Pannus formation in aortic valve prostheses in the late postoperative period

We present three patients who underwent repeat aortic valve replacement for prosthetic valve dysfunction caused by tissue ingrowth in the late postoperative period. These patients (three women aged 48–51 years, mean 49.3 ± 1.53 years) underwent operations for restriction of prosthetic valve leaflet movement by pannus in the left ventricular outflow tract. The interval from the previous operation ranged from 8.0 to 9.6 years (mean 9.6 ± 2.0 years). The symptoms of the patients were New York Heart Association functional class I, II, and IV in one patient each. Diagnosis was made by cinefluoroscopy in two patients and aortography in one patient. The operative procedures consisted of aortic valve replacement (n = 1) and aortic valve replacement with mitral valve replacement (n = 2). Pannus was found at the left ventricular aspect of the prosthetic valve in all patients. In two patients, the pannus directly restricted movement of the leaflet and also severely narrowed the inflow orifice of the prosthetic valve. In the other patient, the pannus had grown at a distance of 7mm from the valve and narrowed the left ventricular outflow tract circularly. The postoperative course was uneventful and all three patients were discharged in a good condition. One patient died of pneumonia 8 months after surgery and the other two patients have remained well and have been followed up for one and a half years. In conclusion, there may be a discrepancy between the clinical symptoms and the grade of subvalvular stenosis caused by pannus. Therefore, it is essential for satisfactory operative results that early diagnosis be made by various means.     

Evaluation of advancing the standard valve dysfunction by multidetector-row CT

We evaluated the diagnostic usefulness of electrocardiographically gated multidetector-row computed tomography (MDCT) for prosthetic valve dysfunction (PVD) of an ATS valve. Twenty-four patients underwent MDCT following echocardiography and cineradiography. Echocardiography and cineradiography showed normal valve function in 17 patients and PVD in 7. PVD included aortic prosthetic valve obstruction in 4 patients, an aortic annular aneurysm with paraprosthetic regurgitation in one, and a blocked leaflet in the mitral position in 2. Among the 7 patients, 5 received reoperation after MDCT. MDCT revealed a subprosthetic mass in all 5 patients with PVD and in 4 patients with normal valve function in the aortic position. In addition to a subprosthetic mass, an annular aneurysm was found in one. Valvular masses were detected in 2 patients with mitral PVD. At reoperation, subprosthetic pannus in the aortic position was detected in 2 patients, subprosthetic pannus and annular aneurysm with paraprosthetic leaks in one, and mitral valve thrombosis in 2. These findings confirmed at reoperation matched to the findings observed on MDCT. The mean CT attenuation of the subprosthetic mass in 6 patients was 152 ± 12 HU and that of the subprosthetic pannus in 3 patients was 163 ± 17 HU. CT attenuation of the thrombus in the mitral valve in the 2 patients was 60 and 99 HU. Our study demonstrates that MDCT is a valuable and reliable diagnostic technique for PVD in an ATS valve and that MDCT may identify an abnormality causing PVD.     

Closing behavior of the mechanical heart valve in a total artificial heart

Recently, cavitation on the surface of mechanical heart valves has been studied as a cause of fractures occurring in implanted mechanical heart valves. The cause of cavitation in mechanical heart valve was investigated in both 25-mm Björk–Shiley and 25-mm Medtronic Hall valves. The closing events of these valves in the mitral position were simulated in an electrohydraulic total artificial heart with a stroke volume of 85?ml. The tests were conducted under physiologic pressures at heart rates of 60, 70, 80, and 90 beats/min with cardiac outputs of 4.5, 5.5, 6.4, and 7.5?l/min, respectively. The disk closing behavior was measured by a laser displacement sensor. The closing behaviors were investigated under various atrial and aortic pressures. In both valves, the duration of closing decreased with an increase in the cardiac output. The greater the amount of atrial pressure, the shorter the closing duration of both valves. The maximum closing velocity of the Medtronic Hall monostrut valve ranged from 0.8 to 0.9?m/s, and that of the Björk–Shiley monostrut valve ranged from 0.73 to 0.78?m/s. In both valves, the maximum closing velocities were less than the reported cavitation thresholds. This suggests that there should be no possibility of occurrence of cavitation in an electrohydraulic total artificial heart with mechanical heart valve.     

