Annals of Pediatric Cardiology
About us | Current Issue | Archives | Ahead of Print | Instructions | Submission | Subscribe | Advertise | Contact | Login 


    Advanced search

    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  

    The Potential fo...
    Impact of Fetal ...
    Impact of Prenat...
    Impact of Prenat...
    Impact on Mode o...
    How and how Far ...
    Technical Develo...
    Article Figures
    Article Tables

 Article Access Statistics
    PDF Downloaded1461    
    Comments [Add]    
    Cited by others 33    

Recommend this journal


PERSPECTIVE Table of Contents   
Year : 2009  |  Volume : 2  |  Issue : 1  |  Page : 41-50
Impact of fetal echocardiography

Department of Congenital Heart Disease, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom

Click here for correspondence address and email

Date of Web Publication17-Jun-2009


Prenatal diagnosis of congenital heart disease is now well established for a wide range of cardiac anomalies. Diagnosis of congenital heart disease during fetal life not only identifies the cardiac lesion but may also lead to detection of associated abnormalities. This information allows a detailed discussion of the prognosis with parents. For continuing pregnancies, appropriate preparation can be made to optimize the postnatal outcome. Reduced morbidity and mortality, following antenatal diagnosis, has been reported for coarctation of the aorta, hypoplastic left heart syndrome, and transposition of the great arteries. With regard to screening policy, most affected fetuses are in the "low risk" population, emphasizing the importance of appropriate training for those who undertake such obstetric anomaly scans. As a minimum, the four chamber view of the fetal heart should be incorporated into midtrimester anomaly scans, and where feasible, views of the outflow tracts should also be included, to increase the diagnostic yield. Newer screening techniques, such as measurement of nuchal translucency, may contribute to identification of fetuses at high risk for congenital heart disease and prompt referral for detailed cardiac assessment.

Keywords: Congenital heart disease, echocardiography, fetal heart

How to cite this article:
Simpson JM. Impact of fetal echocardiography. Ann Pediatr Card 2009;2:41-50

How to cite this URL:
Simpson JM. Impact of fetal echocardiography. Ann Pediatr Card [serial online] 2009 [cited 2022 Dec 7];2:41-50. Available from:

   The Potential for Detection of Congenital Heart Lesions by Fetal Echocardiography Top

A wide range of congenital heart defects can be identified during fetal life with a very high degree of diagnostic accuracy in specialist centers. [1] Virtually all forms of congenital heart disease have been described during prenatal life. In most countries, the major routes of ascertainment of congenital heart defects are, first, a suspicion of a cardiac defect during an obstetric anomaly scan, or second, because specific risk factors have led to a referral to a specialist unit for further evaluation. The types of risk factors that are widely accepted as referral reasons for detailed assessment of the heart are listed in [Table 1] and have been reviewed elsewhere [2] It should be emphasized that most cases of congenital heart disease occur in the "low risk" population. Detection of these cases rests with the sonographer who is assessing the fetal heart as part of obstetric anomaly scans involving an anatomic survey that is not restricted to the heart. Some cardiac lesions, particularly those evident on a "four chamber view" of the fetal heart are more easily detected by the nonspecialist sonographer than others, for which more extended views of the outflow tracts are required for detection. For example, United Kingdom national data obtained between 1993 and 1995 reported a detection rate of 38% for atrioventricular septal defects and 66% for hypoplastic left heart ("four chamber" abnormalities) compared to 3% for transposition of the great arteries (outflow tract views required for detection).[2],[3] [Table 2] summarizes lesions which should be evident on four chamber screening, those which require views of the outflow tracts, for recognition, lesions which are considered very difficult to detect even in specialist hands, and those which cannot be detected during fetal life.

   Impact of Fetal Echocardiography on Prevalence of Congenital Heart Disease Top

When congenital heart disease is diagnosed during fetal life, the expectant parents should have a detailed discussion with a fetal cardiologist with regard to the prognosis of the cardiac lesion, covering not only procedural risks, but also long-term mortality, morbidity, and quality of life. There should also be a discussion with regard to possible associations, including karyotypic abnormalities, noncardiac structural anomalies, and syndromes, [2],[3],[4],[5] to have a full picture of the prognosis for their baby. Thus, effective management demands a close liaison between the cardiologist, fetal medicine specialist, genetics, and other relevant subspecialities. Depending on the severity of the cardiac lesion, the associated abnormalities, gestational age, and local laws, one of the options open to parents may include termination of pregnancy. It is self-evident that if congenital heart disease is diagnosed prenatally and parents elect to terminate the pregnancy, then the prevalence at birth will fall. The proportion of parents who elect to terminate the pregnancy will depend on many factors including religion and cultural norms, as well as, the prognosis of the cardiac lesion and any associated abnormalities. As examples, if hypoplastic left heart is diagnosed then, at my center, over 60% of the parents will elect to terminate the pregnancy, whereas, only a small minority of parents would consider this option for isolated transposition of the great arteries. It should be emphasized that the decision about the fate of the pregnancy rests with the parents after discussion with their medical advisers, and it is not our practice to direct parents as to whether they should or should not continue with pregnancy. Parental decision-making may, however, be constrained by local laws. For example, in the United Kingdom, termination of pregnancy may, among other reasons, be performed if "there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped." Reliable population-based data regarding the impact of prenatal diagnosis on birth prevalence is relatively scant. In the United Kingdom, between 1993 and 1995 such national data was collected. [2],[3] Overall, around half of the pregnancies affected by fetal congenital heart disease ended in termination of pregnancy, although the overall detection rate of congenital heart defects (requiring intervention or surgery in infancy) was only 24%. Thus, if around one-quarter of the affected pregnancies were detected and half of these resulted in termination of pregnancy, then around one-eighth fewer infants might be delivered. Other notable findings from that UK national data include the wide geographical variation in detection rates and that the termination rate was affected by the gestational age at which the diagnosis was made. Early detection was associated with a higher termination rate than diagnoses made later in gestation. More recent European data has confirmed major differences in detection rates between different European countries and emphasized the importance of noncardiac malformations and karyotypic abnormalities in prenatal detection rates and parental decision-making. [6],[7],[8]

