We describe surgical repair of an incomplete atrioventricular septal defect (AVSD) in a 72-year-old woman who had cerebral infarction and severe congestive heart failure. A massive left-to-right shunt and severe left atrioventricular valve regurgitation, associated with pulmonary hypertension, were found on transesophageal echocardiography and cardiac catheterization. She underwent complete closure of the cleft and patch closure of the ostium primum defect. We conclude that surgical correction should be considered even in elderly patients with incomplete AVSD.

Cardiac operations involving cardiopulmonary bypass can cause a systemic inflammatory response such as elevation of inflammatory cytokines, which can cause organ failure. We investigated cytokine production and its inhibition by ulinastatine in patients undergoing elective coronary artery bypass grafting under cardiopulmonary bypass. Thirty-three patients received either ulinastatine (300, 000 units, intracoronary artery injection immediately after aortic closs-clamping, UTI group, n=16) or no ulinastatine (control group, n=17). Arterial blood samples were obtained at aortic closs-clamping, 5 minutes after aortic declamping, and 6, 12 and 18 hours after surgery and there were assayed for interleukin-6 (IL-6), interleukin-8 (IL-8), and polymorphonuclear leukocyte elastase (PMNE). In addition, we examined liver function (GOT, GPT, and total bilirubin), renal function (blood urea nitrogen and serum creatinine), and oxygenatory function (PaO₂/FIO₂) postoperatively. IL-8 levels at 5 minutes after aortic declamping and maximum IL-8 levels were significantly lower in the UTI group than in the control group (25.5±12.8 vs. 47.8±38.9pg/dl, p<0.05, and 28.6±13.2 vs. 58.4±40.0pg/dl, p<0.05). Blood urea nitrogen on the second post operative day (POD) and three POD and creatinine on the second POD were also significantly lower in the UTI group than the control group. Furthermore, IL-8 and PMNE levels significantly correlated positively with blood urea nitrogen and creatinine. There was significant negative correlation between IL-8 and oxygenatory function. These results shows that the ulinastatine can inhibit IL-8 levels following cardiac surgery. To combat the increase of inflammatory cytokines such as IL-8 after cardiopulmonary bypass, the ulinastatine should be used for anticytokine therapy to protect the kidneys, lungs, and other organs, and thereby decrease the risk of complications.

Although insulin resistance in peripheral tissue has been demonstrated in patients with cardiac disease, expression of glucose transporter (GLUT) isoform mRNA in the cardiac muscle is not known. We analyzed GLUT isoform mRNA in the cardiac muscle of 10 patients by RT-PCR. GLUT 4 mRNA was semi-quantitated by kinetic analysis, altering the cycles of PCR, and insulin resistance was examined by euglycemic hyperinsulinemic glucose clamp with an artificial pancreas. In addition to GLUT 2, 3, and 4 mRNA, all of which were constantly demonstrated in the skeletal muscle of normal volunteers, GLUT 1 was documented in all the cardiac samples examined. The quantity of GLUT4 mRNA was not related to the degree of insulin resistance or M values. These results may suggest that glucose uptake in the cardiac muscle is maintained by 4 different glucose transporters and that the response of GLUT 4 mRNA to insulin resistance is different in the cardiac muscle and in the skeletal muscle.

A Case of abdominal aortic occlusion caused by acute aortic dissection (DeBakey's type III b) is reported. A 59-year-old woman was admitted with sudden onset back pain and sensory disturbance of bilateral lower extremities. The pulsations of bilateral femoral arteries were absent. CT and aortogram revealed dissection of the thoracic descending aorta and infrarenal aortic occlusion. Since ischemic change had progressed, bilateral axillofemoral bypass was performed for limb salvage, and the symptoms improved rapidly. Axillofemoral bypass is an easy and safe procedure even in the acute phase of aortic dissection. It provides fast reperfusion, and so is considered to be useful to preventing myonephrotic metabolic syndrome MNMS.