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Presacco A, Chirumamilla VC, Vezina G, Li R, Du Plessis A, Massaro AN, Govindan RB. Prediction of outcome of hypoxic-ischemic encephalopathy in newborns undergoing therapeutic hypothermia using heart rate variability. J Perinatol 2024; 44:521-527. [PMID: 37604967 DOI: 10.1038/s41372-023-01754-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 07/31/2023] [Accepted: 08/10/2023] [Indexed: 08/23/2023]
Abstract
OBJECTIVE To assess the use of continuous heart rate variability (HRV) as a predictor of brain injury severity in newborns with moderate to severe HIE that undergo therapeutic hypothermia. STUDY DESIGN Two cohorts of newborns (n1 = 55, n2 = 41) with moderate to severe hypoxic-ischemic encephalopathy previously treated with therapeutic hypothermia. HRV was characterized by root mean square in the short time scales (RMSS) during therapeutic hypothermia and through completion of rewarming. A logistic regression and Naïve Bayes models were developed to predict the MRI outcome of the infants using RMSS. The encephalopathy grade and gender were used as control variables. RESULTS For both cohorts, the predicted outcomes were compared with the observed outcomes. Our algorithms were able to predict the outcomes with an area under the receiver operating characteristic curve of about 0.8. CONCLUSIONS HRV assessed by RMSS can predict severity of brain injury in newborns with HIE.
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Affiliation(s)
- Alessandro Presacco
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, DC, USA.
| | | | - Gilbert Vezina
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, DC, USA
- Division of Neonatology, Children's National Hospital, Washington, DC, USA
| | - Ruoying Li
- Division of Diagnostic Imaging and Radiology, Children's National Hospital, Washington, DC, USA
| | - Adre Du Plessis
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, DC, USA
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
| | - An N Massaro
- Division of Neonatology, Children's National Hospital, Washington, DC, USA
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
| | - Rathinaswamy B Govindan
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, DC, USA
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
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Christoffel K, De Asis-Cruz J, Govindan RB, Kim JH, Cook KM, Kapse K, Andescavage N, Basu S, Spoehr E, Limperopoulos C, du Plessis A. Central Autonomic Network and heart rate variability in premature neonates. Dev Neurosci 2024:000536513. [PMID: 38320522 PMCID: PMC11300706 DOI: 10.1159/000536513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 01/18/2024] [Indexed: 02/08/2024] Open
Abstract
INTRODUCTION The Central Autonomic Network (CAN) is a hierarchy of brain structures that collectively influence cardiac autonomic input, mediating the majority of brain-heart interactions, but has never been studied in premature neonates. In this study, we use heart rate variability (HRV), which has been described as the "primary output" of the CAN, and resting state functional MRI to characterize brain-heart relationships in premature neonates. METHODS We studied premature neonates who underwent resting state functional MRI (rsfMRI) at term, (37-weeks postmenstrual age [PMA] or above) and had HRV data recorded during the same week of their MRI. HRV was derived from continuous electrocardiogram data during the week of the rsfMRI scan. For rsfMRI, a seed-based approach was used to define regions of interest (ROI) pertinent to the CAN, and blood oxygen level-dependent signal was correlated between each ROI as a measure of functional connectivity. HRV was correlated with CAN connectivity (CANconn) for each region, and sub-group analysis was performed based on sex and clinical comorbidities. RESULTS Forty-seven premature neonates were included in this study, with a mean gestational age at birth of 28.1 +/- 2.6 weeks. Term CANconn was found to be significantly correlated with HRV in approximately one-fifth of CAN connections. Two distinct patterns emerged among these HRV-CANconn relationships. In the first, increased HRV was associated with stronger CANconn of limbic regions. In the second pattern, stronger CANconn at the precuneus was associated with impaired HRV maturation. These patterns were especially pronounced in male premature neonates. CONCLUSION We report for the first time evidence of brain-heart relationships in premature neonates and an emerging CAN, most striking in male neonates, suggesting that the brain-heart axis may be more vulnerable in male premature neonates. Signatures in the heart rate may eventually become an important non-invasive tool to identify premature males at highest risk for neurodevelopmental impairment.
