Figure 2. Mechanisms driving dystrophic calcification responsible for structural valve degeneration.

Both implant‐related (residual donor cells and their debris, loss of glycosaminoglycans, and damage of collagen/elastin fibers during chemical treatment and storage) and recipient‐related (immune cell and red blood cell penetration, serum proteolytic enzymes, and calcium‐binding proteins) factors promote dystrophic calcification of bioprosthetic heart valves (BHVs). ALP indicates alkaline phosphatase; and MMP, matrix metalloproteinase.