Cardiac patients of all ages were managed in the past by internists who specialized in cardiology. During the past 50 years, the medical field has witnessed great strides in the management of congenital heart disease, and thus pediatric cardiology has become a subspecialty in many countries. This review article focuses on the advances in fetal cardiac interventions (FCI) since its inception by our group in 1975. Three major modes of FCI have evolved during the past 42 years: pharmacologic, closed FCI, and open FCI. All treatments require a careful approach by the heart team and are reserved for severe fetal cardiac conditions. They call for prenatal intervention in view of the severity and progressive nature of the diseases that are associated with high fetal morbidity and mortality if left untreated. The well-established pharmacologic FCI approach includes several new and effective agents with recommendations often varying between class I and class IIa and IIb. The advances in prenatal echocardiographic imaging and color flow Doppler has given an impetus to the development of the other FCI modes; however, the need for uterine incision and fetal cardiac bypass in the open technique have limited its advance. Long-term outcomes are still unknown and definite conclusions as to the efficacy and safety of FCI need further investigation, including multicenter trials with long-term data.