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Affiliation(s)
- Kelsey Christoffel
- Developing Brain Institute, Children’s National Hospital, Washington, DC
- Prenatal Pediatrics Institute, Children’s National Hospital, Washington, DC
| | | | | | - Jung Hoon Kim
- Developing Brain Institute, Children’s National Hospital, Washington, DC
| | - Kevin Michael Cook
- Developing Brain Institute, Children’s National Hospital, Washington, DC
| | - Kushal Kapse
- Developing Brain Institute, Children’s National Hospital, Washington, DC
| | | | - Sudeepta Basu
- Division of Neonatology, Children’s National Hospital, Washington, DC
| | - Emma Spoehr
- Developing Brain Institute, Children’s National Hospital, Washington, DC
| | | | - Adre du Plessis
- Prenatal Pediatrics Institute, Children’s National Hospital, Washington, DC
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Hoffman SB, Govindan RB, Johnston EK, Williams J, Schlatterer SD, du Plessis AJ. Autonomic markers of extubation readiness in premature infants. Pediatr Res 2023; 93:911-917. [PMID: 36400925 DOI: 10.1038/s41390-022-02397-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/28/2022] [Accepted: 10/30/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND In premature infants, extubation failure is common and difficult to predict. Heart rate variability (HRV) is a marker of autonomic tone. Our aim is to test the hypothesis that autonomic impairment is associated with extubation readiness. METHODS Retrospective study of 89 infants <28 weeks. HRV metrics 24 h prior to extubation were compared for those with and without extubation success within 72 h. Receiver-operating curve analysis was conducted to determine the predictive ability of each metric, and a predictive model was created. RESULTS Seventy-three percent were successfully extubated. The success group had significantly lower oxygen requirement, higher sympathetic HRV metrics, and a lower parasympathetic HRV metric. α1 (measure of autocorrelation, related to sympathetic tone) was the best predictor of success-area under the curve (AUC) of .73 (p = 0.001), and incorporated into a predictive model had an AUC of 0.81 (p < 0.0001)-sensitivity of 81% and specificity of 78%. CONCLUSIONS Extubation success is associated with HRV. We show an autonomic imbalance with low sympathetic and elevated parasympathetic tone in those who failed. α1, a marker of sympathetic tone, was noted to be the best predictor of extubation success especially when incorporated into a clinical model. IMPACT This article depicts autonomic markers predictive of extubation success. We depict an autonomic imbalance in those who fail extubation with heightened parasympathetic and blunted sympathetic signal. We describe a predictive model for extubation success with a sensitivity of 81% and specificity of 78%.
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Affiliation(s)
- Suma B Hoffman
- Division of Neonatology, Children's National Hospital, Washington, DC, USA.
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
| | - Rathinaswamy B Govindan
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, DC, USA
| | - Elena K Johnston
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | | | - Sarah D Schlatterer
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, DC, USA
- Department of Neurology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Adre J du Plessis
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, DC, USA
- Department of Neurology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Chirumamilla VC, Hitchings L, Mulkey SB, Anwar T, Baker R, Larry Maxwell G, De Asis-Cruz J, Kapse K, Limperopoulos C, du Plessis A, Govindan R. Electroencephalogram in low-risk term newborns predicts neurodevelopmental metrics at age two years. Clin Neurophysiol 2022; 140:21-28. [DOI: 10.1016/j.clinph.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 04/22/2022] [Accepted: 05/04/2022] [Indexed: 12/01/2022]
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Cerebral cortical autonomic connectivity in low-risk term newborns. Clin Auton Res 2021; 31:415-424. [PMID: 33718981 DOI: 10.1007/s10286-021-00793-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 02/24/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE The mature central autonomic network includes connectivity between autonomic nervous system brainstem centers and the cerebral cortex. The study objective was to evaluate the regional connectivity between the cerebral cortex and brainstem autonomic centers in term newborns by measuring coherence between high-density electroencephalography and heart rate variability as measured by electrocardiography. METHODS Low-risk term newborns with birth gestational age of 39-40 weeks were prospectively enrolled and studied using time-synced electroencephalography and electrocardiography for up to 60 min before discharge from the birth hospital. The ccortical autonomicc nervous system association was analyzed using coherence between electroencephalography-delta power and heart rate variability. Heart rate variability measured the parasympathetic tone (root mean square of successive differences of heart rate) and sympathetic tone (standard deviation of heart rate). RESULTS One hundred and twenty-nine low-risk term infants were included. High coherence delta-root mean square of successive differences was found in central, bitemporal, and occipital brain regions, with less robust coherence delta-standard deviation in the central region and bitemporal areas. CONCLUSIONS Our findings describe a topography of ccortical autonomicc connectivity present at term in low-risk newborns, which was more robust to parasympathetic than sympathetic brainstem centers and was independent of newborn state.