Since those studies were published there have been dramatic changes in screening policy for congenital heart disease. Although established risk factors for congenital heart disease, such as a history in a first-degree family member, have been recognized for some time, nuchal translucency (NT) screening is a more recent development, which has far-reaching implications for cardiac screening policies. Nuchal translucency screening involves measurement of a sonographically lucent area at the back of the fetal neck. This technique was introduced to identify fetuses at high risk for trisomy 21, but NT thickness has a correlation with congenital heart disease (CHD), which is independent of the fetal karyotype [9] and has a stronger association with CHD than established risk factors such as family history. [10] From the data of Hyett et al., [9] 6.3% of fetuses with NT above the ninety- ninth percentile (3.5 mm) had congenital heart disease. This is not a simple "cut-off" relationship, but correlates with the NT measurement, the higher the NT thickness, the higher the risk of CHD.[11] The NT measurements are made at 11-14 weeks gestational age and so fetal echocardiography may be indicated shortly thereafter. Some data does not suggest as strong a relationship of NT to congenital heart disease as the original data of Hyett et al. [9],[12],[13] A recent multicenter study suggested that around one-quarter of chromosomally normal fetuses with congenital heart disease have an NT value above 3.5mm.[14] This has led to early identification of CHD [14] and an increased demand for early fetal echocardiography on the basis of such findings. [15],[16] The policy at my unit has been to await fetal karyotype results before performing fetal echocardiography because some parents may base their decision regarding the fate of the pregnancy on the karyotype result alone rather than on the cardiac findings. Other fetal cardiologists, practicing within fetal medicine units are examining the heart even earlier at around 11-13 weeks gestational age, targeting fetuses with increased NT. [17]

   Impact of Prenatal Diagnosis on Cardiac Morbidity and Mortality Top

The vast majority of data on the impact of prenatal diagnosis on the morbidity and mortality of congenital heart disease is from developed countries. The data published to date will be reviewed briefly, but it should be emphasized that all the data comes from countries where the following requirements were met:

  1. Availability of appropriate prenatal investigations: If a cardiac lesion was diagnosed prenatally there was availability of relevant prenatal investigations, such as, fetal karyotyping and detailed ultrasound for noncardiac malformations.
  2. High level delivery facilities and neonatal care was available: Following a prenatal diagnosis of congenital heart disease there would need to be a pattern of referral for delivery and treatment at a high level neonatal nursery/cardiac center if the outcome was to be optimized.
  3. Postnatal surgical, interventional or medical treatment for the cardiac lesion in question was available without this being financially prohibitive.
  4. Availability of long-term therapies: Prenatal diagnosis has an ascertainment bias for more severe forms of congenital heart disease. Cardiac lesions which will lead to single ventricle palliation are overrepresented in prenatal versus postnatal series. Any country or region instituting a prenatal screening program will have to consider which surgical options are available, for example, total cavopulmonary connection, both in terms of surgical feasibility and supportive care, for example, monitoring of anticoagulation.
  5. Program for postnatal detection of congenital heart disease: If a diagnosis of congenital heart disease is not made prenatally, in developed countries there is typically a program of clinical assessment for newborn infants, which includes the cardiovascular system, accepting that some lesions will be extremely difficult to detect clinically in the first days after birth. In some developing countries, early postnatal assessment may not be performed routinely and so CHD may remain undetected for a longer period, and duct-dependent lesions may not be detected prior to death. In this context, prenatal diagnosis may have a more dramatic impact in developing countries than in developed countries.
The lesions for which there is relatively robust published data relates to hypoplastic left heart syndrome, transposition of the great arteries, coarctation of the aorta, and pulmonary atresia.

Hypoplastic left heart syndrome

Tworetzky et al. (2001) [18] described a series of 33 fetuses who were diagnosed prenatally with hypoplastic left heart and who were managed at a single center in the United States. They described zero mortality among 14 prenatally diagnosed infants versus a mortality of 13 of 38 infants who were diagnosed postnatally. In addition to mortality benefit, prenatal diagnosis of hypoplastic left heart was associated with better ventricular function, less tricuspid regurgitation, and a reduced requirement for inotropes and bicarbonate. Other data has confirmed better condition at presentation for infants who were diagnosed prenatally, but this did not lead to reduced overall mortality. [19] A further publication has reported a reduced incidence of abnormal neurological events related to prenatal diagnosis. [20]

Transposition of the great arteries

The largest series examining the impact of prenatal diagnosis of transposition of the great arteries (TGA) on the outcome is from France, where there is a very well-developed prenatal screening program for congenital heart disease. [21] The study included 68 infants who were prenatally diagnosed and 250 who were not. There was zero preoperative mortality in the prenatal group versus 6% in the postnatally diagnosed group. Postoperative mortality was also significantly better for infants who were diagnosed during fetal life. Another study, however, did not observe such an impact of prenatal diagnosis on the condition at presentation or on the operative mortality. [19]

Coarctation of the aorta

A single study has examined the impact of prenatal diagnosis of coarctation of the aorta on the postnatal outcome. [22] This study reported a positive impact of prenatal diagnosis in terms of preoperative morbidity and mortality as well as ventricular function at presentation. Importantly, this study included pathological data relating to infants who died prior to diagnosis. This type of information is difficult to obtain unless there is a population-based pathological registry. Where such pathological data has been reported, there is an important minority of infants who die prior to diagnosis, [23] even in the setting of a developed country.

Pulmonary atresia

My center has published data on the impact of prenatal diagnosis on the outcome of infants with duct-dependent pulmonary blood flow. [24] The prenatally diagnosed infants had better oxygen saturation at presentation than those diagnosed postnatally. However, this did not translate into better short-term mortality or morbidity. In our series of pulmonary atresia, almost all infants were detected postnatally in the first 24 hours after birth, with prompt initiation of prostaglandin E. If there had not been such prompt recognition of cases that were undiagnosed prior to birth, then the results may well have been more favorable toward a benefit of prenatal diagnosis. Thus, the results are likely to be strongly influenced by postnatal screening policies as well as prenatal detection.

