Background and aim: The ultimate goal of mitral valve surgery in young women is to extend life expectancy and improve quality of life. Mitral valve replacement (MVR) prosthesis in middle-aged women is a difficult choice between the lifelong anticoagulation by mechanical prosthesis versus the limited long-term durability of bioprosthesis. The current trend towards reducing women’s age for selecting bioprosthesis over mechanical prosthesis leads to a dilemma for younger women decision making.1,2 The aim of this study was to compare the safety and freedom from complications in pregnancy and survival rate after mitral valve bioprosthesis versus mechanical prosthesis in young women for whom mitral valve repair is not feasible or unsuitable. Methods: This single-center non randomized prospective propensity-matched comparative study included all female patients undergoing MVR at our center from January 2010 to February 2020. Results: In total, 355 patients underwent MVR at our center, of whom 174 received a bioprosthesis and 181 received a mechanical prosthesis. The use of anticoagulation among young women with mechanical prosthesis was associated with a remarkable risk of postoperative bleeding, abortion, and increased frequency of pregnancy-related complications (p < 0.0001). In contrast, there was a considerable survival benefit for those who received bioprosthesis (p = 0.0001). Conclusions: Our data confirm that the use of mitral bioprosthesis in young women who desire to become pregnant is safe, reduces complications, and increases survival.