Patel S, McBrien A, Michelfelder E, Kavanaugh-McHugh A, Samples S, Laternser C, Hornberger L, Moon-Grady A, Srivastava S, Shuplock J. Current Trends in Fetal Cardiology: Results from an International Benchmarking Survey of Fetal Cardiac Programs Through the Fetal Heart Society Research Collaborative. Pediatric Cardiology. 2026;47:1218-1228. doi:10.1007/s00246-025-03895-5.
PubMed: https://pubmed.ncbi.nlm.nih.gov/40439930/
Take-Home Points
- This international benchmarking survey evaluated 95 fetal cardiology programs, providing the first large-scale description of fetal cardiac practice patterns, staffing, resources, and quality initiatives.
- The median annual fetal echocardiography volume was 1,000 studies per program, with a median of five fetal cardiologists and five fetal cardiac sonographers per center.
- Most programs (79%) employed a dedicated fetal cardiac coordinator, and programs with coordinators were significantly more likely to maintain formal quality-improvement (QI) processes.
- Only 46 of 95 programs maintained formal fetal cardiology quality-improvement initiatives, and fewer than one-quarter participated in national-level QI collaboratives.
- Availability of neonatal, maternal-fetal medicine, genetics, and social work services was widespread, but access to psychology (38%) and psychiatry (16%) services was notably limited.
- The survey identifies significant variability in fetal cardiology infrastructure and highlights opportunities to improve standardized care pathways, quality initiatives, and family support services.
Commentary from Dr. Varun Aggarwal (Wilmington, DE, USA), editor-in-chief of Congenital Heart Disease Journal Watch:
The maturation of fetal cardiology has been one of the most important developments in congenital heart disease over the last three decades. What began as a specialized diagnostic service has evolved into a distinct discipline that influences virtually every phase of congenital heart care, from prenatal diagnosis to delivery planning, neonatal stabilization, surgical timing, neurodevelopmental outcomes, and family counseling.
Yet despite its rapid growth, surprisingly little has been known about how fetal cardiology programs function.
The survey by Patel and colleagues, conducted through the Fetal Heart Society Research Collaborative, provides the first comprehensive benchmarking assessment of contemporary fetal cardiology practice. In doing so, it offers a fascinating snapshot of a subspecialty that has matured rapidly but remains remarkably heterogeneous.
Perhaps the most striking observation is simply the scale of modern fetal cardiology. The median participating program performed approximately 1,000 fetal echocardiograms annually and employed five fetal cardiologists and five sonographers dedicated to fetal imaging. These numbers highlight how dramatically prenatal cardiovascular medicine has expanded beyond its early roots as an ancillary imaging service. Today, many large congenital heart centers operate highly specialized fetal cardiovascular programs functioning almost as independent service lines.
Importantly, the survey reinforces that fetal cardiology has become much more than imaging.
Modern fetal heart programs increasingly coordinate multidisciplinary prenatal care involving maternal-fetal medicine, neonatology, genetics, cardiac surgery, intensive care, transplant services, electrophysiology, and palliative care. This evolution reflects an important conceptual shift: prenatal diagnosis is no longer merely about identifying anatomy. Instead, it has become the starting point for comprehensive perinatal planning.
For clinicians caring for patients with complex congenital heart disease, the benefits of this approach are substantial. Prenatal diagnosis facilitates delivery planning, immediate access to specialized neonatal care, optimization of postnatal interventions, and reduction of preventable physiologic deterioration. Increasingly, fetal cardiologists function as coordinators of these complex pathways.
One of the most valuable contributions of the study is its detailed examination of program infrastructure.
The fetal cardiac coordinator emerged as a particularly important resource. Programs employing dedicated coordinators were significantly more likely to maintain quality-improvement initiatives and structured databases. This finding will resonate with many fetal cardiology leaders. As programs expand, effective coordination becomes essential to manage referrals, counseling, delivery planning, follow-up, communication between specialties, and data collection. The survey suggests that coordinators are no longer ancillary personnel but rather core members of successful fetal heart programs.
The quality-improvement data are perhaps the most revealing portion of the report.
Although almost 90% of programs-maintained accreditation through recognized organizations, fewer than half reported formal fetal cardiology quality-improvement programs. Even fewer participated in national collaborative quality initiatives. Given the increasing complexity of fetal cardiac care, this finding is notable. Prenatal diagnosis accuracy, image quality, counseling effectiveness, delivery planning, and neonatal outcomes are all measurable processes that could potentially benefit from systematic quality oversight.
The barriers identified are familiar to anyone involved in congenital quality initiatives: limited personnel, inadequate institutional support, insufficient database infrastructure, and restricted funding. Interestingly, larger-volume programs were more likely to maintain formal quality structures, suggesting that resource availability remains a major determinant of program development.
The survey also offers insight into evolving fetal imaging practices.
More than half of responding programs now perform early gestation fetal echocardiography before 16 weeks, while one-third utilize acute maternal hyperoxygenation testing. These findings suggest increasing adoption of advanced diagnostic techniques that until recently were available only at highly specialized centers. As evidence supporting such approaches grows, they may become increasingly integrated into standard fetal cardiac evaluation.
The data regarding fetal intervention are equally noteworthy. Although only a minority of programs perform fetal cardiac interventions, several centers reported offering fetal aortic valvuloplasty, atrial septal interventions, and pulmonary valvuloplasty. While these procedures remain technically challenging and highly specialized, their continued adoption reflects the expanding therapeutic ambitions of fetal cardiovascular medicine.
Yet perhaps the most important finding in the entire survey relates not to imaging, intervention, or infrastructure, but to mental health.
While genetics, maternal-fetal medicine, neonatology, social work, and cardiac surgery services were widely available, psychology and psychiatry support were strikingly uncommon. Only 38% of programs reported access to psychology services, and only 16% had psychiatric resources available.
This gap deserves serious attention.
A prenatal diagnosis of congenital heart disease is often one of the most emotionally stressful events a family experiences. Multiple studies have demonstrated significant parental anxiety, uncertainty, depression, and psychological distress following fetal CHD diagnosis. Yet the survey demonstrates that mental health support remains among the least accessible aspects of multidisciplinary fetal care.
As fetal cardiology continues to mature, expanding psychological support may be one of the most impactful opportunities for program development.
The findings also highlight substantial variation in delivery planning practices. Some centers maintain integrated maternal and pediatric cardiac services within a single institution, whereas others require neonatal transport after delivery. Likewise, use of formal Level-of-Care stratification systems and delivery algorithms varied considerably. These differences likely reflect local resources but may also contribute to variation in patient outcomes.
Ultimately, the strength of this study lies in its ability to define the current state of the field. Benchmarking surveys rarely generate headlines, but they often provide the foundation upon which future improvements are built. Programs cannot improve what they cannot measure, and fetal cardiology has lacked these comparative data until now.
The survey portrays a subspecialty that is thriving, increasingly sophisticated, and deeply integrated into congenital heart care. At the same time, it identifies important opportunities for growth in quality improvement, multidisciplinary integration, standardized delivery planning, and parental mental health support.
Clinical Perspective
Contemporary fetal cardiology programs are high-volume, multidisciplinary services that play a central role in prenatal diagnosis and perinatal management of congenital heart disease. Dedicated fetal cardiac coordinators, structured databases, and formal quality-improvement initiatives appear to be key features of more mature programs. Significant opportunities remain to expand mental health support, standardize quality metrics, and improve participation in collaborative quality-improvement networks.
