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The five strategies were: (1) no follow\u2010up ultrasound (US) examination but direct referral to fetal echocardiography (FE); (2) one follow\u2010up US, then FE if fetal cardiac views were still suboptimal; (3) up to two follow\u2010up US, then FE if fetal cardiac views were still suboptimal; (4) one follow\u2010up US and no FE; and (5) up to two follow\u2010up US and no FE. The models were designed to identify fetuses with major CHD in a theoretical cohort of 4\u2009000\u2009000 births in the USA. Outcomes related to neonatal mortality and neurodevelopmental disability were evaluated. A cost\u2010effectiveness willingness\u2010to\u2010pay threshold was set at US$100\u2009000 per quality\u2010adjusted life year (QALY). Base\u2010case and sensitivity analysis and Monte\u2010Carlo simulation were performed.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>In our base\u2010case models for all body mass index (BMI) groups, no follow\u2010up US, but direct referral to FE led to the best outcomes, detecting 7%, 25% and 82% more fetuses with CHD in non\u2010obese, obese and Class\u2010III\u2010obese women, respectively, compared with the baseline strategy of one follow\u2010up US and no FE. However, no follow\u2010up US, but direct referral to FE was above the US$100\u2009000\/QALY threshold and therefore not cost\u2010effective. The cost\u2010effective strategy for all BMI groups was one follow\u2010up US and no FE. Both up to two follow\u2010up US with no FE and up to two follow\u2010up US with FE were dominated (being more costly and less effective), while one follow\u2010up US with FE was over the cost\u2010effectiveness threshold. One follow\u2010up US and no FE was the optimal strategy in 97%, 93% and 86% of trials in Monte\u2010Carlo simulation for non\u2010obese, obese and Class\u2010III\u2010obese models, respectively.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>For both non\u2010obese and obese women with incomplete fetal cardiac screening, the optimal CHD follow\u2010up screening strategy is no further US and immediate referral to FE; however, this strategy is not cost\u2010effective. Considering costs, one follow\u2010up US and no FE is the preferred strategy. For both obese and non\u2010obese women, Monte\u2010Carlo simulations showed clearly that one follow\u2010up US and no FE was the optimal strategy. Both non\u2010obese and obese women with initial incomplete cardiac screening examination should therefore be offered one follow\u2010up US. Copyright \u00a9 2019 ISUOG. 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