Congenital heart disease (CHD) commonly includes right-sided valvular heart disease. Patients with CHD may require multiple sternotomies and interventions in their lifetime. The longevity of their replaced valve will be one of the most important factors determining freedom from re-intervention and overall prognosis. The European Society of Cardiology Guidelines for the management of adults with CHD have recommendations as to the indications and timing of pulmonary and tricuspid valve intervention1; however, whether to use a bioprosthetic or mechanical valve is not specifically outlined. The guidelines acknowledge that there is little experience with mechanical valves in this setting, raising concerns about adequate anticoagulation.

The use of bioprosthetic valves as the primary choice for right-sided valve replacement is widespread and the inclination for bioprosthetic valves over mechanical valves stems from several practical considerations. This primarily includes avoidance of life-long commitment to vitamin K antagonist and its implications on patients with CHD who are often still relatively young. Major deterrents include strict adherence to the drug and the need for frequent international normalised ratio (INR) monitoring, the cumulative risk of bleeding, contraindications during pregnancy and precautions when choosing sport activities. The low pressure on the right side of the heart has dual effects on valve performance. While it increases the risk of thrombosis for mechanical valves, it also contributes to the greater durability of right-sided bioprosthetic valves. As a result, the anticipated life span of bioprosthetic valves implanted on the right side is currently considered to be 10–20 years or even more. Furthermore, percutaneous options for treating bioprosthetic valve failure are available, but they are not applicable when a mechanical prosthesis is implanted. The proposed advantages of mechanical valves in terms of longevity and freedom from re-intervention are less evident.

Although bioprosthetic valves are overwhelmingly favoured in current clinical practice, there …