Valve Choices in Aortic Valve Replacement

The aortic valve can sometimes be repaired, but most patients who require surgery currently benefit most from surgical aortic valve replacement. There are two main valve choices in aortic valve replacement: animal tissue and mechanical heart valves.
Last review by Dr Inderpaul Birdi (GMC 3407978): March 2026

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Types of Aortic Valve Replacement

Disclaimer: The information on this page is for general guidance only and does not replace an individual clinical consultation. Mr Inderpaul Birdi will assess your suitability for treatment at your appointment.

Replacement procedures are often required due to a diseased or damaged aortic valve. There are a number of options available for aortic valve replacement, and your surgeon will help to guide you through decision-making.

Here are the valve types we most commonly use at The Keyhole Heart Clinic.

Mechanical Valve Replacement

Mechanical valve replacement (MAVR) is engineered to last a lifetime, making it one of the most durable options available.

st Jude Aortic Valve

Mechanical aortic valves have three main components:

Occluder: The moving part that opens and closes to control blood flow from the heart into the aorta.
Valve housing: A strong ring-shaped structure that holds and guides the moving parts so the aortic valve opens and closes smoothly with each heartbeat.
Sewing ring (sewing cuff): A fabric-covered ring that allows the surgeon to securely stitch the valve into place during aortic valve replacement surgery.

The main caveat with mechanical valves is their tendency to promote clot formation on the valve surface, requiring lifelong anticoagulation (blood thinners) with warfarin. Patients on daily warfarin need regular blood tests to ensure their anticoagulation remains within a safe and effective range.

On-X Carbon Valve

The On-X is a newer generation mechanical valve, made from pure pyrolytic carbon and designed to closely replicate the geometry of a native valve.

Its advanced engineering results in:

Improved blood flow
Reduced red blood cell damage
Lower tendency to form clots compared to earlier mechanical valves
Potentially reduced blood-thinning requirements

After an initial three-month period of standard anticoagulation (INR 2.0–3.0) to allow the valve to settle, suitable patients can transition to a lower warfarin target (INR 1.5–2.0) combined with low-dose aspirin.

This is supported by the PROACT trial and CE mark approval, making the On-X the only mechanical valve approved for this reduced anticoagulation protocol. However, current ESC guidelines recommend an individualised approach, and your care team will advise on the most appropriate regimen for your circumstances.

Cryolife Carbon Valve

Cryolife, Inc On-X Carbon valve (Aortic)

Potential Complications

While MAVR offers many advantages, it carries inherent risks:

Bleeding: Lifelong anticoagulation raises serious bleeding risks as the heart pumps blood. This potential complication is more common in older patients
Infection: As with any valve replacement, endocarditis remains a risk
Prosthetic valve dysfunction: Structural deterioration is extremely rare; complications are more commonly related to clotting or anticoagulation

Biological Valve Replacement

Edwards Magna Valve

Edwards Lifescience Perimount Magna Bioprosthesis

Biological valves, also known as tissue or bioprosthetic valves, can be made from pigs’ valves or from the pericardium of a cow. The risk of cross-infection is extremely low due to rigorous processing and sterilisation, and warfarin is not a requirement.

A large long-term study followed more than 12,000 patients who received the Carpentier-Edwards PERIMOUNT bovine pericardial aortic valve. The results showed great durability. Only around 2% of valves required replacement due to structural wear at 10 years, and around 15% at 20 years.

Durability was generally very good, although younger patients were more likely to need another valve procedure over time. Overall, the findings support the long-term reliability of modern tissue aortic valves, particularly in older patients.

Another extended study found that bioprosthetic heart valves can function well for many years after surgery. Around 60% of patients remained free from major valve-related complications for 10 years.

Sutureless Heart Valves

Newer bioprosthetic valves, known as “Sutureless Valves”, are now available for heart valve replacement. These valves can be implanted more quickly than traditional valves, which may benefit patients at higher surgical risk or those undergoing keyhole aortic valve surgery.

The sutureless aortic valves used by teams at The Keyhole London Heart Clinic are made of the same material as tissue valves.

The PERSIST-AVR trial found that sutureless aortic valves performed comparably to traditional valve types at one year, with stable blood flow and low leakage rates. While early results are promising, long-term data are still limited, and further research is ongoing.

Edwards Sutureless Valve

Edwards Lifescience Sutureless aortic valve

Possible Complications

Most patients enjoy positive results for many years, but complications can occasionally occur.

