Ultrasound Obstet Gynecol 2021; 57: 38–42
Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.23551
Opinion
Evolution of fetal cardiac imaging
in 30 years of ISUOG
R. CHAOUI
Center for Prenatal Diagnosis and Human Genetics, Berlin,
Germany
(e-mail: chaoui@feindiagnostik.de)
My personal journey with ISUOG and UOG
Although, theoretically, history is objective with clear
landmarks, the telling of historical events is invariably
distorted by the perception of the observer. I should
emphasize at the outset that the following account, which
reflects mainly my personal experience and contribution
to ISUOG and the White Journal, is biased. I apologize
for this and also that space constraints prevent me from
citing, thanking and honoring the many individuals who
I have met over the years and who have contributed
tremendously to the development of ultrasound in fetal
medicine.
When I started, in 1986, to perform fetal ultrasound, the
only learning resources available were a handful of books
and a few articles scattered amongst numerous journals.
It is to the credit of Stuart Campbell, and a few fellow
pioneers, that he agreed to found a platform dedicated
to ultrasound in obstetrics and gynecology. As he told
me later, choosing the American spelling ‘gynecology’
instead of the British ‘gynaecology’ was intended to
show openness to the world and to attract American and
other international scientists. The new platform had three
components, namely, a new global Society, ISUOG, an
annual world congress where specialists and enthusiasts
could meet and exchange experiences, and a new journal,
Ultrasound in Obstetrics & Gynecology (UOG), that
would be accessible to prospective authors based on
the quality of their research and images rather than on
their country of origin. A bonus was that publication of
color images was, from the very start, free of charge.
From my first ISUOG World Congress – the second,
organized by Manfred Hansmann in 1992, in Bonn,
Germany – I felt like a member of a family, even though
I was to meet famous people, such as Stuart Campbell,
Kypros Nicolaides, Mark Evans, Sturla Eik-Nes, Juriy
Wladimiroff and others, and be inspired by them. I made
my way in the ISUOG community, becoming a member
of both the Editorial Board of UOG (1998–2005) and the
Board of ISUOG (2004–2013). During these years, I made
many new friends and worked with many extraordinary
ultrasound teachers, including Gianluigi Pilu, Roberto
Romero, the late Philippe Jeanty, Dario Paladini, Yves
Ville and Alfred Abuhamad. Alfred and I developed
© 2021 International Society of Ultrasound in Obstetrics and Gynecology
a long-lasting friendship and close collaboration that
crystallized in the publication of three books. In 2009, I
was elected Chair of the Education Committee of ISUOG,
which took me all over the world, from India to Brazil,
from Egypt to Singapore and Moscow, to disseminate
ultrasound knowledge and help achieve ISUOG’s mission.
I also had my fair share of UOG publications. What an
honor it was when, almost 30 years later, in 2018, I was
presented with the Stuart Campbell Award for Education
and, together with Kurt Hecher, in 2019, invited to host
the 29th ISUOG World Congress in Berlin.
Color and spectral Doppler
The ultrasound unit in East Berlin, in which I started
my residency specializing in ObGyn in 1986, did not
have sophisticated equipment, but I was lucky to have
the chance, sporadically, to scan my patients in the
departments of radiology and cardiology. From early on,
I could scan for a few hours each week on a brand-new
machine with color Doppler capability and taught myself
how to use this new technology with which very few
had experience. In Paris, in 1989, at a fetal cardiology
symposium, I met pioneering experts such as Lindsey
Allan, Laurent Fermont, Greg DeVore and Jim Huhta,
and heard them report on the novel application of color
Doppler in imaging of the fetal heart. I knew that I
was on the right track and could see how, in addition
to elucidating numerous known anomalies of the fetal
heart, technologies such as pulsed and color Doppler
could be key to new research and knowledge. Color
