Cardiac pacing has an established place in the management of patient with bradyarrhythmias. Besides sick sinus syndrome and atrioventricular conduction disorders, newer indications have emerged for cardiac pacing. Endocardial pacing at the right ventricular (RV) apex is a well-accepted and proven concept. However, it has also been established over time that several functional and mechanical alterations may be induced in the heart in a significant proportion of these patients undergoing pacemaker implantation. Apart from this, structural injury to the heart (e.g. tricuspid valve injury, cardiac perforation) and recurrent pulmonary thromboembolism secondary to multiple pacing leads have also been reported. This chapter covers the RV apical pacing, echocardiography in evaluation of effects of RV pacing on LV function, echocardiography in the evaluation of tricuspid regurgitation following cardiac pacing, echocardiography in the evaluation of mitral regurgitation following cardiac pacing, echocardiography in the diagnosis of cardiac perforation by pacemaker leads, echocardiography in the assessment of pacemaker lead infection (endocarditis) and thrombosis.