Pregnancy with prosthetic heart valves: navigating risks, anticoagulation, and valve function in a growing population

Pregnancy in patients with prosthetic heart valves presents complex challenges requiring multidisciplinary care and individualized decision-making. While bioprosthetic valves are often preferred in women of childbearing age to avoid anticoagulation-related fetal risks, these valves are susceptible to structural degeneration potentially accelerated by the physiologic demands of pregnancy. Conversely, mechanical valves offer durability but necessitate lifelong anticoagulation, posing substantial risks of valve thrombosis, fetal hemorrhage, and warfarin embryopathy. The Ross operation, which can be considered for individuals with advanced aortic valve disease, is an appealing option yet is offered only in highly specialized centers. In this review, we present contemporary data on maternal and fetal outcomes, valve function, and anticoagulation strategies in pregnant patients with mechanical and bioprosthetic heart valves. We highlight geographical and knowledge gaps regarding type of valve utilization, optimal anticoagulation in pregnancy, durability of modern valve designs, and long-term reoperation risk. Future research priorities include uniform global approach with improved access to contemporary surgical and medical solutions in low- and middle-income countries, safety of direct oral anticoagulants, improved surveillance of valve function during pregnancy, and comparative studies of bioprosthetic valve models. By consolidating evolving evidence, we aim to support informed decision-making and multidisciplinary management for this high-risk patient population.