   Impact of Prenatal Diagnosis for Management Strategies Top

There are many cardiac lesions for which prenatal diagnosis has little impact on initial neonatal management. Examples include isolated ventricular septal defect and atrioventricular septal defect, that is, those cases without evidence of left or right heart obstruction, which would not be expected to present until the pulmonary vascular resistance falls postnatally. For these cases, there is no cardiac indication to alter delivery plans, provided the need for non-urgent cardiac assessment in the neonatal period is understood.

Location of delivery

For fetuses who have duct-dependent lesions or where there is a potential need for early neonatal surgery or intervention, delivery at or near a cardiac center may be preferable so that prompt postnatal investigations can be planned without the need for transfer of the infant. Importantly, this also ensures that parents are available for explanation and consent for early neonatal procedures. Ensuring delivery at the cardiac center may involve induction of labor at term, but the vast majority of infants can have a vaginal delivery rather than a Caesarean section. In practice, however, many parents may favor delivery at or near a cardiac center, even if the cardiac findings are not suggestive of the need for very early intervention. This largely reflects local facilities and parental concerns about separation from their newborn infant if assessment at a geographically remote cardiac center (even if non-urgent) has been recommended.

   Impact on Mode of Delivery Top

For most cardiac lesions, given prenatal circulatory physiology, a normal vaginal delivery is perfectly satisfactory. In this author's practice Caesarean delivery has been reserved for a minority of cases, in whom there is a predicted need for early neonatal intervention, where it is necessary to have a team immediately available for the resuscitation and immediate cardiac management of the affected fetus. This has included infants with TGA with both a restrictive atrial septum and restrictive arterial duct, fetuses with hypoplastic left heart with restrictive/intact atrial septum, and hydropic fetuses where immediate fluid drainage from body cavities such as the pleural space may be indicated urgently. In such cases immediate cardiological, interventional, and/or cardiac surgical availability needs to be ensured. There should be an individualized discussion between obstetrician, cardiologist, and cardiac surgeon, to optimize care. Aside from fetuses with structural cardiac malformations, some types of arrhythmia such as complete heart block may make it impossible to assess fetal well-being by conventional cardiotocographic monitoring and Caesarean section may be preferred.

Prenatal intervention

Prenatal diagnosis affords a unique opportunity to intervene and alter the natural history of cardiac disease. In this context, it is essential to separate abnormalities of cardiac rhythm and structural abnormalities.

  1. Fetal arrhythmias: For fetal tachycardias, which are most commonly supraventricular tachycardia or atrial flutter, there is ample evidence of the effectiveness of prenatal therapy to control the arrhythmia and lead to the resolution of fetal hydrops if present. [25],[26],[27],[28],[29] The type of therapy used needs to be tailored according to the type of arrhythmia and the presence of hydrops (which affects the placental transfer of drugs). With regard to fetal bradycardia, due to a complete heart block, treatments are more controversial. If the cardiac structure is abnormal, the most common associated abnormalities include isomerism of the left atrial appendages and discordant atrioventricular connections. The prognosis for such fetuses, affected by both structural cardiac disease and complete heart block is guarded, with a minority of fetuses surviving. [30],[31],[32],[33] Heart block with a normal cardiac structure is due to maternal anti-Ro or anti-La antibodies in the vast majority of cases. Prenatal therapy for such cases is controversial with some groups recommending therapy such as dexamethasone and salbutamol for all cases, and others treating only the affected fetuses where there is evidence of hemodynamic compromise. [31],[34],[35],[36],[37]
  2. Structural abnormalities: Prenatal intervention for structural cardiac malformation remains controversial. The lesions for which intervention has been undertaken during fetal life include, critical aortic stenosis, [38],[39],[40] pulmonary atresia, [41] and hypoplastic left heart with intact atrial septum.[42] Using critical aortic stenosis as an example, the rationale for intervening by intrauterine balloon aortic valvuloplasty has been to prevent deterioration in the left heart structures, which is recognized to be a part of the natural history in utero. [43],[44] Despite technical success, and improvements in the echocardiographic parameters the data on clinical outcome has been less convincing, with only a minority of cases achieving a biventricular repair.[40],[45] Currently, such interventions are undertaken at specialist centers, where there is the availability of fetal medicine, fetal cardiology, interventional, surgical, and anesthetic expertise, which are essential for procedural success, follow-up, and postnatal management of the affected infants.

   How and how Far to Train Sonographers to Examine the Fetal Heart Top

From an epidemiological perspective, although groups at high risk for congenital heart disease may be identified, for example, increased NT or family history, most congenital heart lesions will occur in the "low- risk" population. Prenatal detection of CHD in the low- risk population will be dependent on the ability of sonographers to identify deviation from normality on midtrimester anomaly scans. Given the incidence of individual cardiac lesions, sonographers practising in a low-risk setting are unlikely to become familiar with a broad spectrum of congenital cardiac malformations. The goal of training is to ensure that sonographers are familiar with normal cardiac appearances and refer cases which do not fit into the normal pattern. Such referrals are made to specialists who can then provide a precise diagnosis, prognosis, and formulate a management plan for the affected fetus.

