transfer function analysis. Results: In 67 patients, mean age 64.3 +/- 9.5 years, CA was depressed at T2 as shown by values of ARI (3.9 +/- 1.7), compared to T1 (5.6 +/- 1.7) and T3 (5.5 +/- 1.8) (p < 0.001). Impaired CA was found in 37 (55%) patients at T2 and in 7 patients (20%) at T3. Lower ARI at T1 and T2 were predictors of PD (p = 0.003). Conclusion: Dynamic CA was impaired after CABG surgery with CPB and was a significant independent risk factor of PD. Significance: Assessment of CA before and after surgery could have considerable potential for early identification of patients at risk of PD, thus reducing poor outcomes and length of stay.
  • article 0 Citação(ões) na Scopus
    Vasopressin versus Norepinephrine in Patients with Vasoplegic Shock after Cardiac Surgery: The VANCS Randomized Controlled Trial (vol 126, pg 85, 2017)
    (2017) HAJJAR, L. A.; VINCENT, J. L.; GALAS, Barbosa Gomes F. R.; RHODES, A.; LANDONI, G.; OSAWA, E. A.; MELO, R. R.; SUNDIN, M. R.; GRANDE, S. M.; GAIOTTO, F. A.; POMERANTZEFF, P. M.; DALLAN, L. O.; FRANCO, R. A.; NAKAMURA, R. E.; LISBOA, L. A.; ALMEIDA, J. P. de; GERENT, A. M.; SOUZA, D. H.; GAIANE, M. A.; FUKUSHIMA, J. T.; PARK, C. L.; ZAMBOLIM, C.; FERREIRA, Rocha G. S.; STRABELLI, T. M.; FERNANDES, F. L.; CAMARA, L.; ZEFERINO, S.; SANTOS, V. G.; PICCIONI, M. A.; JATENE, F. B.; AULER JR., Costa J. O.; FILHO, R. K.
  • article 53 Citação(ões) na Scopus
    Cerebral blood flow autoregulation in ischemic heart failure
    (2017) CALDAS, J. R.; PANERAI, R. B.; HAUNTON, V. J.; ALMEIDA, J. P.; FERREIRA, G. S. R.; CAMARA, L.; NOGUEIRA, R. C.; BOR-SENG-SHU, E.; OLIVEIRA, M. L.; GROEHS, R. R. V.; FERREIRA-SANTOS, L.; TEIXEIRA, M. J.; GALAS, F. R. B. G.; ROBINSON, T. G.; JATENE, F. B.; HAJJAR, L. A.
    Patients with ischemic heart failure (iHF) have a high risk of neurological complications such as cognitive impairment and stroke. We hypothesized that iHF patients have a higher incidence of impaired dynamic cerebral autoregulation (dCA). Adult patients with iHF and healthy volunteers were included. Cerebral blood flow velocity (CBFV, transcranial Doppler, middle cerebral artery), end-tidal CO2 (capnography), and arterial blood pressure (Finometer) were continuously recorded supine for 5 min at rest. Autoregulation index (ARI) was estimated from the CBFV step response derived by transfer function analysis using standard template curves. Fifty-two iHF patients and 54 age-, gender-, and BP-matched healthy volunteers were studied. Echocardiogram ejection fraction was 40 (20-45) % in iHF group. iHF patients compared with control subjects had reduced end-tidal CO2 (34.1 +/- 3.7 vs. 38.3 +/- 4.0 mmHg, P < 0.001) and lower ARI values (5.1 +/- 1.6 vs. 5.9 +/- 1.0, P = 0.012). ARI <4, suggestive of impaired CA, was more common in iHF patients (28.8 vs. 7.4%, P = 0.004). These results confirm that iHF patients are more likely to have impaired dCA compared with age-matched controls. The relationship between impaired dCA and neurological complications in iHF patients deserves further investigation.
