A 70-year-old man has progressive dyspnea on exertion and a harsh systolic ejection murmur best heard at the right upper sternal border radiating to the carotids. Echocardiography shows a heavily calcified aortic valve with restricted opening. What is the underlying pathological mechanism?

• A Congenital bicuspid valve with superimposed calcification
• B Rheumatic valvular fibrosis and commissural fusion
• C Degenerative calcific changes in a trileaflet valve ✓
• D Infective endocarditis with leaflet destruction

Explanation

In elderly patients, calcific aortic stenosis is usually a degenerative process affecting a trileaflet valve, analogous to atherosclerosis with lipid deposition and inflammation. Bicuspid aortic valve causes earlier stenosis (fifth decade) but this patient is 70. Rheumatic disease causes commissural fusion and affects mitral valve more commonly. Infective endocarditis causes regurgitation, not calcific stenosis. The heavily calcified trileaflet valve in an elderly patient points to senile calcific stenosis.

Reference: Robbins and Cotran Pathologic Basis of Disease, 10th ed.

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Written and medically reviewed by the StethoPrep medical team.