Structural valve deterioration: Over time, the valve tissue may gradually wear out, stiffen, or calcify. If the valve no longer opens or closes properly, another valve procedure may eventually be required.
Non-structural valve dysfunction: In some cases, the valve itself remains intact, but other factors affect its function. This can include blood leaking around the valve (paravalvular leak) or the valve being relatively small for the patient.
Valve thrombosis: A blood clot may form on the valve, which can affect its movement and, in rare cases, increase the risk of complications such as stroke.
Valve infection (endocarditis): Although uncommon, prosthetic valves can become infected.

Factors When Choosing Replacement Heart Valves

When aortic valve replacement is recommended, the next step is choosing the most suitable prosthetic option.

According to the 2025 ESC/EACTS Guidelines for the Management of Valvular Heart Disease, this decision is individualised and depends on factors such as:

Age
Life expectancy
Lifestyle
Bleeding risk
Pregnancy plans
Patient preference

Mechanical Valve	Biological (Tissue) Heart Valve
Often considered for younger patients with a longer life expectancy	Often considered for older patients
May be recommended for patients under 60 years needing aortic valve replacement	Commonly recommended for patients over 65 years
Very durable and may last for several decades	Typically lasts 10 to 20 years before it may need replacement
Requires lifelong blood-thinner medication to prevent clotting	Usually does not require blood-thinning medication
May be suitable for patients who already require long-term anticoagulation	Often preferred for patients with higher bleeding risk or difficulty maintaining stable anticoagulation
Often preferred for patients with higher bleeding risk or difficulty maintaining stable anticoagulation	Often preferred for women considering pregnancy

Your heart surgeon will discuss these factors with you and help you choose the valve that best suits your case.

Trends in Aortic Valve Replacement Choice

A 2022 British Heart Foundation-supported study found a clear shift towards biological valves across all age groups between 1996 and 2018.

By 2018, most patients over 70 received a biological valve, while use in the 60–69 age group rose dramatically from 25% to 82%. Even in younger patients under 50, biological valves accounted for 28% of choices by 2018.

Follow-Up & Monitoring

After valve replacement, regular follow-up is an important part of long-term heart care. Patients with prosthetic heart valves are usually monitored throughout their lives to ensure the valve continues to function well and to check for any changes in heart health.

Current European guidance recommends regular clinical review and heart imaging after valve replacement. For patients with a biological valve, echocardiography is typically performed:

In the first few months post-surgery
At around one year
Annually thereafter, or sooner if symptoms develop

Patients should consult their care team earlier if they notice symptoms such as:

Increasing shortness of breath
Chest pain
High blood pressure
Fatigue or reduced exercise tolerance
Palpitations or irregular heartbeat
Dizziness or fainting
Dwelling of the ankles or legs

These scans allow doctors to assess the valve’s function and identify early changes.

Additional imaging tests may occasionally be required if there are concerns about valve and heart function, infection or blood clots. Your cardiology team will guide you on the most appropriate follow-up schedule based on your individual condition.

Learn more about keyhole aortic valve replacement surgery and how this minimally invasive procedure is performed.

Consultation for aortic valve choice

FAQs

Find out more about mechanical and biological valve replacements.

How long do replacement heart valves last?

Mechanical aortic valves often last a lifetime but require lifelong blood thinners. Bioprosthetic (tissue) valves usually last 10 to 20 years without long-term anticoagulation. Longevity depends on age, health, and valve type, and regular follow-up helps detect problems early.

Are there treatment options for a diseased aortic valve that do not require replacement or surgery?

If surgery or TAVI isn’t suitable, your cardiologist may manage symptoms with medications and regular monitoring. While these approaches can help control symptoms, valve replacement remains the definitive treatment for heart valve disease, like severe aortic regurgitation (leaky valve) or aortic stenosis (narrowed aortic valve).

Your heart team will evaluate the most appropriate option for you.

What is transcatheter aortic valve implantation?

Transcatheter aortic valve implantation (TAVI) is a minimally invasive alternative to surgical valve replacement. It is commonly recommended for older patients, those at higher surgical risk, or where a less invasive approach is preferred. This minimally invasive procedure does not require a heart-lung bypass machine.

Clinical trials show that TAVI offers outcomes comparable to surgery in many patient groups, although long-term durability remains under study. The most appropriate approach depends on individual factors and is decided by a multidisciplinary heart team. This means TAVI is no longer associated with a higher risk of stroke, and there is less concern about leakage around the edges of the new valve.

For patients requiring a good long-term result, heart valve surgery is generally advisable, but the best option depends on patient-specific factors. Modern-day TAVI valve procedures are improving all the time and will undoubtedly play a big role in the treatment of aortic valve disease in the future.

Are sutureless replacement valves better than transcatheter aortic valve implantation?

