Introduction: Due to radiation exposure and other uncertain risks for both mother and fetus, the implantation of a permanent pacemaker during pregnancy is still a controversial topic. (1-3)

Case report: We report a case of successful management of a 30-year-old pregnant woman, at 20^th week of gestation, with intermittent total AV block and consequent 20 seconds of asystolic pause and syncope. The patient was transferred to the electrophysiology laboratory and a fluoroless implantation of the permanent single-chamber pacemaker was performed, guided by intracardiac echocardiography (ICE) (Vivid q^®, GE Healthcare, USA) and three-dimensional (3D) electroanatomical mapping system (CARTO^®3, Biosense Webster (BW), USA). A femoral approach was made for ICE and a decapolar 3D mapping catheter (DecaNav^®, BW, USA), and a cephalic vein cut dawn was performed to insert pacemaker lead avoiding complications, mainly pneumothorax. The mapping catheter was used to create a 3D anatomical geometry of the right heart with the superior and inferior vena cava. Thanks to the special custom-made cable previously described by Kuhne and the FamDx^® module (BW, USA), the permanent electrode was successfully visualized and positioned at the right ventricular apex. Localization, stability, and adequate slack were further confirmed using ICE. No complications occurred during the procedure and the patient was discharged with a programmed backup pacing at a lower rate of 40 ppm and the possibility to explant the pacing device after childbirth and possible restoration of AV conduction.