Pregnancy-associated cardiac remodeling: from physiological adaptation to long-term cardiovascular risk

INTRODUCTION: Pregnancy imposes a sustained hemodynamic load that can unmask latent cardiovascular vulnerability, yet distinguishing physiological adaptation from early maladaptive remodeling remains difficult with conventional echocardiography. AREAS COVERED: This special report reviews trimester-specific cardiac adaptation, myocardial deformation imaging, right ventricular-pulmonary arterial coupling, postpartum reverse remodeling, and the maladaptive phenotypes of preeclampsia, gestational diabetes, and peripartum cardiomyopathy. It also covers circulating biomarkers and the risk framework of the 2025 European Society of Cardiology guidelines, including the modified World Health Organization 2.0 classification and the Pregnancy Heart Team. PubMed/MEDLINE, Scopus, and Web of Science were searched for articles published between January 2000 and March 2026. EXPERT OPINION: Strain imaging and biomarkers can detect subclinical dysfunction that ejection fraction misses, but pregnancy- and ethnicity-specific reference values and outcome data are lacking. Until these are available, such tools should be used selectively, serially, and in combination within Pregnancy Heart Team pathways that extend well beyond delivery.