Doppler has evolved enormously since that time, as shown
in Figure 1, which illustrates imaging of hypoplastic left
heart syndrome from the 1980s to today.
I was fascinated by the detail that could be revealed
by fine-tuning color Doppler. With this approach, it
was possible to visualize, in some circumstances, the
fetal coronary arteries and, in an international meeting
organized by Ulrich Gembruch in Lübeck, Germany, in
1995, I gave an overview of the coronary arterial system,
its regulation and visualization on ultrasound. I was then
approached by Stuart Campbell to write an editorial for
UOG1 , which turned out to be my first paper in the
White Journal! My experience with tiny vessels extended
to the pulmonary and venous systems and later, focusing
on miniscule vessels around the heart, I came across an
aberrant right subclavian artery (ARSA) in a fetus with
Down syndrome, which ultimately led to the discovery
of a new sign2,3 . ARSA has since been adopted as a soft
marker of aneuploidy.
From the mid 90s, I started to focus on new,
high-resolution imaging tools. Along with my partners,
Karim Kalache and Kai-Sven Heling, I worked with
new technologies, including color Doppler4 , power
OPINION
Opinion
Figure 1 Evolution of color Doppler resolution from 1988 until now: visualization of hypoplastic left heart syndrome. (a) My first case using
color Doppler, in 1988, and (b–d) subsequent examples from 1996 (b), 2008 (c) and 2020 (d).
Doppler5 , dynamic or HD flow and three-dimensional
(3D) ultrasound6,7 , to examine the fetal thymus8,9 ,
intracranial translucency10 and maxillary gap11 , among
other signs and structures. Most of these novel findings
were published in UOG and some of the images even
found their way onto the cover of the Journal3,12–15 .
Over the last 30 years, there have been incredible
advances in fetal cardiac imaging. The increased quality
and sensitivity of color Doppler imaging has opened
the door to fetal echocardiographic examination at
11–13 weeks’ gestation. Detection of cardiac anomalies
in many centers has shifted into the first trimester
and, today, the heart can be assessed even earlier
than 11 weeks. The evolution of technology has not
only improved the resolution of grayscale imaging
and color Doppler, but also enriched the arsenal of
fetal cardiology with tools such as power Doppler,
sensitive bidirectional power Doppler, M-mode, color
Doppler M-mode, anatomical M-mode, spatiotemporal
image correlation (STIC) M-mode, spectral flow Doppler,
color and spectral tissue Doppler, speckle tracking, 3D
ultrasound, STIC and 4D ultrasound, cardiac strain
evaluation and magnetic resonance imaging (MRI) of
the fetal heart. The Society has played a huge part in
the progression of cardiac imaging, with many articles
© 2021 International Society of Ultrasound in Obstetrics and Gynecology
39
published over the years, including ISUOG Guidelines on
cardiac screening16 which have been adapted in many
countries as standards to be followed. Figure 2 shows
some of the techniques available today.
Fetal cardiac examination beyond detecting anomalies
In the mid 80s, fetal echocardiographic examination
was introduced by, among others, pediatric cardiologists,
such as Lindsey Allan, Laurent Fermont and Charlie
Kleinman, with the main aim of detecting or ruling out, in
high-risk pregnancies, complex cardiac abnormality that
would impact the neonatal period. With the increasingly
widespread use of spectral and color Doppler ultrasound
in many perinatology units in the early 90s, many
centers started to integrate cardiac examination into the
evaluation of pregnancies with suspected fetal or maternal
disease or risk factors. Today, a fetal echocardiographic
examination may be performed for many reasons,
including as part of genetic screening (to detect conditions
such as echogenic focus, ARSA, pericardial effusion,
linear insertion of the atrioventricular valves, small
thymus), in the workup of severe growth restriction
(assessment of cardiac function, pulmonary vascular
Doppler), in assessing fetal anemia (in Rhesus disease,
Ultrasound Obstet Gynecol 2021; 57: 38–42.
40 Chaoui