Studies show that sutureless surgical valves can have a lower early risk of death and stroke and better 1–2 year survival compared with TAVI. However, transcatheter aortic valve replacement is still an important option for certain patients.

Schedule an appointment at the Keyhole Heart Clinic to discuss your valve choices in aortic valve replacement surgery.

About the Medical Reviewer

Medically reviewed by Mr Inderpaul Birdi, MBBS, MD, FRCS (CTh)
Consultant Cardiothoracic Surgeon | Clinical Lead, The Keyhole Heart Clinic
GMC Registration: 3407978

Mr Inderpaul Birdi (GMC No. 3407978) is a Fellow of the Royal College of Surgeons with over 20 years’ experience as a Consultant Cardiac Surgeon. He trained at the Royal Papworth Hospital and the Royal Brompton Hospital.

References & Further Reading

Chan J, Dimagli A, Fudulu DP, Sinha S, Narayan P, Dong T and Angelini GD (2023) Trend and early outcomes in isolated surgical aortic valve replacement in the United Kingdom. Front. Cardiovasc. Med. 9:1077279. doi: 10.3389/fcvm.2022.1077279
Edwards, T.J., et al. Biological valves beyond fifteen years: The wessex experience,The Annals of Thoracic Surgery, Volume 60, Supplement 2, 1995, Pages S211-S215, ISSN 0003-4975, https://doi.org/10.1016/0003-4975(95)00220-F
Fabien Praz, F., ESC/EACTS Scientific Document Group, et al. 2025 ESC/EACTS Guidelines for the management of valvular heart disease: Developed by the task force for the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS), European Heart Journal, Volume 46, Issue 44, 21 November 2025, Pages 4635–4736, https://doi.org/10.1093/eurheartj/ehaf194
Fischlein T, Caporali E, Asch FM, Vogt F, Pollari F, Folliguet T, Kappert U, Meuris B, Shrestha ML, Roselli EE, Bonaros N, Fabre O, Corbi P, Troise G, Andreas M, Pinaud F, Pfeiffer S, Kueri S, Tan E, Voisine P, Girdauskas E, Rega F, García-Puente J, De Kerchove L and Lorusso R (2022) Hemodynamic Performance of Sutureless vs. Conventional Bioprostheses for Aortic Valve Replacement: The 1-Year Core-Lab Results of the Randomized PERSIST-AVR Trial. Front. Cardiovasc. Med. 9:844876. doi: 10.3389/fcvm.2022.844876
Gopal S, Hauser JM, Alahmadi MH, et al. Mechanical Aortic Valve Replacement. [Updated 2024 Sep 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK564339/
Jagdish Butany, J., et al. Mechanical heart valve prostheses: Identification and evaluation, Cardiovascular Pathology, Volume 12, Issue 1, 2003, Pages 1-22, ISSN 1054-8807, https://doi.org/10.1016/S1054-8807(02)00128-X.
Johnston DR, Soltesz EG, Vakil N, Rajeswaran J, Roselli EE, Sabik JF 3rd, Smedira NG, Svensson LG, Lytle BW, Blackstone EH. Long-term durability of bioprosthetic aortic valves: implications from 12,569 implants. Ann Thorac Surg. 2015 Apr;99(4):1239-47. doi: 10.1016/j.athoracsur.2014.10.070. Epub 2015 Feb 4. PMID: 25662439; PMCID: PMC5132179.
Massimo Meco, Antonio Miceli, Andrea Montisci, Francesco Donatelli, Silvia Cirri, Matteo Ferrarini, Antonio Lio, Mattia Glauber, Sutureless aortic valve replacement versus transcatheter aortic valve implantation: a meta-analysis of comparative matched studies using propensity score matching, Interactive CardioVascular and Thoracic Surgery, Volume 26, Issue 2, February 2018, Pages 202–209, https://doi.org/10.1093/icvts/ivx294
Pibarot, P, Herrmann, H, Wu, C. et al. Standardized Definitions for Bioprosthetic Valve Dysfunction Following Aortic or Mitral Valve Replacement: JACC State-of-the-Art Review. JACC. 2022 Aug, 80 (5) 545–561. https://doi.org/10.1016/j.jacc.2022.06.002
Puskas, J, Gerdisch, M, Nichols, D. et al. Anticoagulation and Antiplatelet Strategies After On-X Mechanical Aortic Valve Replacement. JACC. 2018 Jun, 71 (24) 2717–2726. https://doi.org/10.1016/j.jacc.2018.03.535
Wang, T. Y., et al. (2023). Apixaban or Warfarin in Patients with an On-X Mechanical Aortic Valve. NEJM Evidence, 2(7), EVIDoa2300067. https://doi.org/10.1056/evidoa2300067

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