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Govindan RB, Massaro AN, Kota S, Grabowski RC, Wilson JD, Plessis AD. Effect of EKG Sampling Rate on Heart Rate Variability Analysis. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2019:6780-6783. [PMID: 31947397 DOI: 10.1109/embc.2019.8857754] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
We studied the effect of EKG sampling rate on heart rate variability (HRV) analysis. We acquired EKG from four term hypoxic-ischemic encephalopathic infants undergoing therapeutic hypothermia. The EKG signal was acquired continuously for 4 days from the cardiorespiratory monitor through the analog port. The following HRV metrics were calculated: normalized low-frequency (nLF), normalized high-frequency (nHF), low-frequency (LF), high-frequency (HF), short-term detrended fluctuation analysis (DFA) exponent (αs), long-term DFA exponent (αL), root mean square (RMS) short (RMSS), and RMS long (RMSL). In addition, heart rate was used. These metrics were calculated for EKG acquired at 1 KHz (served as reference, EKGref) as well as from EKGs downsampled at 500 Hz (EKG500), 250 Hz (EKG250), and 125 Hz (EKG125). The bedside monitors were simultaneously sending the EKG to a data warehouse, storing the EKG (EKGDWH) at 250 Hz. All HRV metrics were also calculated for the EKGDWH. The comparison between HRV metrics calculated from EKGref and downsampled EKG (EKG500, EKG250, EKG125) was made with intraclass correlation coefficient (r). The comparisons of HRV metrics between EKG250 and EKGDWH were also made with ICC. Our results show that HRV calculated with EKGref and from downsampled EKG were highly correlated (r>0.8 for all comparisons, P<; 0.001). HRV metrics from EKG250 and EKGDWH were also significantly correlated (r=0.7, P<; 0.001) for all metrics except for HF (r=0.276). These data show that HF power is compromised in the EKGDWH signal and caution must be exercised in interpreting the HF power calculated from this EKG.
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Autonomic nervous system maturation in the premature extrauterine milieu. Pediatr Res 2020; 89:863-868. [PMID: 32396923 PMCID: PMC8011288 DOI: 10.1038/s41390-020-0952-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 04/08/2020] [Accepted: 04/28/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND In premature infants, we investigated whether the duration of extrauterine development influenced autonomic nervous system (ANS) maturation. METHODS We performed a longitudinal cohort study of ANS maturation in preterm infants. Eligibility included birth gestational age (GA) < 37 weeks, NICU admission, and expected survival. The cohort was divided into three birth GA groups: Group 1 (≤29 weeks), Group 2 (30-33 weeks), and Group 3 (≥34 weeks). ECG data were recorded weekly and analyzed for sympathetic and parasympathetic tone using heart rate variability (HRV). Quantile regression modeled the slope of ANS maturation among the groups by postnatal age to term-equivalent age (TEA) (≥37 weeks). RESULTS One hundred infants, median (Q1-Q3) birth GA of 31.9 (28.7-33.9) weeks, were enrolled: Group 1 (n = 35); Group 2 (n = 40); and Group 3 (n = 25). Earlier birth GA was associated with lower sympathetic and parasympathetic tone. However, the rate of autonomic maturation was similar, and at TEA there was no difference in HRV metrics across the three groups. The majority of infants (91%) did not experience significant neonatal morbidities. CONCLUSION Premature infants with low prematurity-related systemic morbidity have maturational trajectories of ANS development that are comparable across a wide range of ex-utero durations regardless of birth GA. IMPACT Heart rate variability can evaluate the maturation of the autonomic nervous system. Metrics of both the sympathetic and parasympathetic nervous system show maturation in the premature extrauterine milieu. The autonomic nervous system in preterm infants shows comparable maturation across a wide range of birth gestational ages. Preterm newborns with low medical morbidity have maturation of their autonomic nervous system while in the NICU. Modern NICU advances appear to support autonomic development in the preterm infant.
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Govindan RB, Massaro A, Vezina G, Chang T, du Plessis A. Identifying an optimal epoch length for spectral analysis of heart rate of critically-ill infants. Comput Biol Med 2019; 113:103391. [PMID: 31446320 PMCID: PMC7040438 DOI: 10.1016/j.compbiomed.2019.103391] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 08/15/2019] [Accepted: 08/15/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND OBJECTIVE To identify the optimal epoch length for power spectral analysis of cardiac beat-to-beat intervals (BBi) in critically ill newborns. MATERIALS AND METHOD BBi of 49 term newborns undergoing therapeutic hypothermia for hypoxic-ischemic encephalopathy with well-defined outcomes (good outcome (n = 28): no or mild brain injury and adverse outcome (n = 21): moderate or severe brain injury or death) served as test population. A power spectrum of BBi was calculated with an autoregressive model in three different epoch lengths: 2 min, 5 min, and 10 min. Spectral power was quantified in three different frequency bands: very low-frequency (0.016-0.04 Hz), low-frequency (0.05-0.25 Hz), and high-frequency (0.3-1 Hz). In each frequency band, the absolute power and the normalized power were calculated. Furthermore, standard deviation (SDNN) of BBi was calculated. These metrics were compared between the outcome groups with a receiver operator characteristic (ROC) analysis in 3-h windows. The ROC curve area >0.7 was regarded as a significant separation. RESULTS The absolute spectral powers in all three epoch lengths in all three frequency bands and SDNN distinguished the two outcome groups consistently for most time points. The spectral metrics calculated with a 2-min epoch length performed as well as the five- and 10-min epoch lengths (paired t-test P < 0.05). CONCLUSION Spectral analysis of BBi in 2-min epoch shows a similar discriminatory power as longer epoch lengths. A shorter epoch also has clinical advantages for translation into a continuous real-time bedside monitor of heart rate variability in the intensive care unit.
