Arrhythmias in pregnancy: development and initial experience of a multidisciplinary pregnancy heart team
M Ragagnin, G Guidotti, L Perrotta, L Sasso, L Checchi, G Bambagioni, G Ricciardi, M Beltrami, L Angeli, M P Rambaldi, C Bartolozzi, F Mecacci, I Olivotto, M Pieroni, P PieragnoliAbstract
Background
Pregnancy in women with cardiovascular disease (CVD) is a demanding clinical scenario in which arrhythmic risk is a major concern and a frequent reason for referral. Physiological changes during pregnancy may trigger new-onset or recurrent arrhythmias, as well as peripartum cardiomyopathy. The Pregnancy Heart Team (PHT), introduced in the 2018 ESC Guidelines, has been associated with improved maternal-fetal outcomes (1).
Purpose
This study aims to describe the development and preliminary experience of a dedicated PHT for women with CVD across pre-conception, pregnancy and postpartum, focusing on management and outcomes in patients referred for arrhythmic disorders.
Methods
A structured registry prospectively collected clinical, imaging, and genetic data of women with established or suspected arrhythmic disorders evaluated by the PHT. Data were organised into three phases: pre-PHT, PHT discussion, and post-PHT follow-up. The updated mWHO 2.0 classification was applied to pregnant women and to those undergoing assisted reproduction (2). Classes I–II were considered low risk, while from II–III upward a PHT counselling was advised. Patients meeting ESC high-risk arrhythmic criteria were followed to assess maternal-fetal outcomes (2-4).
Results
Forty-two women were evaluated between 2023 and 2025. Diagnoses included 16 cardiomyopathies (8 HCM, 3 ARVC, 5 DCM), 3 myocarditis (2 desmoplakin-related, 1 viral), 8 ventricular and 4 supraventricular arrhythmias (including 2 AF), 2 WPW syndromes, 3 channelopathies, 2 arrhythmic mitral valve prolapses, 1 advanced AV block and 3 cases with a family history of cardiomyopathy or sudden cardiac death. 23 women (55%) were mWHO class II–III or higher, while 19 (45%) were class I or II. Management strategies included delivery planning, ECG/Holter monitoring, pregnancy-compatible pharmacological and device therapy. Ventricular arrhythmias were preferably treated with beta-blockers and flecainide; verapamil was used once. Flecainide and digitalis were administered for maternal or fetal supraventricular arrhythmias. Therapy was effective in all but one case, which resolved after delivery. Two devices were implanted without fluoroscopic guidance: one subcutaneous ICD for desmoplakin-related myocarditis and one dual-chamber PM for advanced AV block. Cardiological monitoring in the peripartum period was required in 29% of women. Only one pregnancy was electively terminated due to maternal safety concerns. No major arrhythmias or cardiovascular complications occurred, and all completed pregnancies had favourable outcomes.
Conclusions
Arrhythmic risk is a leading reason for PHT referral. A structured multidisciplinary approach allowed tailored management, including pregnancy-compatible antiarrhythmic therapy and zero-fluoroscopy techniques, ensuring excellent maternal-fetal outcomes and supporting the role of dedicated PHT programs in optimising care for women with CVD across all stages of pregnancy.