Ionescu-Shiley low profile pericardial valve explanted at >20 years from a 76-year-old male. (a) Gross photograph of the flow surface showing thickened cusps and pannus covering the sewing cuff (asterisk). (b) The nonflow surface of the same valve shows thickened cusp, tears at the stent post (white arrows), pannus (asterisk), and the alignment suture (black arrow).