Figure 2 Examples of various tools for fetal heart examination. Fetal heart is generally examined with grayscale 2D ultrasound (a), but, in
last 30 years, numerous imaging tools have been introduced to provide additional information on, among other things, flow events and
function. These include: (b) color Doppler, (c) bidirectional sensitive power Doppler, (d) spectral Doppler of valves and tissue, (e) M-mode
of valves and cardiac walls, (f) M-mode in combination with color Doppler, (g) 3D/4D rendering of intracardiac flow using spatiotemporal
image correlation (STIC), (h) assessment of cardiac wall movements with speckle tracking and (i) magnetic resonance imaging (MRI).

parvovirus infection, monochorionic twins) and volume
overload (in recipient in twin–twin transfusion syndrome,
arteriovenous fistula), in evaluating maternal disease (e.g.
diabetes mellitus, systemic lupus erythematosus) and
effects of maternal drug intake (e.g. indomethacin) and
in the monitoring of fetal therapy (arrhythmia, cardiac
intervention, intrauterine diaphragmatic hernia surgery).
Knowledge of the assessment of cardiac function has
expanded dramatically in recent years.
Three-dimensional ultrasound, from the face to the
heart
Thirty years ago, the first steps in the journey of 3D
ultrasound were taken, with offline reconstruction of a
fetal face following acquisition of adjacent slices of the
regions of interest with a special mechanical transducer17 .
Another approach was proposed soon after, in the mid
90s, with a sensor attached to a regular transducer and the
data being analyzed by remote computer after free-hand
acquisition. Initially, the calculation of data took hours,
and later minutes. With advances in computer science
in the late 90s and, in particular, with the advent of
rapid processors, the time required for the calculation
was reduced to a matter of seconds. The combination of
3D technology with grayscale and color or power Doppler
opened a new door to assessment of the cardiovascular
system.
The invention of STIC and the development of matrix
transducers enabled the first steps to be taken into the new
field of 3D cardiac imaging. It was again at the ISUOG
World Congresses and in UOG that new data were pre-
sented and published18 . The modern approach, inspired
largely by ultrasound specialist and artist, Bernard Benoit,
considers 3D not as a gimmick, to view the baby’s face,
but as technology that enables the acquisition and storage
of information in the form of raw volume data for later
offline analysis. The acquisition of a fetal heart volume
can be achieved today as static 3D, or with STIC or live

© 2021 International Society of Ultrasound in Obstetrics and Gynecology Ultrasound Obstet Gynecol 2021; 57: 38–42.
Opinion 41

Figure 3 Variation on a theme of three dimensions (3D): examples in single fetus with diagnosis of transposition of the great arteries,
showing different 3D displays that may be applied to visualize abnormal course of great vessels: (a) tomography multiplanar mode,
(b) orthogonal biplane mode, (c) OmniView combined with color Doppler, (d) surface rendering mode, (e) inversion mode, (f) minimum
mode, (g) volume contrast imaging (VCI) of A-plane in combination with inversion mode, (h) color Doppler with glass-body mode using
spatiotemporal image correlation (STIC) and (i) STIC with transparent silhouette mode and color Doppler.

4D with an electronic probe, with the display of informa-
tion varying depending on the acquisition technique and
the combination with grayscale or color Doppler19 . The
tools used for the different displays resemble smartphone
or tablet applications and enable different extraction and
use of information. Figure 3 illustrates, in a fetus with
a diagnosis of transposition of the great arteries, how
data may be variously displayed in different modes. It
is likely that the huge potential of 3D technology will
lie in the ability to standardize the cardiac volume, with
automatic reconstruction of the typical planes, pioneered
by Alfred Abuhamad and his team20 and examined by
others since21 . In an era in which artificial intelligence
(AI) has started to infiltrate medicine, volume ultrasound
is potentially the best enabler of its application in fetal
imaging. The background assessment of structures during
scanning22 or the offline analysis of raw data enables
the comparison of acquired images with ‘learned’ images
of normal and abnormal cases. Recent use of MRI
technology in the fetal heart, alone or in combination
with ultrasound as fusion technology, is likely to allow
creation of new data acquisition platforms for learning
machines. Trying to resist automation and AI in medicine
may sound heroic today, but will be, in the end, as naive as
was fighting against the Internet and digitalization at the
beginning of the millennium. It is our role, as specialists,
to define how AI can improve our daily work, helping us
to acquire the best images and achieve accurate diagnosis.
UOG will, as always, be the best venue for documenting
the resultant innovations and exchanging opinions.
Conclusion
Since its conception, ISUOG has stood witness, through
its congresses and members’ contributions, to the many
outstanding developments in fetal ultrasound. UOG has
become the main forum in which, in thousands of articles,
these innovations are documented. I can only conclude by
saying ‘Happy Birthday, ISUOG and UOG’, and thanking
you for all the fulfilling years. I look forward with great
excitement and optimism to the 40th anniversary and
beyond!
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