Effects of diet and exercise on obesity-related vascular dysfunction in children

Congenital Heart Disease

tion. Further public health efforts will be extremely valuable to help children learn healthy diet and exercise habits at an early age. CG

Abstracts Effects of Diet and Exercise on Obesity-Related Vascular Dysfunction in Children

Surgical Reconstruction of Occluded Pulmonary Arteries in Patients With Congenital Heart Disease: Effects on Pulmonary Artery Growth

Woo KS, Chook P, Yu CW, et al. Circulation 2004;109:1981– 6. Study Question: Is obesity-related arterial dysfunction and carotid intima-media thickening reversible with diet and/or exercise intervention? Methods: Obese children, ages 9 –12, were recruited to participate in a clinical trial. Patients were randomly assigned to either a diet program (serial dietary counseling sessions encouraging a 900 –1200-kcal diet, low in fat and high in complex carbohydrates) or the same diet program combined with an exercise regimen for 6 weeks. Patients were given the option to continue with the diet and/or exercise programs for a complete year. Arterial endothelial function at the brachial artery and intima-media thickness of the carotid artery was measured at baseline, at 6 weeks and at 1 year. Results: Eighty-two obese patients were enrolled in this study (BMI 25⫾3; 54 boys). At baseline, endotheliumdependent vasodilation was abnormal (6.9⫾2.0%) compared with healthy historical controls (9.7⫾3.5%). Both treatment groups had a decrease in waist-to-hip ratios and lower total cholesterol levels. The exercise-intervention group was found to have lower LDL cholesterol levels. No significant change occurred from baseline for either group at 6 weeks in body-fat content, fat-free mass or BMI. There was demonstrated improvement in endothelial-dependent vasodilation for both groups at 6 weeks, though no change occurred in endothelial-independent dilation. Exercise training and lowered LDL cholesterol were both identified as independent predictors of improved endothelial-dependent vasodilation. For patients who continued to be involved in the exercise program at 1 year, further improvements in endothelial-dependent vasodilation were recognized and carotid intima-media thickness was improved, whereas for those patients who discontinued the exercise program, measures of endothelial-dependent vasodilation at 1-year follow-up tended toward baseline. Conclusions: Vascular dysfunction associated with obesity can be improved with only a short period of dietary modification. This improvement is furthered by the inclusion of an exercise regimen and diet and exercise program extension. Discontinuation of diet and exercise modification is associated with loss of improved vascular function. Perspective: The prevalence of obesity, and with it an increased risk for major morbidities, continues to climb for children and adults alike. Though there is limited long-term data, vascular reactivity likely serves as an early sign in children for development of atherosclerotic disease. It is reassuring that these investigators have demonstrated that diet and exercise programs can improve vascular dysfunc-

Agnoletti GA, Boudjemline Y, Bonnet D, Sidi D, Vouhe P. Circulation 2004;109:2314 –18. Study Question: What are the outcomes and best strategies for treatment of occluded pulmonary arteries in children with congenital heart disease? Methods: A retrospective study was performed reviewing all patients from a single center who were born with conotruncal abnormalities and subsequently found to have an occluded pulmonary artery. Data pertaining to diagnosis, surgical course and duration of occlusion were collected. Duration of occlusion was estimated based on prior operation dates and echocardiographic data. Results: Twenty-three patients met the inclusion criteria. The original congenital heart diseases for this group included: pulmonary atresia/ventricular septal defect (n⫽11), tetralogy of Fallot (n⫽6), single ventricle with pulmonary atresia or stenosis (n⫽4), tricuspid atresia with pulmonary atresia (n⫽1) and pulmonary atresia with an intact ventricular septum (n⫽1). Thirteen of the 23 patients were known to have prior pulmonary artery stenosis or hypoplasia. Patients underwent surgical intervention if the duration of occlusion was thought to be ⬍6 months. Twelve patients underwent surgical intervention after a mean estimated duration of occlusion of 2 months. Surgical intervention was pericardial patch reconstruction (n⫽6), end-to-end anastomosis (n⫽3), thrombectomy (n⫽2) and placement of a BTS (n⫽1). At follow-up catheterization performed in 11 of the 12 subjects, 8 were found to have branch pulmonary artery patency; reocclusion was identified in 3. Conclusions: It is possible to reestablish pulmonary artery patency of occluded branch pulmonary arteries in children with congenital heart disease. Perspective: This study describes an important role for surgical intervention once an occlusion has occurred. However, as noted in this report, only a select group may be helped by surgical intervention. As neonatal surgery and survival through infancy and early childhood has become more commonplace, even for children with complex malformations, the potential for later morbidities has become more evident. Recognizing the risk of pulmonary artery occlusion must prompt us both to careful surveillance of patients at risk and to determine the optimal methods to prevent development of branch pulmonary artery occlusion. CG

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