How often do you have Echocardiograms

Depends on your primary heart diagnosis and your symptoms

by crustyg - 2020-11-23 07:40:33

If you are feeling well and your underlying heart rhythm disorder is well understood, there should be no need for routine echoes at all.

On the other hand, if you are fairly heavily paced in your RV and you have an RV-apical lead, I think there's an argument for an annual %LVEF measurement - but many would disagree.  IMHO the evidence is accumulating that long-term RV-apical pacing results in LV remodelling (=>reduced %LVEF) in a worrying percentage of patients, and leaving it until the patient complains of breathlessness before considering (hopefully) restorative CRT-P is not best practice.

From the health provider's perspective (and they *are* humans after all), they are keen to minimise echoes at present - it's really up-close-and-personal and while, in general, young healthcare providers are unlikely to die from Covid-19, there is a much greater awareness of the possible damage of 'Long Covid' which can really mess up a young person - rare, but real.

HTH.

Usually every two years

by Gemita - 2020-11-23 08:30:28

but I agree totally with crustyg, it will depend on your symptoms and heart condition being treated.  If you have worsening symptoms, or a falling ejection fraction, enlarged chambers, leaky heart valves for example, they may wish to keep a closer eye on you and monitor you more frequently.  It will also depend on other health conditions present too and whether these would be likely to impact on your heart health.  It will be so individual PacedNRunning.

As an example when I first saw a cardiologist about 20 years ago for a significant heart murmur, echocardiogram found mild to moderate leaky valves (3 in number) and my cardiologist said I would need an echocardiogram every two years.  When 5 years later they found my leaky valves had not progressed, they said further echocardiography was not needed.  Now with fairly significant atrial arrhythmias, it is still only approx every 2 years, although my EP is keeping a close eye on me and is always happy to recommend further imaging if there are any concerns.

By the way your ejection fraction looks great !!  My EF is at least 10% less than that and probably lower now.

RV-apical pacing results in LV remodelling (=>reduced %LVEF)

by quikjraw - 2020-11-23 08:58:46

Hi Crustyg

Just picking up on your point. During my early journey on my learning curve one of my underlying concerns is pacing when pacing is not needed.

I think what you mention is elabroated on in the paper seen in the link below.

https://www.uscjournal.com/articles/minimizing-unnecessary-right

Have you discussed this paper on the forum before?

It seems to suggest that there is a possible compromise in some patients with a pacing mode called AAIsafeR. 

In your opinion do you think this is something that could minimise the effects of a long term reduction in Left Ventricular efficiency in certain patients?

echo

by Tracey_E - 2020-11-23 11:59:50

When I was in my 20's and 30's, just had an echo if something was going on. Then we started doing them every other year, now once a year. I like knowing that we are keeping an eye on my EF. So far, so good. 

I had an echo since covid. I think there was a person under all the PPE.

Quickjraw

by crustyg - 2020-11-23 14:26:33

Hi: I don't think we've reviewed that paper specifically, and I'm not a leading expert in this area.

IMHO, in a few years time we will regard anything less than a His-bundle pacing wire placement for those where it's possible/appropriate as the gold standard for RV pacing.  It does seem to be very uncommon for folk with healthy heart muscle (e.g. CCHB) to run into problems with long-term RV-apical pacing, whereas it's not uncommon for folk with a damaged myocardium to suffer from this type of pacing.

AAISafe: I agree, my dual-channel, dual-lead PM has a clever pacing mode that attempts to reduce RV-pacing to an absolute minimum, but still managed to pace my RV 1% of the time, despite there being zero clinical need for this.  My RV lead is now switched off.

All of the major PM vendors are trying to reduce RV-pacing where it's not essential, but at the same time, they do make money out of selling their CRT-P devices.  The issue is really where the RV lead is placed: RV-apex, quick, easy, reliable.  His-bundle: difficult, time-consuming, and for those who like to worry about this stuff, lots of X-radiation from the fluoroscope to help show where the leads are (but actually the doses are *tiny* - a CT-scan is a much bigger dose).  Time in the cardiac suite is really important - fewer patients per day, massive increase in cost-per-procedure.

Echo

by AgentX86 - 2020-11-23 15:37:07

I get an echo once a year (next week, in fact).  I'm V-only paced  with a CRT pacemaker (VVIRV), so paced 100% in the ventricle (no atrial lead at all).