  • article 205 Citação(ões) na Scopus
    Vasopressin versus Norepinephrine in Patients with Vasoplegic Shock after Cardiac Surgery The VANCS Randomized Controlled Trial
    (2017) HAJJAR, Ludhmila Abrahao; VINCENT, Jean Louis; GALAS, Filomena Regina Barbosa Gomes; RHODES, Andrew; LANDONI, Giovanni; OSAWA, Eduardo Atsushi; MELO, Renato Rosa; SUNDIN, Marcia Rodrigues; GRANDE, Solimar Miranda; GAIOTTO, Fabio A.; POMERANTZEFF, Pablo Maria; DALLAN, Luis Oliveira; FRANCO, Rafael Alves; NAKAMURA, Rosana Ely; LISBOA, Luiz Augusto; ALMEDIA, Juliano Pinheiro de; GERENT, Aline Muller; SOUZA, Dayenne Hianae; GAIANE, Maria Alice; FUKUSHIMA, Julia Tizue; PARK, Clarice Lee; ZAMBOLIM, Cristiane; FERREIRA, Graziela Santos Rocha; STRABELLI, Tania Mara; FERNANDES, Felipe Lourenco; CAMARA, Ligia; ZEFERINO, Suely; SANTOS, Valter Garcia; PICCIONI, Marilde Albuquerque; JATENE, Fabio Biscegli; AULER JR., Jose Otavio Costa; KALIL FILHO, Roberto
    Background: Vasoplegic syndrome is a common complication after cardiac surgery and impacts negatively on patient outcomes. The objective of this study was to evaluate whether vasopressin is superior to norepinephrine in reducing postoperative complications in patients with vasoplegic syndrome. Methods: This prospective, randomized, double-blind trial was conducted at the Heart Institute, University of Sao Paulo, Sao Paulo, Brazil, between January 2012 and March 2014. Patients with vasoplegic shock (defined as mean arterial pressure less than 65 mmHg resistant to fluid challenge and cardiac index greater than 2.2 l.min(-1).m(-2)) after cardiac surgery were randomized to receive vasopressin (0.01 to 0.06 U/min) or norepinephrine (10 to 60 mu g/min) to maintain arterial pressure. The primary endpoint was a composite of mortality or severe complications (stroke, requirement for mechanical ventilation for longer than 48 h, deep sternal wound infection, reoperation, or acute renal failure) within 30 days. Results: A total of 330 patients were randomized, and 300 were infused with one of the study drugs (vasopressin, 149; norepinephrine, 151). The primary outcome occurred in 32% of the vasopressin patients and in 49% of the norepinephrine patients (unadjusted hazard ratio, 0.55; 95% CI, 0.38 to 0.80; P = 0.0014). Regarding adverse events, the authors found a lower occurrence of atrial fibrillation in the vasopressin group (63.8% vs. 82.1%; P = 0.0004) and no difference between groups in the rates of digital ischemia, mesenteric ischemia, hyponatremia, and myocardial infarction. Conclusions: The authors' results suggest that vasopressin can be used as a first-line vasopressor agent in postcardiac surgery vasoplegic shock and improves clinical outcomes.
  • article 19 Citação(ões) na Scopus
    Dynamic cerebral autoregulation is impaired during submaximal isometric handgrip in patients with heart failure
    (2018) CALDAS, J. R.; PANERAI, R. B.; SALHIET, A. M.; SENG-SHU, E.; FERREIRA, G. S. R.; CAMARA, L.; PASSOS, R. H.; GALAS, F. R. B. G.; ALMEIDA, J. P.; NOGUEIRA, R. C.; OLIVEIRA, M. de Lima; ROBINSON, T. G.; HAJJAR, L. A.
    The incidence of neurological complications, including stroke and cognitive dysfunction, is elevated in patients with heart failure (HF) with reduced ejection fraction. We hypothesized that the cerebrovascular response to isometric handgrip (iHG) is altered in patients with HF. Adults with HF and healthy volunteers were included. Cerebral blood velocity (CBV; transcranial Doppler, middle cerebral artery) and arterial blood pressure (BP; Finometer) were continuously recorded supine for 6 min, corresponding to 1 min of baseline and 3 min of iHG exercise, at 30% maximum voluntary contraction, followed by 2 min of recovery. The resistance-area product was calculated from the instantaneous BP-CBV relationship. Dynamic cerebral autoregulation (dCA) was assessed with the time-varying autoregulation index estimated from the CBV step response derived by an autoregressive moving-average time-domain model. Forty patients with HF and 23 BP-matched healthy volunteers were studied. Median left ventricular ejection fraction was 38.5% (inter-quartile range: 0.075%) in the HF group. Compared with control subjects. patients with HF exhibited lower time-varying autoregulation index during iHG, indicating impaired dCA (P < 0.025). During iHG, there were steep rises in CBV. BP, and heart rate in control subjects but with different temporal patterns in HF, which, together with the temporal evolution of resistance-area product, confirmed the disturbance in dCA in HF. Patients with HF were more likely to have impaired dCA during iHG compared with age-matched control subjects. Our results also suggest an impairment of myogenic, neurogenic. and metabolic control mechanisms in HF. The relationship between impaired dCA and neurological complications in patients with HF during exercise deserves further investigation. NEW & NOTEWORTHY Our findings provide the first direct evidence that cerebral blood flow regulatory mechanisms can be affected in patients with heart failure during isometric handgrip exercise. As a consequence, eventual blood pressure modulations are buffered less efficiently and metabolic demands may not be met during common daily activities. These deficits in cerebral autoregulation are compounded by limitations of the systemic response to isometric exercise, suggesting that patients with heart failure may be at greater risk for cerebral events during exercise.