Recommendations I. Recommendations for prosthetic valve selection.

Recommendations	Classa	Levelb
Mechanical prostheses
A mechanical prosthesis is recommended according to the desire of the informed patient and if there are no contraindications to longterm anticoagulation.c	I	C
A mechanical prosthesis is recommended in patients at risk of accelerated SVD.d	I	C
A mechanical prosthesis should be considered in patients already on anticoagulation because of a mechanical prosthesis in another valve position.	IIa	C
A mechanical prosthesis should be considered in patients aged <60 years for prostheses in the aortic position and aged <65 years for prostheses in the mitral position. 462,464 e	IIa	B
A mechanical prosthesis should be considered in patients with a reasonable life expectancy for whom future redo valve surgery or TAVI (if appropriate) would be at high risk.f	IIa	C
A mechanical prosthesis may be considered in patients already on long-term anticoagulation due to the high risk for thromboembolism.f	IIb	C
Biological prostheses
A bioprosthesis is recommended according to the desire of the informed patient.	I	C
A bioprosthesis is recommended when goodquality anticoagulation is unlikely (adherence problems, not readily available), contraindicated because of high bleeding risk (previous major bleed, comorbidities, unwillingness, adherence problems, lifestyle, occupation) and in those patients whose life expectancy is lower than the presumed durability of the bioprosthesis.g	I	C
A bioprosthesis is recommended in case of reoperation for mechanical valve thrombosis despite good long-term anticoagulant control.	I	C
A bioprosthesis should be considered in patients for whom there is a low likelihood and/or a low operative risk of future redo valve surgery.	IIa	C
A bioprosthesis should be considered in young women contemplating pregnancy.	IIa	C
A bioprosthesis should be considered in patients aged >65 years for a prosthesis in the aortic position or aged >70 years in a mitral position.	IIa	C
A bioprosthesis may be considered in patients already on long-term NOACs due to the high risk for thromboembolism. 466,467,468,469 f	IIb	B
AF: atrial fibrillation; NOAC: non-vitamin K antagonist oral anticoagulant; SVD: structural valve deterioration; TAVI: transcatheter aortic valve implantation. aClass of recommendation. bLevel of evidence. cIncreased bleeding risk because of comorbidities, adherence concerns or geographic, lifestyle or occupational conditions. dYoung age (<40 years), hyperparathyroidism, haemodialysis. eIn patients 60-65 years of age who should receive an aortic prosthesis and those between 65 and 70 years of age in the case of mitral prosthesis, both valves are acceptable and the choice requires careful analysis of factors other than age. fRisk factors for thromboembolism are AF, previous unprovoked proximal deep venous thromboembolism and/or symptomatic pulmonary embolism, hypercoagulable state, antiphospholipid antibody. gLife expectancy should be estimated at >10 years according to age, sex, comorbidities, and country-specific life expectancy.