Late results of aortic valve replacement with Bjork Shiley prostheses: a comparison of standard aortic valve prosthesis with reversed mitral valve prosthesis implanted in aortic position

Between 1976 and 1983, 435 patients underwent aortic valve replacement (AVR) with Bjork Shiley prostheses. Standard aortic Bjork Shiley prostheses (ABP) were used in 150 patients (Group I) and a reversed mitral Bjork Shiley prostheses in 285 (MBP in 250 and MBC in 35) patients (Group II). There was no significant difference in the number of the patients with valve calcification or the size of aortic root in the 2 groups. There was no significant difference in the early mortality in these two groups. The total follow up period in Group I was 912 years and 2130 years in Group II. The incidence of major aseptic prosthetic dehiscence and valve occlusion with tissue ingrowth were higher in Group I than in Group II. Reversed Bjork Shiley mitral valve prosthesis was successfully used in aortic position with reduced incidence of valve related complications.     

Dysfunction of an ATS valve in the aortic position: the first reported case caused by pannus formation

A 64-year-old woman underwent aortic valve replacement with a 21-mm Advancing The Standard (ATS) open-pivot mechanical heart valve for bicuspid aortic valve stenosis. In addition to the appearance of a new cardiac murmur, echocardiography performed 3 years after surgery showed a high pressure gradient across the ATS valve and a reduction in the valve orifice area. Cineradiography of the valve revealed restricted leaflet opening. Subsequent multidetector-row computed tomography clearly demonstrated pannus overgrowth on the inflow aspect of the ATS valve. During a repeat operation, subvalvular overgrown pannus was confirmed and the ATS valve was replaced with a bioprosthetic valve. This is the first reported case of prosthetic valve dysfunction resulting from pannus formation in a patient with an ATS valve in the aortic position.     

Increased risk for double valve replacement with tissue and mechanical prostheses

We wanted to determine whether there is any advantage of using a mitral tissue valve, when aortic and mitral valves are simultaneously replaced. We placed a tissue valve in the mitral position and a mechanical valve in the aortic position in 22 cases (combined group). In 31 other double valve replacements, mechanical prostheses were chosen for both positions (mechanical group). The mean follow-up time for the combined group was 8.9 years, and that for the mechanical group was 7.2 years. The 10-year survival rate and freedom from thromboembolism at 10 years were not different in the two groups. Treatment-related hemorrhage was seen in 3 patients of the combined group alone. Five patients among the combined group underwent reoperation because of bioprosthetic dysfunction, and the rate of freedom from reoperation at 10 years was 75 ±12%. The rate of freedom from all complications at 10 years was 43±11% for the combined group and 70±8% for the mechanical group. We find no advantage in mixing aortic mechanical and mitral tissue valves when performing double valve replacement.     

Pericardial patch repair of the left atrioventricular valve in atrioventricular septal defect: long-term changes in the patch

A 31-year-old woman with partial atrioventricular septal defect underwent left atrioventricular valve (LAVV) replacement. Her initial repair was at 8 years of age. At 23 years of age, she underwent reoperation due to a combination of severe left ventricular outlet obstruction and moderate LAVV regurgitation. At that reoperation, she had a Dacron patch enlargement of the infundibular septum and repair of her LAVV with a xenograft (bovine) pericardial patch sutured into the superior bridging leaflet. LAVV replacement was required 8 years later because of valve insufficiency. There was a perforation in the patch with fibrosis, thickening due to pannus, and calcification of the pericardial tissue and the leaflet tissue, leading to stiffening of the tissue.     

Late aortic dilatation and regurgitation after Ross operation

The Ross operation, a procedure of replacement of the diseased aortic valve with an autologous pulmonary valve, has many advantages such as no need for anticoagulation therapy and similar valve function and growth potential as native valves. However secondary aortic disease has emerged as a significant complication and indication for reoperation. We report a 48-year-old woman who had Ross operation in 1997 for a damaged bicuspid aortic valve and severe aortic regurgitation due to subacute bacterial endocarditis complicated by aortic root abscess. In 2009, 12 years later, progressive severe aortic regurgitation with incomplete coaptation and mild dilatation of the aortic root was shown on echocardiography and contrasted CT, while the pulmonary homograft retained normal function. She subsequently underwent aortic valve replacement. Histopathological examination of the explanted neo-aortic valve and neo-arterial wall revealed pannus formation at the nodulus Arantii area of the three valve cusps, ventricularis, and arterialis. The amount of elastic fibres in the neo-aorta media was less than usual for an aorta of this patient's age but was similar to a pulmonary artery. The pathological findings were not different from other studies of specimens removed between 7 to 12 years after Ross operation. However, the pathophysiology and long-term implications of these findings remain debatable. Considering the anatomical and physiological changes induced by the procedure, separate mechanisms for aortic dilatation and regurgitation are worthy of consideration.     

