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.................................................................................................................. (see table ‘Recommendations for the management of arrhythmias’). Idiopathic RV outflow tract tachycardia is the most frequent VT type and may require prophylactic treatment with a beta-blocker, verapamil, or other antiarrhythmic drugs, and even catheter ablation if drug treatment fails.

ICD implantation is recommended if an indication emerges during pregnancy (see table ‘Recommendations for the management of arrhythmias’).72,330,331 Implantation of an ICD in PPCM patients with VT or low EF should follow ESC Guidelines,72 considering the relatively high rate (50%) of spontaneous recovery after delivery. Nonselective beta-blockers should be continued throughout pregnancy and during the post-partum period (at least 40 weeks after delivery)323 in patients with congenital LQTS332 and those with catecholaminergic polymorphic VT.72,333 Exceptions may be LQTS patients without prior syncope or torsade de pointes (TdP), or any other risk profile, for whom a selective beta-blocker may be chosen. Management of cardiac arrest in pregnancy is described elsewhere.256

9.7 Bradyarrhythmias

9.7.1 Sinus node dysfunction Rare cases of sinus bradycardia may be related to the supine hypotensive syndrome of pregnancy. Symptomatic bradycardia should be managed by changing the position of the mother to a left lateral decubitus position. For persistent symptoms, a temporary pacemaker may be necessary.

9.7.2 Atrioventricular block Isolated congenital complete heart block in the mother has a favourable outcome during pregnancy, especially when the escape rhythm has a narrow QRS complex.334,335 Temporary ventricular pacing during delivery is unnecessary in stable patients with complete heart block,334 but recommended in selected women with symptoms due to the risk of bradycardia and syncope.

9.8 Interventions

9.8.1 Electrical cardioversion Cardioversion seems safe in all phases of pregnancy as it does not compromise foetal blood flow,336 and the risk of inducing foetal arrhythmias or initiating pre-term labour seems small.337,338

The foetal heart rate should routinely be controlled after cardioversion.339

9.8.2 Catheter ablation Catheter ablation should be postponed to the second trimester if possible, and performed at an experienced centre using nonfluoroscopic electroanatomical mapping and catheter navigation systems.15,16 Catheter ablation of recurrent drugrefractory AV nodal re-entry tachycardia, AV re-entrant tachycardia, focal ATs, cavotricuspid isthmus-dependent atrial flutter, and certain benign right-sided VTs may be considered for ablation to avoid potentially harmful medications during pregnancy (see table ‘Recommendations for the management of arrhythmias’),12,15,17 but has no role for other macroreentry tachycardias or AF.15,17

9.8.3 Implantable cardioverter-defibrillator and pacing The implantation of an ICD should be considered prior to pregnancy in patients with high-risk factors for SCD.72,340 Treatment with an ICD during pregnancy does not cause an increased risk of major ICD-related complications and is recommended if an indication emerges (see table ‘Recommendations for the management of arrhythmias’).330,340 Safety considerations regarding radiation during ICD implantation are similar to those discussed for catheter ablation. Subcutaneous ICD is limited by a lack of pacing capability and a higher risk of inappropriate shock, which may warrant ICD inactivation during delivery.341,342 The use of WDCs in PPCM patients is limited343 and deserves further study as it has not undergone clinical testing in pregnant patients. Routine ICD interrogation and advice is recommended prior to delivery. Implantations, for ICD preferably one chamber, can be performed safely, especially if the foetus is beyond 8 weeks of gestation. Echocardiographic guidance or electroanatomical mapping may be helpful.344 Downloaded from academic.oup.com/eurheartj/article/39/34/3165/5078465 by guest on 07 October 2026