Before the First Beat: The Vital Role of Cardiology in Fetal Surgery

A fetal cardiologist is a pediatric cardiologist with advanced training in detecting and managing heart conditions before birth. 

When a family meets with our team, they should expect a very patient-centered and family-focused approach to care. This starts with a thorough maternal medical and obstetric history for each mother to determine if there are any general medical problems that may be affecting the pregnancy. 

Then, we’ll complete a fetal echocardiogram, with specialized equipment and techniques to take detailed images of the baby’s heart. If there are any concerns, the specific diagnosis will help guide individualized care plans for each mother and child, including delivery logistics and planning for any potential postnatal cardiac interventions. 
 

What kinds of heart conditions do you most often see before birth?

There’s a wide spectrum of congenital heart disease. Some are minor and resolve on their own—like small atrial or ventricular septal defects (ASD or VSD). Others are more serious, or complex, such as tetralogy of Fallot or transposition of the great arteries, and may require surgery shortly after birth. 

Prenatal diagnosis enables us to counsel families regarding congenital heart disease before the child is even born. This includes explaining the specific diagnosis as well as the care plan to expect after delivery. This helps prepare families, clinically and emotionally, for what lies ahead. Fetal cardiology also plays an important role in detecting and managing fetal arrhythmias as well as monitoring the fetal cardiovascular health in fetuses undergoing interventions at the Fetal Care Center.

 

Two primary areas stand out:

1. Treatment of fetal arrhythmias 
   
   We manage fetal arrhythmias (irregular heartbeat) using transplacental therapy.  If a fetus has a life-threatening arrhythmia:
    
   1. We admit mom to the hospital and administer anti-arrhythmic medications that cross the placenta to correct the baby’s heart rhythm.
   2. This approach requires close coordination between pediatric and adult cardiology, MFM, and OB teams.
   3. Moms typically stay a few days in the hospital. Using this highly coordinated approach, we are able to treat the baby’s arrhythmia effectively while ensuring safety for mother and child.
       

2.     Cardiac evaluation in twin-twin transfusion syndrome (TTTS)
   
   TTTS presents a unique challenge, in which abnormal blood flow between identical twins leads to an unequal distribution of blood and nutrients. This imbalance can cause one twin (the donor twin) to have less blood volume and the other twin (the recipient twin) to have excessive blood volume, potentially leading to serious complications.

   In the recipient twin, we often see cardiac complications: heart enlargement, valve leakage, poor pump function, and fluid buildup around the heart.

   Our fetal echocardiograms are critical in determining the stage of TTTS and deciding when intervention such as laser photocoagulation (typically performed by Dr. Crombleholme) is needed. After this procedure, the heart often shows an impressive ability to recover.
    

Advances in fetal echocardiography have revolutionized our field. Just 15–20 years ago, many serious congenital heart defects (CHDs) went undetected until after birth. Now, we can diagnose most congenital heart disease before birth, allowing us to create an individualized care plan and treatment course for each family.

What should referring clinicians and families know about fetal cardiology?

When families learn they need to meet with a fetal cardiologist, it can often create a lot of worry and anxiety at first, but our role is to provide clarity, compassion, and a personalized roadmap for families facing a diagnosis of congenital heart disease. We want colleagues to know that many forms of CHD have excellent long-term outcomes, and we’re here to support families from diagnosis through delivery and beyond.

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Fetal cardiologists like Dr. Enos play a vital role in fetal care. Their expertise not only shapes surgical decision-making but ensures families receive a coordinated, informed, and compassionate approach to care.