Management and outcomes of cardiovascular disease in pregnancy: the experience of the Florence Pregnancy Heart Team

Background Pregnancy in women with cardiovascular disease (CVD) is a demanding clinical scenario and may be associated with adverse outcomes. The Pregnancy Heart Team (PHT), introduced in the 2018 ESC Guidelines, has been associated with improved maternal-fetal outcomes. Purpose to describe the experience of our dedicated Florence PHT for women with CVD across pre-conception, pregnancy and postpartum. Methods A structured registry prospectively collected clinical, imaging, and genetic data of women with established or suspected CVD evaluated by our PHT during 3 phases: pre-PHT, PHT discussion, and post-PHT follow-up. The updated mWHO 2.0 classification of maternal cardiovascular risk was applied. Results From 01/2020 to 11/2025, 114 women were evaluated, for a total of 126 pregnancies. 72 women were referred for congenital heart disease (CHD), 42 for arrhythmic disorders (AD). Among these, 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 prolapse, 1 advanced AV block and 3 with family history of cardiomyopathy/SCD. According to mWHO 2.0 risk assessment, 54 pregnancies (57%) were classified mWHO2.0 ≥ II–III, while 72 (45%) were in mWHO 2.0 class I and II. Median age of pregnant women was 34 years (range 20-44) while median gestational age at the time of delivery was 38 weeks (range 25-41). Cardiological monitoring during peri-delivery period was required in 16% of women. Only 1 pregnancy was electively terminated due to maternal safety concerns. Elective caesarean sections (CS) were planned in 23/126 pregnancies (18%), mostly for cardiological reasons (14/23), while 7% of pregnancies required an emergency CS, all for obstetric reasons. AD were preferably treated with beta-blockers and flecainide or digitalis, especially for maternal or fetal supraventricular AD. Two devices were implanted without fluoroscopic guidance: one s-ICD for desmoplakin-related myocarditis and one dual-chamber PM for advanced AV block. Maternal cardiac complications occurred in only two mWHO 2.0 class III patients: a case of peripheral oedema in a Fontan patient with a twin pregnancy who required treatment with i.v. diuretics post-partum and a case of thrombotic dysfunction of an aortic valve mechanical prosthesis successfully treated with unfractionated heparin. Neonatal complications were reported in 16 pregnancies of women with CHD (12%), including 11 preterm delivery and 5 small gestational age. No maternal or fetal death occurred. Conclusions In the group of patients with CVD referred to our PHT, a structured multidisciplinary approach allowed tailored management, 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 care.