Replacement of the diseased aortic valve represents one of the triumphs of cardiac surgery; however, the perfect valve substitute continues to elude surgeons after almost four decades of clinical experience. The characteristics of the ideal valve substitute include the following: central flow capacity, low transvalvular gradient, low thrombogenicity, durability, easy availability, resistance to infection, non-immunogenicity, and easy implantability. The pulmonary autograft first performed by Ross (Lancet 1967, 2:956-958) came closest to achieving these goals, but creates a double valve procedure for single valve disease. Aortic valve replacement (AVR) with homograft aortic valve was introduced by Ross in 1962 (Lancet 1962, 2:487) and Barratt-Boyes in 1964 (Thorax 1964, 19:131-150). Like the pulmonary autograft, homograft AVR results in an excellent hemodynamic outcome but suffers from limitations of graft availability, lack of durability, and difficulty with implantation. Mechanical valves and stented tissue valves allow "off the shelf" easy availability as well as easy implantability. These valves are unfortunately intrinsically obstructed to some extent because of the space occupied by the stent and sewing ring. Stent mounted tissue valves also continue to exhibit limited durability. Stentless xenograft aortic valves have been developed as a compromise between these ends of the valve spectrum to allow excellent hemodynamics and hopefully improved durability while allowing "off the shelf" availability in a variety of standard sizes. We examine the rationale for use of the stentless xenograft aortic valve, the clinical development of this valve, and the surgical techniques of implantation.