Thanks all!

by PacedNRunning - 2020-11-23 18:52:07

Thanks for all replies. I like Tracey E's response. Your active like me and hope that keeps my heart strong to avoid HF from chronic RV pacing. 

Crusty - I do pace 100% RV but my lead is not apical but Septal placement.  Supposedly better than apical but not equal to HIS bundle. My doctor debated a HIS bundle placement for me at the time of implant but opted out because he didn't think I would pace much. Wrong. Wrong prediction. I didn't pace much the first 18 mos of having my PM.  It varied 18-50% of the time.  Since Feb it significantly increased to 100% by May. Block just got worse and worse.  I just feel maybe waiting until next summer, this will give a full year of 100% paced to give a better picture. I just feel doing it now and not again until next December is too long. My EF may be good now but maybe one year later it tanks but we don't do another echo until December. I'm just thinking out loud.  

to answer QuickJraw- there are algorithms that minimize pacing in the RV lead for those that either have intermittent block or don't have block. Studies show greater than 40% RV pacing increasing the risk of HF due to chronic RV pacing. Unfortunately, you can't avoid it in people with heart block.  I'm not sure if HIS bundle is the answer. It's still too knew to really say if it's better than CRT therapy.  A lot of issue with HIS bundle. We tried limiting my pacing which work great when I had intermittent block but I no longer have intermittent block.  

my ep's thoughts

by Tracey_E - 2020-11-24 11:18:13

My ep is an adult congenital specialist, the clinic is in a large research hospital and sees literally hundreds of people like me who are paced for a lifetime. We had a long talk about EF and CRT. In his experience, he said if EF holds steady for 5 years of RV pacing, he almost never sees a drop after that. That really surprised me. I thought that was my biggest long term risk but he said he'd be surprised if it ever became a problem. I've paced every beat for 25+ years and my EF is still in the neighborhood of 55. As for CRT, he said they're great once EF drops but he hasn't seen evidence that it will prevent it so he doesn't recommend until needed.

My EP's thoughts are largely the same

by Gemita - 2020-11-24 13:28:03

My EP in a large London Teaching Hospital, a very conservative doctor when it comes to any intervention said much the same about heavy RV pacing (which I don't have at present).  He feels that if HF symptoms are going to appear from RV pacing they can appear quite rapidly say within months and certainly by year 4-5, but if EF holds firm during this period then this is a very good sign indeed.  Only time will tell.   My EP also believes there is absolutely no benefit in using CRT until it is needed.  

PacedNRunning, I too am right septal paced which I believe is somewhat superior to right apical pacing, although again, only time will tell.  We still have a long way to go to perfect a more physiological approach.  We are not there yet with HIS pacing are we

Thanks Tracey and Gemita

by PacedNRunning - 2020-11-25 02:14:21

Such great info! So reassuring.  I'm not sure how much my doctor knows about statistics and effects of chronic RV pacing.  He just said he's never had anyone in his practice with this issue. Or should I say he says it's rare and has only happened a hand full of times. But most people are old in his practice.  All reassuring! I appreciate both of your feedback and knowledge 

expertise

by Tracey_E - 2020-11-25 07:11:18

It's uncommon to find an ep with a lot of experience with long term pacing, with more than a few younger patients, but they are out there. I had a cardiologist for 20 years that I adored and I don't hesitate to recommend him to friends looking for a cardiologist. He's wonderful, but once I turned 50 I didn't feel he was the right doctor for me any longer. For years, I was his youngest paced patient. He eventually got two other younger paced patients but no one else congenital. He was great about doing research but had no first hand experience with very long term pacing. When I first learned about adult congenital clinics, I only intended to go for a consult. I never planned to change my care, but seeing someone with so much experience with others like me was night and day! The old one would say I'm doing great. The new one tells me how to continue to feel great and he's much more versed on what my long term risks/prospects are. 

Certainly is reassuring

by quikjraw - 2020-11-25 07:12:09

That certainly is reassuring and very interesting thanks Tracey. I hope I am able to speak to my EP about things like you clearly do.

Now I know what LVEF is! I have also found it on my discharge sheet and it was 61%.

Not sure if it would have been done on my echo or MRI but at least I have a baseline.