A SAM valve prosthesis in the mitral position: report of a case of long-term survival

No long-term survivals over 20 years after valve replacement with SAM (Sakakibara-Arai-Mera) valve prostheses have been described. We report a 57-year-old woman who survived for 31 years after mitral valve replacement with the SAM valve (Type M, 5M). Echocardiography revealed remarkable dilatation of the left atrium and moderate tricuspid regurgitation. Cineradiography, however, showed no restricted or asymmetric disc movement of the SAM valve. Cardiac catheterization revealed moderate pulmonary hypertension (64/30mmHg), with a mean pulmonary capillary wedge pressure of 25mmHg and a mean transprosthetic pressure gradient of 13mmHg. The mitral valve area was calculated to be 0.9 cm². No findings of pannus overgrowth around the SAM valve were confirmed on echocardiograms or left ventriculograms. Although the diagnosis of prosthetic valve obstruction resulting from pannus formation was suspected, the patient strongly refused replacement of the SAM valve because of her poor prognosis with bilateral breast cancer with systemic metastases. We believe that this patient may be the last living patient with the SAM valve.     

心脏人工机械瓣相关并发症外科治疗初步经验

目的　总结 15例心脏人工机械瓣相关并发症外科治疗初步经验。方法　本组 15例患者中 ,男 7例 ,女 8例 ,年龄 315 9岁 ,平均 (4 5 .5± 8.0 )岁。术前均明确诊断 ,人工机械瓣心内膜炎 4例 ,单纯主动脉瓣周漏 4例 ,单纯二尖瓣周漏 4例 ,单纯主动脉瓣并二尖瓣周漏 2例 ,二尖瓣栓塞 1例。肺水肿 10例 ,充血性心力衰竭 6例。再次手术距首次手术时间间隔 1个月至 72个月 ,平均 (2 1.9± 18.2 )个月。本组在全麻中度低温体外循环下行再次主动脉瓣替换术 4例 ,再次二尖瓣替换术 2例 ,主动脉瓣周漏修补术 2例 ,二尖瓣周漏修补术 5例 ,主动脉瓣和二尖瓣周漏修补术 2例。同期手术包括主动脉右心室交通残余漏修补术 1例 ,三尖瓣成形术 4例 ,主动脉瓣替换术 1例 ,冠状动脉旁路移植术 1例。结果　手术死亡 5例 (33.3% )。术后低心排、多脏器功能衰竭 (3例 )为死亡主要原因。 1例为劈胸骨时损伤主动脉大出血 ,术后深昏迷死亡 ,中毒性休克死亡 1例。存活 10例 ,随访 ,死亡 1例为再次主动脉瓣替换术后半年瓣膜栓塞 ,余 9例心功能明显改善。结论　人工机械瓣膜病外科治疗值得 ,但手术危险性较高     

Pannus overgrowth after mitral valve replacement with a Carpentier-Edwards pericardial bioprosthesis

A Carpentier-Edwards pericardial (CEP) bioprosthesis was explanted from an 81-year-old woman due to nonstructural dysfunction 9 years after mitral valve replacement. The nonstructural dysfunction produced severe regurgitation in the mitral position. During the surgery, excessive pannus overgrowth was seen on the left ventricular side of the CEP bioprosthesis. Pannus overgrowth was prominent on one leaflet. That leaflet was stiff and shortened due to the excessive overgrowth of pannus. In this patient, the distortion of one leaflet was the main reason for transvalvular leakage of the CEP bioprosthesis in the mitral position. A new CEP bioprosthesis was implanted in the mitral position. Pathological analysis revealed fibrotic pannus with a small amount of cellular material over the leaflets of the resected CEP valve. This change was marked on the distorted leaflet.     