One of the key views of the fetal heart is the "four chamber view," which underpins effective prenatal cardiac screening. This view has the advantage of having external reference points, the fetal ribs, to ensure that the sonographer has "cut" the thorax in the appropriate plane. In a correct four chamber view there should be the appearance of a single rib around the fetal thorax [Figure 1b]. As a minimum, a four chamber view should be obtained, when the heart is imaged as part of "routine" obstetric anomaly scanning in the midtrimester. From the published data, the yield of congenital heart defects increases if the outflow tracts are examined, as well as the four chamber view, but appreciation of abnormalities of the outflow tracts is more challenging than the four chamber view. The approach that we have adopted, in common with others, [46],[47],[48],[49] has been to advocate visualization of five key sonographic views [Figure 1a], [Figure 1b], [Figure 1c], [Figure 1d], [Figure 1e]. All these views can be obtained by cranial or caudal angulation of the ultrasound probe from the four chamber view. Examples of cardiac abnormalities that can be suspected on the four chamber view are shown in [Figure 2a], [Figure 2b], [Figure 2c]. Some cardiac lesions that are compatible with a normal four chamber view and for which extended views of the outflow tracts are required to make the diagnosis are illustrated in [Figure 3a], [Figure 3b], [Figure 3c]. For fetuses with major congenital heart disease, a full diagnosis requires a sequential segmental approach, [50] similar to postnatal practice.

The question of how to train sonographers to examine the fetal heart is challenging, both for the sonographer and for those who would provide such training. In terms of prenatal detection rates, the benefit of sonographer training has been described, [51],[52],[53] as well as the impact of sonographer experience [54] and variability of performance following training. [55] .Whether such training is delivered by cardiologists with expertise in fetal diagnosis or obstetricians or sonographers with particular expertise will depend on local factors. It is also important to distinguish the detection rates that are reported by individual centers [56] from those that are population-based. [3],[57] Individual center data will depend on the nature of the unit reporting their data, referral patterns, and the expertise within the unit. There is also publication selection bias toward better results. When population-based data is examined the results are usually much less impressive in terms of overall detection rate, with observation of vari ability of detection rates between centers and regions. [3]

One of the major limitations for using fetal echocardiography as a screening tool is that it is operator-dependent, in a way that other forms of pregnancy screening, for example, serum screening for major trisomies, are not. Published data has confirmed the influence of operator training and experience [54],[55] on the ability to confirm normality of the cardiac connections. Sonographers frequently report that they find imaging of the fetal heart one of the most challenging aspects of prenatal anomaly scanning. For countries where anomaly scanning in general is not well-established, it may be most appropriate to initially incorporate some core views of the heart, such as, the four chamber view, into fetal anomaly scans before aspiring to more extensive cardiac imaging as part of anomaly scans, in the low-risk population. With time and training, operators may be more confident about the views of the outflow tracts, visualisation of which will improve overall detection rates.

   Technical Developments Top

In recent years, technical advances in three-dimensional echocardiography show that it is possible to include all fetal cardiac structures within a "volume" of the fetal heart. The most common technique employed is spatiotemporal image correlation (STIC), which involves a slow sweep of the ultrasound probe in a pyramid that includes all cardiac structures. Such sweeps typically take 7-12 seconds to achieve a full volume, which can be obtained with or without color flow Doppler. [58] The software algorithm permits a display of multiple moving "slices" of the heart to show the anatomy from situs views below the heart, the four chamber view, and views of the outflow tracts. By incorporating the views within a single volume these can be interrogated retrospectively in any desired projection. [59],[60] Although attractive, retrospective analysis does take time [61] and is dependent on the image quality in common with all ultrasound techniques. Furthermore, the relatively slow acquisition times mean that fetal movement can render some volumes useless and acoustic shadows interfere with image quality in exactly the same way as standard cross-sectional techniques. Several studies have demonstrated that such datasets can be interpreted retrospectively either to confirm normality or confirm congenital heart disease. Datasets can be sent to remote sites to be interrogated retrospectively by fetal cardiologists, which may assist screening centers that are geographically remote from the specialist centers. [62],[63] Regardless of the technique that is used to obtain or analyze images of the fetal heart, an accurate interpretation of such images will depend on a firm understanding of the anatomy of the fetal heart, either to diagnose a congenital abnormality or to confirm normality. Currently, the role of STIC in "routine" screening for congenital heart defects has not been established.

