Using present-day high-resolution ultrasound scanners, it is possible to visualize and study the heart during the different stages of fetal growth in patients at risk of some forms of congenital heart disease. Detailed anatomical knowledge of cardiac structures combined with the accurate interpretation of echocardiographic images made during fetal development enable early diagnosis of particular forms of congenital disease that have serious pathophysiologic consequences. In addition, it also becomes possible to select the most appropriate nature and timing of delivery, and to organize early treatment for the newborn. Any decision taken on how to treat a fetus in which a congenital cardiac abnormality has been identified must be taken by a multidisciplinary team. This will help in coordinating the measures that must be taken after delivery and, in the near future, in implementing intrauterine surgery. Fetal echocardiography is establishing itself as a valuable tool in the management of the various types of congenital malformation, which together comprise the main cause of death among the newborn. In addition, the technique can be used to confirm and broaden our knowledge of the natural history of cardiac malformations, which are the most common congenital malformations. There is no doubt that the application and understanding of this imaging technology will increase the survival rate of newborns with specific congenital cardiac abnormalities, and will have a significant impact on long-term clinical outcome and quality of life in these patients.