Mechanical versus bioprosthetic aortic valves: the ultimate trade-offs every middle-aged patient should know

aortic valve replacement continues to be the therapeutic modality of choice for unrepairable aortic valve pathology. A major debate regarding the selection of mechanical versus biological valves remains. The current meta-analysis evaluated both choices in middle-aged patients undergoing aortic valve replacement. PubMed, Scopus, and Web of Science were searched (2020–2025). Forty-eight articles were identified. Of them, 46 entered quantitative analysis. We investigated the differences between mechanical and biological valves in terms of all-cause mortality, reoperation, early mortality and major bleeding events. Secondary outcomes measuring safety and efficacy between different valves were analyzed. Biological valves demonstrated significantly increased all-cause mortality (HR 1.27, 95% CI 1.15–1.40; P < 0.001), higher reoperation rates (RR 1.61, 95% CI 1.21–2.15), and higher early mortality risk (RR 1.44, 95% CI 1.05–1.98; P = 0.024) compared to mechanical valves. These disadvantages were consistent across age subgroups (50–70 years). However, major bleeding risks were significantly lower with biological (RR 0.63, 95% CI 0.52–0.77; P < 0.001). While pooled estimates suggest biological valves may be associated with higher all-cause mortality and reoperation rates, and mechanical valves with higher bleeding risk, these findings should be interpreted with considerable caution given the very high between-study heterogeneity (I² 89–93%) and wide prediction intervals that frequently cross the null. The certainty of evidence is very low to low (GRADE). Valve selection for middle-aged patients should remain individualized and guided by shared decision-making.