Journal of Cardiology and Heart Failure

ABSTRACT

Background

The clinical advantages of stentless compared with conventional stented bioprosthetic valves in surgical aortic valve replacement (SAVR) remain uncertain, particularly in the context of evolving lifetime valve management strategies and the increasing role of transcatheter interventions.

Objectives

To compare early clinical outcomes and hemodynamic performance between stented and stentless bioprosthetic valves used in SAVR.

Methods

A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines and registered in PROSPERO. PubMed, Embase, the Cochrane Library, and Scopus were searched from database inception through September 2025. Randomized controlled trials and observational studies comparing stented and stentless bioprostheses in SAVR were included. Outcomes of interest included early clinical outcomes (in-hospital or within 30 days), together with intermediate and late hemodynamic outcomes when available. Random-effects models were used to pool effect estimates.

Results

A total of 56 studies comprising 17,260 patients were included. Early mortality, stroke, myocardial infarction, endocarditis, reoperation, and hospital length of stay were comparable between the two valve types. Stentless valves were associated with improved hemodynamic performance, demonstrated by larger effective orifice areas (mean difference [MD] 0.38 cm², 95% CI 0.28–0.48) and lower mean transvalvular gradients (MD −0.68 mmHg, 95% CI −1.05 to −0.31). Left ventricular mass regression was similar between groups. Moderate to high heterogeneity was observed across hemodynamic outcomes.

Conclusion

Stentless bioprosthetic valves demonstrate superior hemodynamic performance compared with stented valves but do not appear to improve early clinical outcomes. Given the predominance of observational evidence and the growing importance of lifetime valve management strategies, including valve-in-valve feasibility, prosthesis selection should be individualized.

Keywords: Aortic Valve Replacement; Stented Valve; Stentless Valve; Hemodynamics; Mortality; Systematic Review; Meta-Analysis