Performance of Early Fetal Echocardiography: An Expert Statement from the Fetal Heart Society.

Congenital heart defects (CHD) are the most common lethal congenital anomalies. Fetal echocardiography is the mainstay for the diagnosis and subsequent serial assessment of fetal cardiovascular disease. Ideal timing for fetal echocardiography has traditionally been cited as between 18-22 weeks gestation, though many centers now offer evaluations at 16 weeks gestation and onward. Improved ultrasound resolution and a better understanding of early fetal cardiac development have enabled experienced specialists to diagnose major CHD as early as 11-15 weeks gestation. An earlier diagnosis of CHD allows families to make time-sensitive decisions regarding the continuation of pregnancy while also providing time for additional prenatal testing and thoughtful perinatal planning. Reassuring early fetal echocardiography (eFE) can reduce anxiety in families with elevated risk for fetal CHD, such as those with a prior fetus or child with CHD. Given the benefits of early detection, the American Society of Echocardiography's 2023 Guidelines and Recommendations for Performance of the Fetal Echocardiogram included a section on eFE, which reviewed suggested elements, benefits, and limitations. However, there are challenges regarding the technical aspects of imaging a smaller heart as well as prognosticating during the late first and early second trimester. Most pediatric cardiologists have not had specific training in these skills and, therefore, often do not offer fetal echocardiography before 16 weeks gestation. To overcome these challenges, the Program Leaders' Committee of the Fetal Heart Society developed this document, in which we review potential indications, propose an imaging protocol for early transabdominal and adjunct transvaginal (or endo-vaginal) fetal echocardiography, discuss unique findings in early gestation fetal heart morphology and hemodynamics, consider limitations, and discuss important aspects of patient counseling for eFE. Figures and videos of both normal and abnormal eFE are included in the Appendix/Supplementary Media.