Short- and Long-Term Results of Triple Valve Surgery: A Single Center Experience

Triple valve surgery is usually complex and carries a reported operative mortality of 13% and 10-yr survival of 61%. We examined surgical results based on our hospital''s experience. A total of 160 consecutive patients underwent triple valve surgery from 1990 to 2006. The most common aortic and mitral valve disease was rheumatic disease (82%). The most common tricuspid valve disease was functional regurgitation (80%). Seventy-four percent of the patients were in New York Heart Association (NYHA) class III and IV. Univariate and multivariable analyses were performed to identify predictors of early and late survival. Operative mortality was 6.9% (n=11). Univariate factors associated with mortality included old age, preoperative renal failure, postoperative renal failure, pulmonary complications, and stroke. Of them, postoperative renal failure and stroke were associated with mortality on multivariable analysis. Otherwise, neither tricuspid valve replacement nor reoperation were statistically associated with late mortality. Survival at 5 and 10 yr was 87% and 84%, respectively. Ninety-two percent of the patients were in NYHA class I and II at their most recent follow-up. Ten-year freedom from prosthetic valve endocarditis was 97%; from anticoagulation-related hemorrhage, 82%; from thromboembolism, 89%; and from reoperation, 84%. Postoperative renal failure and stroke were significantly related with operative mortality. Triple valve surgery, regardless of reoperation and tricuspid valve replacement, results in acceptable long-term survival.     

个体化治疗预防小主动脉瓣环瓣膜置换后瓣膜与患者的不匹配

背景：小主动脉瓣环主动脉瓣置换是心外科手术的难点,治疗不当可能出现瓣膜与患者不匹配现象,使左室流出道狭窄、跨瓣压差增大,引起左室后负荷增加致心肌肥厚甚至充血性心力衰竭。 目的：总结预防小主动脉瓣环瓣膜置换后发生人工心脏瓣膜与患者不匹配的治疗策略。 方法：小主动脉瓣环均主动脉瓣置换患者85例。瓣口直径>17 mm,≤19 mm的患者,选19 mm SJM Regent 瓣;对瓣口直径≤17 mm的患者,用牛心包补片加宽瓣环,再选19 mm SJM Regent 瓣行瓣膜置换;对于瓣口直径>19 mm,≤21 mm,选21 mm Hancock II ultra生物瓣置换。治疗后应用超声心动图测量有效瓣口面积指数、左心室重量指数、室间隔厚度、左心室后壁厚度、跨瓣峰速、跨瓣压差和跨瓣平均压。出院后通过门诊对患者进行随访,定期复查超声心动图。 结果与结论：治疗后早期无死亡病例,均治愈出院。随访时间为6个月-3年。主要并发症为低心排综合征2例、二次开胸止血1例、呼吸机依赖2例。所以患者均未出现脑栓塞或脑出血等脑部并发症。无瓣膜功能失调或卡瓣。未发现牛心包补片撕裂、瘤样膨出、钙化、血栓形成、免疫反应和感染等情况。81例获随访,随访率为 95%(81/85)。NYHA心功能分级Ⅰ级65例,Ⅱ级16例。各不同瓣环直径患者治疗后跨主动脉瓣峰速和平均压差均明显降低,有效瓣口面积指数明显增加,左心室重量指数、室间隔厚度和左心室后壁厚度均明显降低,均未出现人工心脏瓣膜与患者不匹配。置换21 mm Hancock II ultra 生物瓣和21 mm SJM Regent 瓣组间的比较,前者获得了更好的跨瓣峰速和平均压差,以及更好的左心室重塑指标。19 mm Regent 瓣患者治疗后体质量和体表面积较治疗前明显增加。结果提示对于小主动脉瓣环的患者应采取个体化的治疗策略预防主动脉瓣置换后瓣膜与患者不匹配的发生。 中国组织工程研究杂志出版内容重点：肾移植;肝移植;移植;心脏移植;组织移植;皮肤移植;皮瓣移植;血管移植;器官移植;组织工程全文链接：     

In vitro velocity measurements in the near vicinity of the Bjork-Shiley aortic prosthesis using a laser-Doppler anemometer

In this study,in vitro velocity measurements in the near vicinity of a Björk-Shiley aortic valve, one of the more commonly used aortic valve prostheses, were made using a laser-Doppler anemometer. The velocity measurements identified a zone of stagnation, about 20 mm wide, immediately downstream from the fully open disc. The measurements also showed that the flow through the valve was divided into two unequal regions, namely, the major and minor outflow regions. Because of the low flow in the minor outflow region, the shear stresses along the perimeter of the valve in that region were considerably lower than the shear stresses along the sewing ring of the major outflow region. Pathologic studies of nine recovered Björk-Shiley aortic valves indicated varying amounts of thrombus formation on the outflow face of the disc and excess growth of endothelial tissue along the perimeter of the minor outflow region. If the large stagnation zone and the relatively low shear in the minor outflow region which were observed in thein vitro measurements also existin vivo, they could lead to the clinically observed thrombus formation and tissue overgrowth, respectively.     

