Figure 1. Resected aortic valve showing six fibrous strands, with one strand ruptured (black arrow).

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Myocardial hibernation is recognised as chronic hypoperfusion of the myocardium and its functional recovery after surgical revascularisation has been described. A case of surgery for complex lesions including severe aortic valve regurgitation, coronary ostial stenosis, and aortic calcification (porcelain aorta) caused by Takayasu's arteritis is presented. The onset of left ventricular functional improvement after aortic valve replacement and coronary revascularisation were indicative of preoperative atypical myocardial hibernation caused by aortic valve disease and coronary artery disease associated with Takayasu's arteritis.A 59 year old woman was referred to our hospital for detailed examination for congestive heart failure and arteritis. She had previously noted heart murmur and diminished upper body pulse during pregnancy at the age of 23. She remained entirely asymptomatic over the next 35 years with no evidence of relapse. Ultimately, however, she presented with an approximately one year history of worsening exertional dyspnoea and chest discomfort. She was a smoker (10 cigarettes a day for 35 years) and severe hypertension and hyperlipidaemia were noted.On admission, active inflammation was not noticed, with no fever and with a C reactive protein concentration of 2.3 mg/l, but her haemodynamic condition was unstable. Chest radiography showed cardiomegaly with a cardiothoracic ratio of 59.4% and mild congestion. A transthoracic echocardiogram showed severe aortic regurgitation with left ventricular dilatation and global dysfunction (diastolic dimension of 65 mm, systolic dimension of 51 mm, and fractional shortening of 0.21). Cardiac catheterisation data showed severe systemic hypertension (238 mm Hg), decreased diastolic pressure (62 mm Hg), and increased left ventricular end diastolic pressure (47 mm Hg). Left ventriculography showed a severely dilated and dysfunctional left ventricle with an end diastolic volume index of 171.1 ml/m 2 , end systolic volume index of 119.5 ml/m 2 , and ejection fraction of 30%. Neither inotropic stimulation nor stress induced evaluation of left ventricular function could be performed preoperatively because of persistently unstable haemodynamic status caused by severe aortic regurgitation. Angiographic findings were typical of Takayasu's arteritis: severe aortic regurgitation, mid left subclavian arterial stenosis, descending thoracic aortic narrowing, and stenosis of both coronary ostia. Furthermore, computed tomography showed severe aortic calcification (porcelain aorta). Early surgical intervention was indicated for these complex lesions.At operation, the heart was approached through a median sternotomy. After institution of cardiopulmonary bypass with right atrial drainage and right axillary perfusion, the heart was arrested by antegrade infusion of blood cardioplegia. The aortic valve was replaced and double coronary artery bypass grafting (with saphenous vein grafts to the left anterior descending branch and the right coronary artery) was performed. The patient was su...

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