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Affiliation(s)
- R B Govindan
- Fetal Medicine Institute, Children's National Medical Center, Washington, DC, USA; The George Washington University School of Medicine, USA.
| | - An Massaro
- The George Washington University School of Medicine, USA; Neonatology, Children's National Medical Center, Washington, DC, USA
| | - Gilbert Vezina
- The George Washington University School of Medicine, USA; Diagnostic Imaging and Radiology, Children's National Medical Center, Washington, DC, USA
| | - Taeun Chang
- The George Washington University School of Medicine, USA; Neurology, Children's Medical Center, Washington, DC, USA
| | - Adre du Plessis
- Fetal Medicine Institute, Children's National Medical Center, Washington, DC, USA; The George Washington University School of Medicine, USA
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Mulkey SB, Govindan R, Metzler M, Swisher CB, Hitchings L, Wang Y, Baker R, Larry Maxwell G, Krishnan A, du Plessis AJ. Heart rate variability is depressed in the early transitional period for newborns with complex congenital heart disease. Clin Auton Res 2019; 30:165-172. [PMID: 31240423 PMCID: PMC6930356 DOI: 10.1007/s10286-019-00616-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 06/03/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE To compare early changes in autonomic nervous system (ANS) tone between newborns with complex congenital heart disease (CHD) and newborns without CHD. METHODS We performed a case-control study of heart rate variability (HRV) in newborns with complex CHD [transposition of the great arteries (TGA) or hypoplastic left heart syndrome (HLHS)] and low-risk control newborns without CHD. Cases with CHD were admitted following birth to a pediatric cardiac intensive care unit and had archived continuous ECG data. Control infants were prospectively enrolled at birth. ECG data in cases and controls were analyzed for HRV in the time and frequency domains at 24 h of age. We analyzed the following HRV metrics: alpha short (αs), alpha long (αL), root mean square short and long (RMSs and RMSL), low-frequency (LF) power, normalized LF (nLF), high-frequency (HF) power, and normalized HF (nHF). We used ANOVA to compare HRV metrics between groups and to control for medication exposures. RESULTS HRV data from 57 infants with CHD (TGA, n = 33 and HLHS, n = 24) and from 29 controls were analyzed. The HRV metrics αS, RMSL, LF, and nLF were significantly lower in infants with CHD than in the controls. Due to the effect of normalization, nHF was higher in CHD infants (P < 0.0001), although absolute HF was lower (P = 0.0461). After adjusting for medications, αS and nLF remained lower and nHF higher in newborns with CHD (P < 0.0005). CONCLUSIONS Infants with complex CHD have depressed autonomic balance in the early postnatal period, which may complicate the fetal-neonatal transition.
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Affiliation(s)
- Sarah B Mulkey
- Division of Fetal and Transitional Medicine, Children's National Health System, Washington, DC, USA.
