Severe Trileaflet Aortic Stenosis Without Significant Valve Calcification in an Older Adult.

Severe aortic stenosis (AS) is most often caused by progressive valve calcification; however, rare cases occur with little or no calcification. We report a 79-year-old man with a trileaflet aortic valve and progressive, hemodynamically severe AS despite an almost complete absence of valve calcification (aortic valve calcium score of 76.5 Agatston units). Multimodality imaging confirmed the severity of obstruction, and the patient underwent successful surgical bioprosthetic aortic valve replacement with good postoperative outcomes. This case demonstrates that severe AS can occur in elderly patients with trileaflet valves through fibrosis-predominant remodeling without significant calcification, and that computed tomography-based calcium scoring may underestimate disease severity in this rare phenotype.