Progressive shortness of breath. A 73-year-old male with history of hypertension, orthotopic heart transplantation 19 years ago has been followed closely for symptoms of worsening shortness of breath in the setting of severe aortic stenosis. His functional capacity has been gradually declined to NYHA Class IV (New York Heart Association). Hypertension, status post heart transplantation, allograft non occlusive vasculopathy and aortic stenosis. Included above. Physical examination upon admission: He was noted to have elevated jugular venous pulse, bibasilar lung crackles and bilateral pedal edema. None. Follow up transthoracic echocardiograms as per routine protocol did not show any aortic valve disease until 15 years post transplantation when the aortic valve was noted to be mildly sclerotic at that time and gradually progressed to symptomatic severe aortic stenosis over the next 4 years.