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
- Department of Neurology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
| | - Rathinaswamy Govindan
- Division of Fetal and Transitional Medicine, Children's National Health System, Washington, DC, USA
| | - Marina Metzler
- Division of Fetal and Transitional Medicine, Children's National Health System, Washington, DC, USA
| | - Christopher B Swisher
- Division of Fetal and Transitional Medicine, Children's National Health System, Washington, DC, USA
| | - Laura Hitchings
- Division of Fetal and Transitional Medicine, Children's National Health System, Washington, DC, USA
| | - Yunfei Wang
- Biostatistics and Study Methodology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Robin Baker
- Department of Pediatrics, Inova Children's Hospital, Fairfax, VA, USA
- Fairfax Neonatal Associates, Fairfax, VA, USA
| | - G Larry Maxwell
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Fairfax, VA, USA
| | - Anita Krishnan
- Department of Cardiology, Children's National Health System, Washington, DC, USA
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Adre J du Plessis
- Division of Fetal and Transitional Medicine, Children's National Health System, Washington, DC, USA
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Department of Neurology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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10
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The effect of unilateral stroke on autonomic function in the term newborn. Pediatr Res 2019; 85:830-834. [PMID: 30712058 DOI: 10.1038/s41390-019-0320-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 12/28/2018] [Accepted: 01/21/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND The mature cerebral cortex has a topographically organized influence on reflex autonomic centers of the brainstem and diencephalon and sympathetic activation coming primarily from the right hemisphere and parasympathetic activation from the left. In the term newborn, the maturational status of this central autonomic system remains poorly understood. METHODS Sixteen term newborns admitted to Children's National with unilateral middle cerebral artery (MCA) strokes (n = 8 left, n = 8 right) had archived continuous electrocardiograph (EKG) signals available. We compared stroke laterality and severity with indices of autonomic function, as measured by heart rate variability. We performed both time- and frequency-domain analyses on the R-R interval (RRi) over 24h of continuous EKG data at around 7 days of age. RESULTS Right MCA stroke significantly increased sympathetic tone, while left MCA stroke increased parasympathetic tone. Regardless of laterality, stroke severity was associated inversely with sympathetic tone and positively with parasympathetic tone. Surprisingly, injury to either insular region had no significant autonomic effect. Phenobarbital blood levels were positively associated with sympathetic tone and inversely related to parasympathetic tone. CONCLUSION Based on these findings, it is difficult to reconcile the functional topography of the central autonomic system in term newborns with that currently proposed for the normal mature brain. Further investigation is clearly needed.
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Autonomic Dysfunction in Neonates with Hypoxic Ischemic Encephalopathy Undergoing Therapeutic Hypothermia Impairs Physiological Responses to Routine Care Events. J Pediatr 2018; 196. [PMID: 29519539 PMCID: PMC7307868 DOI: 10.1016/j.jpeds.2017.12.071] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To evaluate whether infants with hypoxic-ischemic encephalopathy and evidence of autonomic dysfunction have aberrant physiological responses to care events that could contribute to evolving brain injury. STUDY DESIGN Continuous tracings of heart rate (HR), blood pressure (BP), cerebral near infrared spectroscopy, and video electroencephalogram data were recorded from newborn infants with hypoxic-ischemic encephalopathy who were treated with hypothermia. Videos between 16 and 24 hours of age identified 99 distinct care events, including stimulating events (diaper changes, painful procedures), and vagal stimuli (endotracheal tube manipulations, pupil examinations). Pre-event HR variability was used to stratify patients into groups with impaired versus intact autonomic nervous system (ANS) function. Postevent physiological responses were compared between groups with the nearest mean classification approach. RESULTS Infants with intact ANS had increases in HR/BP after stimulating events, whereas those with impaired ANS showed no change or decreased HR/BP. With vagal stimuli, the HR decreased in infants with intact ANS but changed minimally in those with impaired ANS. A pupil examination in infants with an intact ANS led to a stable or increased BP, whereas the BP decreased in the group with an impaired ANS. Near infrared spectroscopy measures of cerebral blood flow/blood volume increased after diaper changes in infants with an impaired ANS, but were stable or decreased in those with an intact ANS. CONCLUSION HR variability metrics identified infants with impaired ANS function at risk for maladaptive responses to care events. These data support the potential use of HR variability as a real-time, continuous physiological biomarker to guide neuroprotective care in high-risk newborns.
