How often should echocardiograms be ordered for a patient with a dual-chamber pacemaker (DCP) whose last echocardiogram was in 2017?

Echocardiogram Surveillance for Dual-Chamber Pacemaker Patients

For a patient with a dual-chamber pacemaker whose last echocardiogram was in 2017 (now 8 years ago), an echocardiogram should be ordered immediately if the patient has any change in clinical status, and otherwise should be considered now given the prolonged interval, particularly if there is frequent right ventricular pacing (≥20%).

Risk-Based Surveillance Strategy

High-Risk Patients Requiring Immediate Echocardiography

Patients with dual-chamber pacemakers who have frequent right ventricular pacing (≥20%) are at significant risk for pacing-induced cardiomyopathy (PICM), which occurs in approximately 23% of such patients and can reduce ejection fraction from normal to severely depressed (mean 35%) over 2-3 years 1.

Screen immediately with echocardiography if:

• Paced QRS duration is ≥150 milliseconds (95% sensitive for PICM) 1
• Any new heart failure symptoms or signs have developed 1
• The patient has not had echocardiography for >2-3 years with frequent RV pacing 1

Clinical Status Changes Mandate Immediate Imaging

Order echocardiography urgently if any of the following develop:

• New or worsening dyspnea, fatigue, or exercise intolerance 2
• New heart failure signs (edema, elevated JVP, pulmonary congestion) 2
• New murmur detected on examination 3
• Symptoms suggesting pacemaker syndrome (dizziness, pulsations in neck, dyspnea) 4
• Concerns about ventricular function based on clinical assessment 3

Routine Surveillance in Stable Patients

For Patients Without Structural Heart Disease

If the patient has a dual-chamber pacemaker for isolated conduction disease (complete heart block, sick sinus syndrome) with no known structural heart disease and remains clinically stable:

• No routine annual echocardiograms are required in the absence of clinical status changes 3
• However, given the 8-year gap since 2017, obtaining a baseline echocardiogram now is reasonable to assess for:
  • Development of pacing-induced cardiomyopathy 1
  • Interval development of valvular disease 2
  • Changes in ventricular size or function 2

For Patients With Known Cardiac Conditions

If the patient has underlying structural heart disease, follow disease-specific surveillance intervals 2:

Valvular disease:

• Severe regurgitation or stenosis: annual echocardiography 2
• Moderate disease: every 2 years 2
• Mild disease: every 2-3 years 2

Cardiomyopathy:

• Hypertrophic, dilated, or arrhythmogenic cardiomyopathy: annual echocardiography 2

Prosthetic valves:

• Bioprosthetic valves >5 years post-implant: annual echocardiography 2
• Mechanical valves: no routine annual imaging if baseline normal and clinically stable 2

Practical Approach for This Patient

Immediate Assessment Required

Given the 8-year interval since the last echocardiogram (2017 to 2025):

1. Review pacemaker interrogation data:

   • Determine percentage of ventricular pacing 1
   • Measure paced QRS duration on ECG 1
   • If ≥20% RV pacing and/or QRS ≥150 ms, order echocardiogram immediately 1

2. Assess clinical status:

   • Any new symptoms (dyspnea, fatigue, edema, palpitations) 2
   • Physical examination for new murmurs or heart failure signs 3
   • If any changes present, order echocardiogram immediately 2

3. If clinically stable with minimal RV pacing (<20%):

   • Consider obtaining echocardiogram now given prolonged 8-year interval to establish new baseline 2
   • Then follow routine surveillance based on findings 2

Common Pitfalls to Avoid

• Do not assume stability without pacemaker interrogation data - many patients with PICM are asymptomatic at diagnosis 1
• Do not rely solely on symptoms - 50% of patients with PICM lack heart failure symptoms when echocardiography reveals significant dysfunction 1
• Do not ignore paced QRS duration - this is the strongest predictor of PICM and should guide screening decisions 1
• Do not delay imaging if there is any clinical uncertainty after an 8-year gap, particularly in elderly patients who may have developed interval cardiac disease 2