   References Top

1.Allan LD, Sharland GK, Milburn A, Lockhart SM, Groves AM, Anderson RH, et al. Prospective diagnosis of 1,006 consecutive cases of congenital heart disease in the fetus. J Am Coll Cardiol 1994;23:1452-8.  Back to cited text no. 1    
2.Allan L, Dangel J, Fesslova V, Marek J, Mellander M, Oberhδnsli I, et al. Recommendations for the practice of fetal cardiology in Europe. Cardiol Young 2004;14:109-14.  Back to cited text no. 2    
3.Bull C. Current and potential impact of fetal diagnosis on prevalence and spectrum of serious congenital heart disease at term in the UK. British Paediatric Cardiac Association. Lancet 1999;354:1242-7 ik.  Back to cited text no. 3    
4.Sharland G. Fetal cardiology. Semin Neonatol 2001;6:3-15.  Back to cited text no. 4    
5.Sharland G. What should be provided by a service for fetal cardiology? Cardiol Young 2000;10:625-35.  Back to cited text no. 5    
6.Stoll C, Garne E, Clementi M; EUROSCAN Study Group. Evaluation of prenatal diagnosis of associated congenital heart diseases by fetal ultrasonographic examination in Europe. Prenat Diagn 2001;21:243-52.  Back to cited text no. 6    
7.Garne E, Stoll C, Clementi M; Euroscan Group. Evaluation of prenatal diagnosis of congenital heart diseases by ultrasound: Experience from 20 European registries. Ultrasound Obstet Gynecol 2001;17:386-91.  Back to cited text no. 7    
8.Garne E, Berghold A, Johnson Z, Stoll C. Different policies on prenatal ultrasound screening programmes and induced abortions explain regional variations in infant mortality with congenital malformations. Fetal Diagn Ther 2001;16:153-7.  Back to cited text no. 8    
9.Hyett J, Perdu M, Sharland G, Snijders R, Nicolaides KH. Using fetal nuchal translucency to screen for major congenital cardiac defects at 10-14 weeks of gestation: Population based cohort study. BMJ 1999;318:81-5.  Back to cited text no. 9    
10.Atzei A, Gajewska K, Huggon IC, Allan L, Nicolaides KH. Relationship between nuchal translucency thickness and prevalence of major cardiac defects in fetuses with normal karyotype. Ultrasound Obstet Gynecol 2005;26:154-7.  Back to cited text no. 10    
11.Ghi T, Huggon IC, Zosmer N, Nicolaides KH. Incidence of major structural cardiac defects associated with increased nuchal translucency but normal karyotype. Ultrasound Obstet Gynecol 2001;18:610-4.  Back to cited text no. 11    
12.Mavrides E, Cobian-Sanchez F, Tekay A, Moscoso G, Campbell S, Thilaganathan B, et al. Limitations of using first-trimester nuchal translucency measurement in routine screening for major congenital heart defects. Ultrasound Obstet Gynecol 2001;17:106-10.  Back to cited text no. 12    
13.Michailidis GD, Spencer K, Economides DL. The use of nuchal translucency measurement and second trimester biochemical markers in screening for Down's syndrome. BJOG 2001;108:1047-52.  Back to cited text no. 13    
14.Makrydimas G, Sotiriadis A, Huggon IC, Simpson J, Sharland G, Carvalho JS, et al. Nuchal translucency and fetal cardiac defects: A pooled analysis of major fetal echocardiography centers. Am J Obstet Gynecol 2005;192:89-95.  Back to cited text no. 14    
15.Simpsom JM, Jones A, Callaghan N, Sharland GK. Accuracy and limitations of transabdominal fetal echocardiography at 12-15 weeks of gestation in a population at high risk for congenital heart disease. BJOG 2000;107:1492-7.  Back to cited text no. 15    
16.Carvalho JS, Moscoso G, Ville Y. First-trimester transabdominal fetal echocardiography. Lancet 1998;351:1023-7.  Back to cited text no. 16    
17.Huggon IC, Ghi T, Cook AC, Zosmer N, Allan LD, Nicolaides KH. Fetal cardiac abnormalities identified prior to 14 weeks' gestation. Ultrasound Obstet Gynecol 2002;20:22-9.  Back to cited text no. 17    
18.Tworetzky W, McElhinney DB, Reddy VM, Brook MM, Hanley FL, Silverman NH. Improved surgical outcome after fetal diagnosis of hypoplastic left heart syndrome. Circulation 2001;103:1269-73.  Back to cited text no. 18    
19.Kumar RK, Newburger JW, Gauvreau K, Kamenir SA, Hornberger LK. Comparison of outcome when hypoplastic left heart syndrome and transposition of the great arteries are diagnosed prenatally versus when diagnosis of these two conditions is made only postnatally. Am J Cardiol 1999;83:1649-53.  Back to cited text no. 19    
20.Mahle WT, Clancy RR, McGaurn SP, Goin JE, Clark BJ. Impact of prenatal diagnosis on survival and early neurologic morbidity in neonates with the hypoplastic left heart syndrome. Pediatrics 2001;107:1277-82.  Back to cited text no. 20    
21.Bonnet D, Coltri A, Butera G, Fermont L, Le Bidois J, Kachaner J, Sidi D, et al. Detection of transposition of the great arteries in fetuses reduces neonatal morbidity and mortality. Circulation 1999;99:916-8.  Back to cited text no. 21    
22.Franklin O, Burch M, Manning N, Sleeman K, Gould S, Archer N. Prenatal diagnosis of coarctation of the aorta improves survival and reduces morbidity. Heart 2002;87:67-9.  Back to cited text no. 22    
23.Abu-Harb M, Hey E, Wren C. Death in infancy from unrecognised congenital heart disease. Arch Dis Child 1994;71:3-7.  Back to cited text no. 23    
24.Tzifa A, Barker C, Tibby SM, Simpson JM. Prenatal diagnosis of pulmonary atresia: Impact on clinical presentation and early outcome. Arch Dis Child Fetal Neonatal Ed 2007;92:F199-203.  Back to cited text no. 24    
25.Krapp M, Kohl T, Simpson JM, Sharland GK, Katalinic A, Gembruch U. Review of diagnosis, treatment, and outcome of fetal atrial flutter compared with supraventricular tachycardia. Heart 2003;89:913-7.  Back to cited text no. 25    
26.Simpson JM, Sharland GK. Fetal tachycardias: Management and outcome of 127 consecutive cases. Heart 1998;79:576-81.  Back to cited text no. 26    
27.van Engelen AD, Weijtens O, Brenner JI, Kleinman CS, Copel JA, Stoutenbeek P, et al. Management outcome and follow-up of fetal tachycardia. J Am Coll Cardiol 1994;24:1371-5.  Back to cited text no. 27    
28.Fouron JC. Fetal arrhythmias: The Saint-Justine hospital experience. Prenat Diagn 2004;24:1068-80.  Back to cited text no. 28    
29.Simpson JM. Fetal arrhythmias. Ultrasound Obstet Gynecol 2006;27:599-606.  Back to cited text no. 29    
30.Schmidt KG, Ulmer HE, Silverman NH, Kleinman CS, Copel JA. Perinatal outcome of fetal complete atrioventricular block: A multicenter experience. J Am Coll Cardiol 1991;17:1360-6.  Back to cited text no. 30    
31.Lopes LM, Tavares GM, Damiano AP, Lopes MA, Aiello VD, Schultz R, et al. Perinatal outcome of fetal atrioventricular block: One-hundred-sixteen cases from a single institution. Circulation 2008;118:1268-75.  Back to cited text no. 31    
32.Jaeggi ET, Hornberger LK, Smallhorn JF, Fouron JC. Prenatal diagnosis of complete atrioventricular block associated with structural heart disease: Combined experience of two tertiary care centers and review of the literature. Ultrasound Obstet Gynecol 2005;26:16-21.  Back to cited text no. 32    
33.Berg C, Geipel A, Kohl T, Breuer J, Germer U, Krapp M, et al. Atrioventricular block detected in fetal life: Associated anomalies and potential prognostic markers. Ultrasound Obstet Gynecol 2005;26:4-15.  Back to cited text no. 33    