Early and Two-year Outcomes after Sutureless and Conventional Aortic Valve Replacement: a Nationwide Population-based Study

BackgroundWe compared early and 2-year clinical outcomes of sutureless aortic valve replacement (SAVR) with conventional aortic valve replacement (CAVR) in a nationwide study based on claims data.MethodsFrom December 2016 to November 2018, 3,173 patients underwent bioprosthetic aortic valve replacements. SAVR and CAVR were performed in 641 and 2,532 patients, respectively. Propensity score-matched analysis was performed in 640 patient pairs.ResultsOperative mortality rate was 2.8% without significant differences between the SAVR (3.4%) and CAVR (2.3%) groups (P = 0.324). There were no significant differences in postoperative morbidities between the groups except for permanent pacemaker (PPM) implantation. PPM implantation rate was significantly higher in the SAVR (3.8%) than in the CAVR group (0.9%) (P < 0.001). One- and two-year overall survival was 89.1% and 87.5%, respectively, without significant differences between the groups (SAVR group vs. CAVR group = 89.9% and 90.5% vs. 87.2% and 88.7%, respectively; P = 0.475). There were no significant differences in the cumulative incidence of cardiac death, stroke, aortic valve reoperation and infective endocarditis between the groups. Cumulative PPM implantation incidence at 6 months in the CAVR was 1.1%, and no patient required PPM implantation after 6 months. In the SAVR, the cumulative PPM implantation incidence at 0.5, one, and two years was 3.9%, 5.0% and 5.6%, respectively. The cumulative PPM implantation rate was higher in the SAVR group than in the CAVR group (P < 0.001).ConclusionEarly and 2-year clinical outcomes between SAVR and CAVR were not different except for a high rate of permanent pacemaker implantation in the SAVR group.     

Twelve-year comparison of a Bjork-Shiley mechanical heart valve with porcine bioprostheses

BACKGROUND. Patients undergoing heart-valve replacement may receive a mechanical prosthesis, necessitating lifelong anticoagulant treatment, or a porcine bioprosthesis, which involves no absolute need for anticoagulants. METHODS. We carried out a randomized, prospective trial to compare the durability of the Bjork-Shiley mechanical prosthesis (spherical tilting-disk model) and the incidence of valve-related complications with those variables in the Hancock and the Carpentier-Edwards porcine prostheses. The mitral valve was replaced in 261 patients, the aortic valve in 211, and both in 61; the survivors have been followed up for a mean of 12 years. RESULTS. We found a trend toward improved actuarial survival after 12 years with the Bjork-Shiley prosthesis, but this trend was not statistically significant (group with Bjork-Shiley valve vs. group with porcine valve [mean +/- SE], 51.5 +/- 3.2 vs. 44.4 +/- 3.2 percent; P = 0.08). There was no significant difference in the actuarial incidence of reoperation after 5 years, but after 12 years significantly more patients with a porcine prosthesis had undergone reoperation (8.5 +/- 2.0 vs. 37.1 +/- 4.1 percent, P less than 0.001). An analysis combining death and reoperation as end points for an actuarial assessment of survival with the original prosthesis intact confirmed that the patients with Bjork-Shiley Shiley prostheses had improved survival (48.6 +/- 3.2 vs. 30.0 +/- 3.0 percent after 12 years, P less than 0.001). Bleeding requiring hospitalization or blood transfusion was significantly more frequent in the patients with Bjork-Shiley prostheses (18.6 +/- 3.2 vs. 7.1 +/- 2.3 percent after 12 years, P less than 0.01). There was no significant difference after 12 years in the actuarial occurrence of embolism (Bjork-Shiley vs. porcine, 21.1 +/- 3.1 vs. 26.4 +/- 3.5 percent) or endocarditis (3.7 +/- 1.4 vs 4.6 +/- 1.6 percent). CONCLUSIONS. Survival with an intact valve is better among patients with the Bjork-Shiley spherical tilting-disk prosthesis than among patients with porcine bioprostheses, but use of the Bjork-Shiley valve carries an attendant increased risk of bleeding associated with the need for anticoagulant treatment.     

