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Fetal echocardiography was introduced to clinical medicine in the early 1980s when the first studies reported its use for evaluation of cardiac arrhythmias as well as basic cardiac anatomy using M-mode, M-mode-directed real-time, and real-time ultrasound.1-29 Although the prenatal diagnosis of congenital heart defects was the goal, a logical approach to the problem was not available until investigators in 1985 suggested the concept of using the four-chamber view as an initial screening tool to detect fetuses at risk for structural malformations.30-36 After DeVore et al introduced the inclusion of color Doppler in the screening protocol to improve detection of congenital heart defects, other investigators reported similar results.32,37-44 While using the four-chamber view to screen for congenital heart disease seemed promising, it met with varied success.1,32,45-49 One of the main reasons was that not all major heart defects altered the size, shape, or anatomy of the structures identified in the four-chamber view.47
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To overcome the limitations of the four-chamber view screening examination, the the American College of Obstetricians and Gynecologists (ACOG), the American Institute of Ultrasound in Medicine (AIUM), and the American College of Radiology (ACR), published between 2003 and 2007 recommendations stating that an attempt, if “technically feasible,” should be made to examine the outflow tracts of the fetal heart during the screening examination.50-53 In 2013, the AIUM, ACOG, the ACR, and the Society of Radiologists in Ultrasound jointly published recommendations that the outflow tracts should be evaluated in all fetuses undergoing second and third trimester ultrasound, while ISUOG in 2010 stated that it was still optional (Table 47-1).54,55
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