34.Groves AM, Allan LD, Rosenthal E. Therapeutic trial of sympathomimetics in three cases of complete heart block in the fetus. Circulation 1995;92:3394-6.  Back to cited text no. 34    
35.Groves AM, Allan LD, Rosenthal E. Outcome of isolated congenital complete heart block diagnosed in utero. Heart 1996;75:190-4.  Back to cited text no. 35    
36.Jaeggi ET, Fouron JC, Silverman ED, Ryan G, Smallhorn J, Hornberger LK. Transplacental fetal treatment improves the outcome of prenatally diagnosed complete atrioventricular block without structural heart disease. Circulation 2004;110:1542-8.  Back to cited text no. 36    
37.Rosenthal E, Gordon PA, Simpson JM, Sharland GK. Letter regarding article by Jaeggi et al. "transplacental fetal treatment improves the outcome of prenatally diagnosed complete atrioventricular block without structural heart disease". Circulation 2005;111:e287-8 author reply e287-8.  Back to cited text no. 37    
38.Maxwell D, Allan L, Tynan MJ. Balloon dilatation of the aortic valve in the fetus: A report of two cases. Br Heart J 1991;65:256-8.  Back to cited text no. 38    
39.Kohl T, Sharland G, Allan LD, Gembruch U, Chaoui R, Lopes LM, et al. World experience of percutaneous ultrasound-guided balloon valvuloplasty in human fetuses with severe aortic valve obstruction. Am J Cardiol 2000;85:1230-3.  Back to cited text no. 39    
40.Tworetzky W, Wilkins-Haug L, Jennings RW, van der Velde ME, Marshall AC, Marx GR, et al. Balloon dilation of severe aortic stenosis in the fetus: Potential for prevention of hypoplastic left heart syndrome: Candidate selection, technique, and results of successful intervention. Circulation 2004;110:2125-31.  Back to cited text no. 40    
41.Tulzer G, Arzt W, Franklin RC, Loughna PV, Mair R, Gardiner HM. Fetal pulmonary valvuloplasty for critical pulmonary stenosis or atresia with intact septum. Lancet 2002;360:1567-8.  Back to cited text no. 41    
42.Marshall AC, van der Velde ME, Tworetzky W, Gomez CA, Wilkins-Haug L, Benson CB, et al. Creation of an atrial septal defect in utero for fetuses with hypoplastic left heart syndrome and intact or highly restrictive atrial septum. Circulation 2004;110:253-8.  Back to cited text no. 42    
43.McCaffrey FM, Sherman FS. Prenatal diagnosis of severe aortic stenosis. Pediatr Cardiol 1997;18:276-81.  Back to cited text no. 43    
44.Simpson JM, Sharland GK. Natural history and outcome of aortic stenosis diagnosed prenatally. Heart 1997;77:205-10.  Back to cited text no. 44    
45.Makikallio K, McElhinney DB, Levine JC, Marx GR, Colan SD, Marshall AC, et al. Fetal aortic valve stenosis and the evolution of hypoplastic left heart syndrome: Patient selection for fetal intervention. Circulation 2006;113:1401-5.  Back to cited text no. 45    
46.Viρals F, Heredia F, Giuliano A. The role of the three vessels and trachea view (3VT) in the diagnosis of congenital heart defects. Ultrasound Obstet Gynecol 2003;22:358-67.  Back to cited text no. 46    
47.Yagel S, Cohen SM, Achiron R. Examination of the fetal heart by five short-axis views: A proposed screening method for comprehensive cardiac evaluation. Ultrasound Obstet Gynecol 2001;17:367-9.  Back to cited text no. 47    
48.Yagel S, Arbel R, Anteby EY, Raveh D, Achiron R. The three vessels and trachea view (3VT) in fetal cardiac scanning. Ultrasound Obstet Gynecol 2002;20:340-5.  Back to cited text no. 48    
49.Lee W, Allan L, Carvalho JS, Chaoui R, Copel J, Devore G, et al. ISUOG consensus statement: What constitutes a fetal echocardiogram? Ultrasound Obstet Gynecol 2008;32:239-42.  Back to cited text no. 49    
50.Carvalho JS, Ho SY, Shinebourne EA. Sequential segmental analysis in complex fetal cardiac abnormalities: A logical approach to diagnosis. Ultrasound Obstet Gynecol 2005;26:105-11.  Back to cited text no. 50    
51.Hunter S, Heads A, Wyllie J, Robson S. Prenatal diagnosis of congenital heart disease in the northern region of England: Benefits of a training programme for obstetric ultrasonographers. Heart 2000;84:294-8.  Back to cited text no. 51    
52.Sharland GK, Allan LD. Screening for congenital heart disease prenatally. Results of a 21/2-year study in the South East Thames Region. Br J Obstet Gynaecol 1992;99:220-5.  Back to cited text no. 52    
53.Pιzard P, Bonnemains L, Boussion F, Sentilhes L, Allory P, Lιpinard C, et al. Influence of ultrasonographers training on prenatal diagnosis of congenital heart diseases: A 12-year population-based study. Prenat Diagn 2008;28:1016-22.  Back to cited text no. 53    
54.Tegnander E, Eik-Nes SH. The examiner's ultrasound experience has a significant impact on the detection rate of congenital heart defects at the second-trimester fetal examination. Ultrasound Obstet Gynecol 2006;28:8-14.  Back to cited text no. 54    
55.Rustico MA, Benettoni A, D'Ottavio G, Fischer-Tamaro L, Conoscenti GC, Meir Y, et al. Early screening for fetal cardiac anomalies by transvaginal echocardiography in an unselected population: The role of operator experience. Ultrasound Obstet Gynecol 2000;16:614-9.  Back to cited text no. 55    
56.Stümpflen I, Stümpflen A, Wimmer M, Bernaschek G. Effect of detailed fetal echocardiography as part of routine prenatal ultrasonographic screening on detection of congenital heart disease. Lancet 1996;348:854-7.  Back to cited text no. 56    
57.Buskens E, Grobbee DE, Frohn-Mulder IM, Stewart PA, Juttmann RE, Wladimiroff JW, et al. Efficacy of routine fetal ultrasound screening for congenital heart disease in normal pregnancy. Circulation 1996;94:67-72.  Back to cited text no. 57    
58.Chaoui R, Hoffmann J, Heling KS. Three-dimensional (3D) and 4D color Doppler fetal echocardiography using spatio-temporal image correlation (STIC). Ultrasound Obstet Gynecol 2004;23:535-45.  Back to cited text no. 58    
59.Viρals F, Poblete P, Giuliano A. Spatio-temporal image correlation (STIC): A new tool for the prenatal screening of congenital heart defects. Ultrasound Obstet Gynecol 2003;22:388-94.  Back to cited text no. 59    
60.DeVore GR, Falkensammer P, Sklansky MS, Platt LD. Spatio-temporal image correlation (STIC): New technology for evaluation of the fetal heart. Ultrasound Obstet Gynecol 2003;22:380-7.  Back to cited text no. 60    
61.Wanitpongpan P, Kanagawa T, Kinugasa Y, Kimura T. Spatio-temporal image correlation (STIC) used by general obstetricians is marginally clinically effective compared to 2D fetal echocardiography scanning by experts. Prenat Diagn 2008;28:923-8.  Back to cited text no. 61    
62.Viρals F, Mandujano L, Vargas G, Giuliano A. Prenatal diagnosis of congenital heart disease using four-dimensional spatio-temporal image correlation (STIC) telemedicine via an Internet link: A pilot study. Ultrasound Obstet Gynecol 2005;25:25-31.  Back to cited text no. 62    
63.Michailidis GD, Simpson JM, Karidas C, Economides DL. Detailed three-dimensional fetal echocardiography facilitated by an Internet link. Ultrasound Obstet Gynecol 2001;18:325-8.  Back to cited text no. 63    

