COR LOE Recommendations Women with a prosthetic valve should undergo pre-pregnancy assessment, including echocardiography, by a cardiologist with expertise in managing women with VHD during pregnancy. Pregnant women with a mechanical prosthesis should be monitored in a tertiary-care center with a dedicated MDT of cardiologists, surgeons, anesthesiologists, and maternal-fetal medicine obstetricians with expertise in the management of high-risk cardiac conditions Women with mechanical heart valves considering pregnancy should be counselled that pregnancy is high risk and that there is no anticoagulation strategy that is consistently safe for the mother and baby.3 6 Pregnant women with a mechanical prosthetic valve who have prosthetic valve obstruction or experience an embolic event should undergo Synopsis Pregnancy in women with mechanical heart valves is very high risk and has been classified by the World Health Or- ganization as Risk Category III (significantly increased risk of maternal mortality or severe morbidity). Contemporary studies and prospective registries of pregnancy in women with mechanical heart valves confirm that maternal risk re- mains high: Maternal mortality rate is approximately 1%, and the risk of valve thrombosis is approximately 5%.2,5,9 Given the substantial risk of adverse maternal and fetal CLINICAL STATEMENTS AND GUIDELINES events, there is a need for specialized expertise in the coun- seling and care of women with prosthetic heart valves who are considering pregnancy or who are pregnant. Recommendation-Specific Supportive Text 1. A preconception TTE is used to assess valve func- tion, ventricular function, and pulmonary artery systolic pressure. Preconception TTE can help identify women with valve dysfunction who may benefit from valve intervention before concep- tion. Results can facilitate patient counseling about specific risks of pregnancy. 2. The management of prosthetic heart valves during pregnancy is substantially different from the man- agement of prosthetic heart valves in a nonpregnant patient. 