This case involves a male patient who died shortly after undergoing a procedure to implant a prosthetic aortic valve. The patient in question had a past medical history significant for coronary artery disease as well as a general narrowing of the aorta. In light of the progressive nature of the patient’s condition, it was decided that he should undergo an aortic valve replacement as soon as possible. The patient underwent the procedure, which was marked by the need for siginficant blood transfusions but otherwise occored without incident. Shortly after the patient was brought to the surgical intensive care unit, his condition began to deteriorate. Despite heroic efforts to save the patient’s life, the man passed away in the surgical ICU. An autopsy discovered a number of troubeling findings, which appeared to be linked to an error in the position of the aortic valve prosthetic by the treating surgeon.