Correspondence Address:
John M Simpson
Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust London
United Kingdom
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-2069.52806

Rights and Permissions


  [Figure 1a], [Figure 1b], [Figure 1c], [Figure 1d], [Figure 1e], [Figure 2a], [Figure 2b], [Figure 2c], [Figure 3a], [Figure 3b], [Figure 3c]

  [Table 1], [Table 2]

This article has been cited by
1 Impact of Fetal Echocardiography Comprehensiveness on Diagnostic Accuracy
Sarina K. Behera, Victoria Y. Ding, Sukyung Chung, Theresa A. Tacy
Journal of the American Society of Echocardiography. 2022;
[Pubmed] | [DOI]
2 Prenatal diagnosis lowers neonatal cardiac care costs in resource-limited settings
Balu Vaidyanathan, Karthika Rani, Farooq Kunde, Stephy Thomas, Abish Sudhakar, Raman Krishna Kumar, Bistra Zheleva
Cardiology in the Young. 2022; : 1
[Pubmed] | [DOI]
3 Developing a standardized approach to prenatal counseling following the diagnosis of a complex congenital heart abnormality
Yulia Gendler, Einat Birk
Early Human Development. 2021; 163: 105507
[Pubmed] | [DOI]
4 Major heart defects: the diagnostic evaluations of first-year-olds
Jan Pavlicek, Eva Klaskova, Sabina Kapralova, Alzbeta Moravova Palatova, Alicja Piegzova, Richard Spacek, Tomas Gruszka
BMC Pediatrics. 2021; 21(1)
[Pubmed] | [DOI]
5 Prenatal diagnosis of obstructed supracardiac total anomalous pulmonary venous connection at 23 weeks with successful immediate postnatal surgical correction
Danish Memon, Balu Vaidyanathan
Annals of Pediatric Cardiology. 2021; 14(3): 432
[Pubmed] | [DOI]
6 3D / 4D spatiotemporal image correlation ( STIC ) fetal echocardiography provides incremental benefit over 2D fetal echocardiography in predicting postnatal s
B. Karmegaraj, S. Kumar, B. Srimurugan, A. Sudhakar, J. M. Simpson, B. Vaidyanathan
Ultrasound in Obstetrics & Gynecology. 2021; 57(3): 423
[Pubmed] | [DOI]
7 Automatic detection of complete and measurable cardiac cycles in antenatal pulsed-wave Doppler signals
Eleonora Sulas, Monica Urru, Roberto Tumbarello, Luigi Raffo, Danilo Pani
Computer Methods and Programs in Biomedicine. 2020; 190: 105336
[Pubmed] | [DOI]
8 Ultrasound in the Service of Early Diagnosis and Treatment of Congenital Heart Defects: Bosnian and Herzegovinian Experience
Asim Kurjak, Milan Stanojevic, Edin Medjedovic, Amer Iglica, Zijo Begic, Edin Begic, Nedim Begic
Donald School Journal of Ultrasound in Obstetrics and Gynecology. 2020; 14(2): 131
[Pubmed] | [DOI]
9 Development, effectiveness, and current possibilities in prenatal detection of congenital heart defects
Jan Pavlícek, Alicja Piegzová, Eva Klásková, Sabina Kaprálová, Alžbeta Palátová, Richard Špacek, TomᚠGruszka
Cor et Vasa. 2020; 62(1): 21
[Pubmed] | [DOI]
10 A low threshold for neonatal intervention yields a high rate of biventricular outcomes in pulmonary atresia with intact ventricular septum
Gareth J. Morgan, Srinivas A. Narayan, Sebastian Goreczny, Henry Chubb, Thomas Krasemann, Eric Rosenthal, Shakeel A. Qureshi
Cardiology in the Young. 2020; 30(5): 649
[Pubmed] | [DOI]
11 Fetal hydrops – a review and a clinical approach to identifying the cause
Esther Dempsey, Tessa Homfray, John M Simpson, Steve Jeffery, Sahar Mansour, Pia Ostergaard
Expert Opinion on Orphan Drugs. 2020; 8(2-3): 51
[Pubmed] | [DOI]
12 Prenatal cardiac care: Goals, priorities & gaps in knowledge in fetal cardiovascular disease: Perspectives of the Fetal Heart Society
Nelangi M. Pinto, Shaine A. Morris, Anita J. Moon-Grady, Mary T. Donofrio
Progress in Pediatric Cardiology. 2020; 59: 101312
[Pubmed] | [DOI]
13 Outcomes of infants with prenatally diagnosed congenital heart disease delivered in a tertiary-care pediatric cardiac facility
Trupti Deepak Changlani,Annu Jose,Abish Sudhakar,Reshma Rojal,Radhamany Kunjikutty,Balu Vaidyanathan
Indian Pediatrics. 2015; 52(10): 852
[Pubmed] | [DOI]
14 Evaluation of Fetal Pulmonary Veins During Early Gestation by Pulsed Doppler Ultrasound: A Feasibility Study
Aldo L. Schenone,Gelsy Giugni,Mauro H. Schenone,Luis Diaz,Alberto Bermudez,David Majdalany,Alberto Sosa-Olavarria