Novel "biomechanical" polymeric valve prostheses with special design for aortic and mitral position: a future option for pediatric patients?

In children, systemic heart valve replacement with bioprostheses is associated with accelerated valve degeneration, and mechanical prostheses require permanent anticoagulation. Novel "biomechanical" polymeric valve prostheses ("bio" = flexible, "mechanical" = synthetic), solely made of polycarbonate urethane (PCU), were tested in vitro and in a growing animal (calf) model with the aim of improved durability without permanent anticoagulation. The trileaflet aortic prosthesis has diminished pressure loss and reduced stress and strain peaks. The asymmetric bileaflet mitral valve mimics natural nonaxial inflow. The valves underwent long-term in vitro testing and in vivo testing in growing calves for 20 weeks [mitral (7), aortic (7)] with comparison to different commercial bioprostheses [mitral (7), aortic (2)]. In vitro durability of PCU valves was proved up to 20 years. Survival of PCU valves versus bioprostheses was 7 versus 2 mitral and 5 versus 0 aortic valves, respectively. Two animals with PCU aortic valves died of pannus overgrowth causing left ventricular outflow tract obstruction. Degeneration and calcification were mild (mitral) and moderate (aortic) in PCU valves but were severe in biological valves. There was no increased thrombogenicity of the PCU valves compared to bioprostheses. The novel polymeric valve prostheses revealed superior durability compared to current bioprostheses in growing animal model without permanent anticoagulation and thus, may be a future option for pediatric patients.     

Case report of Streptomyces endocarditis of a prosthetic aortic valve.

We describe the first case of prosthetic valve endocarditis due to a Streptomyces sp. The patient presented with fever, cutaneous embolic lesions, and bacteremia 3 months after aortic valve replacement. Treatment required valve replacement and a long course of parenteral imipenem.     

Role of surgery in infective endocarditis

One-hundred-and-thirteen patients with endocarditis and valvular insufficiency were studied retrospectively with special regard to indications for operation and the optimum time for cardiac valve surgery. Thirty patients (group I) had acute, 63 (group II) subacute and 20 (group III) prosthetic valve endocarditis. Group I: Eleven patients underwent surgery in the acute stage, 8 while bacteremic; 5 of the latter died perioperatively. Of the 19 patients treated medically, 16 died. Group II: All patients underwent operation in a bacteria-free state. The mortality was 5%. Group III: Eight patients had early (less than 60 days postoperatively) and 12 late endocarditis. Total mortality was 40% (71% early and 25% late mortality). Ten patients underwent reoperation, with a mortality of 20%, compared with 60% in the medically treated group. The results support the indication for early operation in acute endocarditis with progressive cardiac failure and renal failure and prosthetic valve endocarditis, even during bacteremia.     

Potential complications of transcatheter aortic valve implantation (TAVI)—an autopsy perspective

ObjectiveDegenerative or post-endocarditic destruction of aortic valves with secondary left ventricular hypertension and cardiac insufficiency is seen more frequently in patients of increasing age. When conventional aortic valve replacement is no longer an option, because of age and co-morbidity, patients are increasingly treated with interventional aortic valve replacement using transcatheter aortic valve implantation (TAVI).Methods and resultsTAVI has been performed in Cologne since 2008. We screened our autopsy registry for cases of TAVI, identifying and characterizing complications in connection with the TAVI procedure. We found 13 patients who underwent TAVI procedure. Five of these patients died of non-TAVI specific postoperative complications, whereas in 8 patients there was a direct relationship between TAVI complications and the cause of death. The Patients died within hours and few days after TAVI procedure respectively. Problems observed included predominantly complications due to calcifications of the aortic valve cusps as well as acute endocarditis in 20% of cases. In one case there was an irreversible compression of the implanted valve due to cardiac resuscitation and a malposition of the bioprosthesis.ConclusionsFuture improvements of preoperative evaluation, especially concerning the degree of calcifications of the aortic valve, appear necessary to increase the chance of preventing such complications. Until then, autopsy analysis of complications may help to improve the TAVI procedure.