Silent but fatal: Sudden death from asymptomatic severe aortic stenosis

Abstract

Aortic stenosis (AS) is the most common valvular heart disease and typically progresses slowly, often becoming symptomatic in older people. Sudden death in previously asymptomatic individuals is rare, particularly in middle-aged adults. We report a case of a 48-year-old male carpenter who collapsed while engaging in his routine work. He was pronounced dead shortly after arrival at hospital. Medico-legal autopsy revealed a markedly enlarged heart weighing 682 g. The aortic valve was severely stenosed, heavily calcified and distorted, producing an orifice of approximately 1 cm. The valve appeared to have two cusps, suggesting possible congenital bicuspid morphology, though definitive confirmation was precluded by advanced calcification. The left ventricle demonstrated symmetrical concentric hypertrophy with a wall thickness of 2.5 cm. No right ventricular hypertrophy, septal asymmetry or pulmonary oedema were observed. Histology confirmed hypertrophied myocardial fibres without myofibrillar disarray or fibrosis. Urine toxicology was negative. Death was attributed to severe aortic stenosis, with the probable mechanism being fatal arrhythmia precipitated by exertion. This case highlights the silent but potentially fatal nature of severe AS, the importance of thorough autopsy examination, and the value of forensic insight in sudden unexpected deaths.