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Nino G, Govindan RB, Al-Shargabi T, Metzler M, Massaro AN, Perez GF, McCarter R, Hunt CE, du Plessis AJ. Premature Infants Rehospitalized because of an Apparent Life-Threatening Event Had Distinctive Autonomic Developmental Trajectories. Am J Respir Crit Care Med 2017; 194:379-81. [PMID: 27479062 DOI: 10.1164/rccm.201601-0150le] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Gustavo Nino
- 1 Children's National Health System Washington, DC.,2 The George Washington University School of Medicine Washington, DC and
| | - R B Govindan
- 1 Children's National Health System Washington, DC
| | | | | | - An N Massaro
- 1 Children's National Health System Washington, DC.,2 The George Washington University School of Medicine Washington, DC and
| | - Geovanny F Perez
- 1 Children's National Health System Washington, DC.,2 The George Washington University School of Medicine Washington, DC and
| | | | - Carl E Hunt
- 2 The George Washington University School of Medicine Washington, DC and.,3 Uniformed Services University Bethesda, Maryland
| | - Adre J du Plessis
- 1 Children's National Health System Washington, DC.,2 The George Washington University School of Medicine Washington, DC and
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Metzler M, Govindan R, Al-Shargabi T, Vezina G, Andescavage N, Wang Y, du Plessis A, Massaro AN. Pattern of brain injury and depressed heart rate variability in newborns with hypoxic ischemic encephalopathy. Pediatr Res 2017; 82:438-443. [PMID: 28376079 PMCID: PMC5570625 DOI: 10.1038/pr.2017.94] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 03/17/2017] [Indexed: 12/27/2022]
Abstract
BackgroundDecreased heart rate variability (HRV) is a measure of autonomic dysfunction and brain injury in newborns with hypoxic ischemic encephalopathy (HIE). This study aimed to characterize the relationship between HRV and brain injury pattern using magnetic resonance imaging (MRI) in newborns with HIE undergoing therapeutic hypothermia.MethodsHRV metrics were quantified in the time domain (αS, αL, and root mean square at short (RMSS) and long (RMSL) timescales) and frequency domain (relative low-(LF) and high-frequency (HF) power) over 24-27 h of life. The brain injury pattern shown by MRI was classified as no injury, pure cortical/white matter injury, mixed watershed/mild basal ganglia injury, predominant basal ganglia or global injury, and death. HRV metrics were compared across brain injury pattern groups using a random-effects mixed model.ResultsData from 74 infants were analyzed. Brain injury pattern was significantly associated with the degree of HRV suppression. Specifically, negative associations were observed between the pattern of brain injury and RMSS (estimate -0.224, SE 0.082, P=0.006), RMSL (estimate -0.189, SE 0.082, P=0.021), and LF power (estimate -0.044, SE 0.016, P=0.006).ConclusionDegree of HRV depression is related to the pattern of brain injury. HRV monitoring may provide insights into the pattern of brain injury at the bedside.
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Affiliation(s)
- Marina Metzler
- Division of Fetal and Transitional Medicine, Children’s National Health System, Washington, DC
| | - Rathinaswamy Govindan
- Division of Fetal and Transitional Medicine, Children’s National Health System, Washington, DC,The George Washington University School of Medicine, Washington, DC
| | - Tareq Al-Shargabi
- Division of Fetal and Transitional Medicine, Children’s National Health System, Washington, DC
| | - Gilbert Vezina
- Division of Diagnostic Imaging and Radiology, Children’s National Health System, Washington, DC,The George Washington University School of Medicine, Washington, DC
| | - Nickie Andescavage
- Divsion of Neonatology, Children’s National Health System, Washington, DC,The George Washington University School of Medicine, Washington, DC
| | - Yunfei Wang
- Division of Biostatistics and Study Methodology, Children’s National Health System, Washington, DC,The George Washington University School of Medicine, Washington, DC
| | - Adre du Plessis
- Division of Fetal and Transitional Medicine, Children’s National Health System, Washington, DC,The George Washington University School of Medicine, Washington, DC
| | - An N Massaro
- Division of Fetal and Transitional Medicine, Children’s National Health System, Washington, DC,Divsion of Neonatology, Children’s National Health System, Washington, DC,The George Washington University School of Medicine, Washington, DC
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Kota S, Swisher C, Al-Shargabi T, Andescavage N, du Plessis A, Govindan R. Identification of QRS complex in non-stationary electrocardiogram of sick infants. Comput Biol Med 2017; 87:211-216. [DOI: 10.1016/j.compbiomed.2017.05.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 05/30/2017] [Accepted: 05/30/2017] [Indexed: 01/08/2023]
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Al-Shargabi T, Govindan RB, Dave R, Metzler M, Wang Y, du Plessis A, Massaro AN. Inflammatory cytokine response and reduced heart rate variability in newborns with hypoxic-ischemic encephalopathy. J Perinatol 2017; 37:668-672. [PMID: 28252659 PMCID: PMC5446303 DOI: 10.1038/jp.2017.15] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 12/04/2016] [Accepted: 12/19/2016] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To determine whether systemic inflammation-modulating cytokine expression is related to heart rate variability (HRV) in newborns with hypoxic-ischemic encephalopathy (HIE). STUDY DESIGN The data from 30 newborns with HIE were analyzed. Cytokine levels (IL-2, IL-4, IL-6, IL-8, IL-10, IL-13, IL-1β, TNF-α, IFN-λ) were measured either at 24 h of cooling (n=5), 72 h of cooling (n=4) or at both timepoints (n=21). The following HRV metrics were quantified in the time domain: alpha_S, alpha_L, root mean square (RMS) at short time scales (RMS_S), RMS at long time scales (RMS_L), while low-frequency power (LF) and high-frequency power (HF) were quantified in the frequency domain. The relationships between HRV metrics and cytokines were evaluated using mixed-models. RESULT IL-6, IL-8, IL-10, and IL-13 levels were inversely related to selected HRV metrics. CONCLUSION Inflammation-modulating cytokines may be important mediators in the autonomic dysfunction observed in newborns with HIE.