Journal of Fetal Medicine. 2015; 2(1): 27
[Pubmed] | [DOI]
15 How useful is pulse oximetry for screening of congenital heart disease in newborns?
Joseph L. Mathew,Deepak Chawla,Dinesh Kumar
Indian Pediatrics. 2014; 51(11): 913
[Pubmed] | [DOI]
16 Fetal Echocardiography Assists in Determining Optimal Delivery Site
Anne Berndl,Kelly Pearce,Tapas Mondal
Journal of Obstetrics and Gynaecology Canada. 2014; 36(3): 210
[Pubmed] | [DOI]
17 Clinical and socioeconomic predictors of pregnancy termination for fetuses with congenital heart defects: a population-based evaluation
Karim Tararbit,Thi Thanh Thao Bui,Nathalie Lelong,Anne-Claire Thieulin,François Goffinet,Babak Khoshnood
Prenatal Diagnosis. 2013; 33(2): 179
[Pubmed] | [DOI]
18 Clinical and socioeconomic predictors of pregnancy termination for fetuses with congenital heart defects: A population-based evaluation
Tararbit, K. and Bui, T.T.T. and Lelong, N. and Thieulin, A.-C. and Goffinet, F. and Khoshnood, B.
Prenatal Diagnosis. 2013; 33(2): 179-186
19 Does fetal echo help the fetus?
Kulkarni, S.
Annals of Pediatric Cardiology. 2013; 6(1): 21-23
20 Conotruncal anomalies in the fetus: Referral patterns and pregnancy outcomes in a dedicated fetal cardiology unit in South India
Vaidyanathan, B. and Kumar, S. and Sudhakar, A. and Kumar, R.K.
Annals of Pediatric Cardiology. 2013; 6(1): 15-20
21 Foetal echocardiography of transposition of the great arteries and common arterial trunk
Freire, G. and Miller, M. and Huhta, J.
Cardiology in the Young. 2012; 22(6): 671-676
22 The diagnosis of the fetus with heart disease [El diagnóstico en el feto cardiópata]
Guevara, C.G. and Pedregosa, J.P. and Cazzaniga, M.
Anales de Pediatria Continuada. 2012; 10(6): 324-333
23 Detection of congenital heart defects throughout pregnancy; Impact of first trimester ultrasound screening for cardiac abnormalities
Eleftheriades, M. and Tsapakis, E. and Sotiriadis, A. and Manolakos, E. and Hassiakos, D. and Botsis, D.
Journal of Maternal-Fetal and Neonatal Medicine. 2012; 25(12): 2546-2550
24 Foetal echocardiography of transposition of the great arteries and common arterial trunk
Grace Freire,Michelle Miller,James Huhta
Cardiology in the Young. 2012; 22(06): 671
[Pubmed] | [DOI]
25 El diagnóstico en el feto cardiópata
Carlos García Guevara,Javier Pérez Pedregosa,Mario Cazzaniga
Anales de Pediatría Continuada. 2012; 10(6): 324
[Pubmed] | [DOI]
26 Impact of prenatal diagnosis on outcome of pulmonary atresia and intact ventricular septum
Giulia Tuo, Paolo Volpe, Sara Bondanza, Nicola Volpe, Margherita Serafino, Valentina De Robertis, Lucio Zannini, Giacomo Pongiglione, Maria Grazia Calevo, Maurizio Marasini
Journal of Maternal-Fetal and Neonatal Medicine. 2012; 25(6): 669
[VIEW] | [DOI]
27 Detection of congenital heart defects throughout pregnancy; impact of first trimester ultrasound screening for cardiac abnormalities
Makarios Eleftheriades,Elsa Tsapakis,Alexandros Sotiriadis,Emmanouil Manolakos,Demetrios Hassiakos,Demetrios Botsis
Journal of Maternal-Fetal and Neonatal Medicine. 2012; 25(12): 2546
[Pubmed] | [DOI]
28 Screening for congenital heart defects in the Moravian-Silesian Region: past and present
Jan Pavlícek, TomᚠGruszka
Cor et Vasa. 2011; 53(12): 703
[Pubmed] | [DOI]
29 Antenatal imaging: does the postnatal impact justify the effort?
Laurent Garel
Pediatric Radiology. 2011; 41(4): 417
[VIEW] | [DOI]
30 Screening for congenital heart defects in the Moravian-Silesian Region: Past and present [Vývoj a stav prenatálního screeningu vrozených srdečních vad v Moravskoslezském kraji]
Pavlíček, J. and Gruszka, T.
Cor et Vasa. 2011; 53(12): 703-711
31 Fetal cardiology | [Cardiología fetal]
Álvarez Martín, T., Maroto Álvaro, E.
Revista Espanola de Pediatria. 2011; 67(3): 127-135
32 Advances and clinical application of fetal echocardiography
Zhang, Y.-Q.
Journal of Shanghai Jiaotong University (Medical Science). 2011; 31(9): 1235-1239
33 Fetal echocardiography in Lithuania: traditions, significance and problems
Ramune Vankeviciene
Acta medica Lituanica. 2010; 17(3): 116
[Pubmed] | [DOI]