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Affiliation(s)
- Tareq Al-Shargabi
- Division of Fetal and Transitional Medicine, Fetal Medicine Institute, Children’s National Health System, Washington, United States
| | - R. B. Govindan
- Division of Fetal and Transitional Medicine, Fetal Medicine Institute, Children’s National Health System, Washington, United States,The George Washington University, Washington, DC, United States
| | - Rhiya Dave
- The George Washington University, Washington, DC, United States
| | - Marina Metzler
- Division of Fetal and Transitional Medicine, Fetal Medicine Institute, Children’s National Health System, Washington, United States
| | - Yunfei Wang
- Division of Biostatistics and Study Methodology, Children’s National Health System, Washington, DC, United States
| | - Adre du Plessis
- Division of Fetal and Transitional Medicine, Fetal Medicine Institute, Children’s National Health System, Washington, United States,The George Washington University, Washington, DC, United States
| | - An N. Massaro
- Division of Fetal and Transitional Medicine, Fetal Medicine Institute, Children’s National Health System, Washington, United States,Division of Neonatology, Children’s National Health System, Washington, DC, United States,The George Washington University, Washington, DC, United States,Dr. An N. Massaro, MD, Division of Neonatology, Children’s National Health System, 111 Michigan Ave, NW, Washington, DC 20010, United States, Phone: +1-202-476-5448, Fax: +1-202-476-3459,
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Schneebaum Sender N, Govindan RB, Whitehead MT, Massaro AN, Metzler M, Wang J, Cheng YI, du Plessis AJ. Cerebral modulation of the autonomic nervous system in term infants. J Perinatol 2017; 37:558-562. [PMID: 28079874 DOI: 10.1038/jp.2016.248] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 11/02/2016] [Accepted: 11/22/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Central topography of autonomic nervous system (ANS) function has yet to be fully deciphered. In adults it has been shown to lateralize sympathetic and parasympathetic influence predominantly to the right and left cerebral hemispheres, respectively. We examined functional topography of central ANS in newborn subjects utilizing spectral analysis of heart rate variability (HRV), an established measure of ANS function. STUDY DESIGN We studied newborns with hypoxic-ischemic encephalopathy participating in a prospective study undergoing a therapeutic hypothermia protocol.We included subjects with continuous heart rate data over the first 3 h of normothermia (post rewarming) and brain magnetic resonance imaging, which was reviewed and scored according to a 4 region scheme. HRV was evaluated by spectral analysis in the low-frequency (0.05 to 0.25 Hz) and high-frequency (0.3 to 1 Hz) ranges. The relationship between injured brain regions and HRV was studied using multiple regressions. RESULTS Forty eight newborns were included. When examined in isolation, right hemisphere injury had a significant negative effect on HRV (-0.088; 95% CI: -0.225,-0.008). The combination of posterior fossa region injury with right hemispheric injury or left hemispheric injury demonstrated significant positive (0.299; 95% CI: 0.065, 0.518) and negative (-0.475; 95% CI: -0.852, -0.128) influences on HRV, respectively. The association between brain injury location and HRV in the high-frequency range did not reach significance. CONCLUSION Our data support the notion that lateralized cerebral modulation of the ANS, specifically of its sympathetic component, is present in the term newborn, and suggest complex modulation of these tracts by components of the posterior fossa.
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Affiliation(s)
- N Schneebaum Sender
- Department of Fetal and Transitional Medicine, Fetal Medicine Institute, Children's National Health System, Washington, DC, USA
| | - R B Govindan
- Department of Fetal and Transitional Medicine, Fetal Medicine Institute, Children's National Health System, Washington, DC, USA
| | - M T Whitehead
- Department of Radiology, Children's National Health System, Washington, DC, USA
| | - A N Massaro
- Division of Neonatology and Division of Fetal and Transitional Medicine, Children's National Health Systems Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
| | - M Metzler
- Department of Fetal and Transitional Medicine, Fetal Medicine Institute, Children's National Health System, Washington, DC, USA
| | - J Wang
- Division of Biostatistics and Study Methodology, Center for Translational Science, Children's Research Institute, Children's National Health System, Washington, DC, USA
| | - Y I Cheng
- Division of Biostatistics and Study Methodology, Center for Translational Science, Children's Research Institute, Children's National Health System, Washington, DC, USA
| | - A J du Plessis
- Department of Fetal and Transitional Medicine, Fetal Medicine Institute, Children's National Health System, Washington, DC, USA
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Effect of Temperature on Heart Rate Variability in Neonatal ICU Patients With Hypoxic-Ischemic Encephalopathy. Pediatr Crit Care Med 2017; 18:349-354. [PMID: 28198757 PMCID: PMC5402340 DOI: 10.1097/pcc.0000000000001094] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To determine whether measures of heart rate variability are related to changes in temperature during rewarming after therapeutic hypothermia for hypoxic-ischemic encephalopathy. DESIGN Prospective observational study. SETTING Level 4 neonatal ICU in a free-standing academic children's hospital. PATIENTS Forty-four infants with moderate to severe hypoxic-ischemic encephalopathy treated with therapeutic hypothermia. INTERVENTIONS Continuous electrocardiogram data from 2 hours prior to rewarming through 2 hours after completion of rewarming (up to 10 hr) were analyzed. MEASUREMENTS AND MAIN RESULTS Median beat-to-beat interval and measures of heart rate variability were quantified including beat-to-beat interval SD, low and high frequency relative spectral power, detrended fluctuation analysis short and long α exponents (αS and αL), and root mean square short and long time scales. The relationships between heart rate variability measures and esophageal/axillary temperatures were evaluated. Heart rate variability measures low frequency, αS, and root mean square short and long time scales were negatively associated, whereas αL was positively associated, with temperature (p < 0.01). These findings signify an overall decrease in heart rate variability as temperature increased toward normothermia. CONCLUSIONS Measures of heart rate variability are temperature dependent in the range of therapeutic hypothermia to normothermia. Core body temperature needs to be considered when evaluating heart rate variability metrics as potential physiologic biomarkers of illness severity in hypoxic-ischemic encephalopathy infants undergoing therapeutic hypothermia.
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Heart rate variability in encephalopathic newborns during and after therapeutic hypothermia. J Perinatol 2014; 34:836-41. [PMID: 24921413 PMCID: PMC4216618 DOI: 10.1038/jp.2014.108] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 04/11/2014] [Accepted: 04/11/2014] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To evaluate whether heart rate variability (HRV) measures are predictive of neurological outcome in babies with hypoxic ischemic encephalopathy (HIE). STUDY DESIGN This case-control investigation included 20 term encephalopathic newborns treated with systemic hypothermia in a regional neonatal intensive care unit. Electrocardiographic data were collected continuously during hypothermia. Spectral analysis of beat-to-beat heart rate interval was used to quantify HRV. HRV measures were compared between infants with adverse outcome (death or neurodevelopmental impairment at 15 months, n = 10) and those with favorable outcome (survivors without impairment, n = 10). RESULT HRV differentiated infants by outcome during hypothermia through post-rewarming, with the best distinction between groups at 24 h and after 80 h of life. CONCLUSION HRV during hypothermia treatment distinguished HIE babies who subsequently died or had neurodevelopmental impairment from intact survivors. This physiological biomarker may identify infants in need of adjuvant neuroprotective interventions. These findings warrant further investigation in a larger population of infants with HIE.
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Govindan RB, Massaro AN, Andescavage NN, Chang T, du Plessis A. Cerebral pressure passivity in newborns with encephalopathy undergoing therapeutic hypothermia. Front Hum Neurosci 2014; 8:266. [PMID: 24795612 PMCID: PMC4006030 DOI: 10.3389/fnhum.2014.00266] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 04/10/2014] [Indexed: 11/13/2022] Open
Abstract
We extended our recent modification of the power spectral estimation approach to quantify spectral coherence. We tested both the standard and the modified approaches on simulated data, which showed that the modified approach was highly specific and sensitive to the coupling introduced in the simulation while the standard approach lacked these features. We also applied the modified and standard approaches to quantify the pressure passivity in 4 infants receiving therapeutic hypothermia. This was done by measuring the coupling between continuous cerebral hemoglobin differences and mean arterial blood pressure. Our results showed that the modified approach identified a lower pressure passivity index (PPI, percent time the coherence was above a predefined threshold) than the standard approach (P = 0.0027).
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Affiliation(s)
| | - An N Massaro
- Division of Neonatology, Children's National Medical Center , Washington, DC , USA
| | - Nickie N Andescavage
- Division of Neonatology, Children's National Medical Center , Washington, DC , USA
| | - Taeun Chang
- Department of Neurology, Children's National Medical Center , Washington, DC , USA
| | - Adré du Plessis
- Division of Fetal and Transitional Medicine, Children's National Medical Center , Washington, DC , USA
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