BackgroundPacing the right ventricle is established practice, but there remains controversy as to the optimal site to preserve hemodynamic function.AimsTo evaluate clinical and hemodynamic differences between apical and septal pacing in pacemaker-dependent patients.MethodsPatients receiving their first pacemaker for advanced atrioventricular block, with the atria in sinus rhythm, were randomized to receive apical (Group A) or septal (Group S) ventricular leads. After implant, with the device programmed VVI 70 beats/min fixed rate, patients underwent a 6-minute walk test and a transthoracic echocardiogram. Then, DDDR was programmed at nominal settings. The same tests were performed at 6 months and 12 months follow-up. If ventricular pacing was less than 98%, the patient was excluded.ResultsA total of 142 patients were included in the study. During the study year, 71 (50%) were excluded for not fulfilling the condition of 98% ventricular pacing. Groups A and S had 34 and 37 patients, respectively. Age and gender were similar in the groups. At implant, QRS duration was significantly greater in Group A (158 ms) than Group S (146 ms; P = 0.018), and the QRS axis was different: –74.5° in Group A and 1° in Group S (P < 0.001). At 1 year, the 6-minute walk improved significantly in both groups: Group A 15% (P = 0.048) and Group S 24% (P = 0.001). Left ventricular ejection fraction (LVEF) increased from 0.57 to 0.61 (P = 0.008) in Group S, without significant change in Group A.ConclusionsAfter 1 year, pacemaker-dependent patients with septal ventricular leads have better clinical and functional (LVEF) outcome.

Background-Cryoablation (cryo) has a high success rate in the short-term treatment of atrial flutter (AFL), but evidence of long-term efficacy is lacking. The present study reports the long-term effect of cryo of the cavotricuspid isthmus (CTI) in patients with common AFL. Methods and Results-Thirty-five consecutive patients (28 men; mean age, 53 years) underwent cryo of the CTI. In 34 patients, the AFL had a counterclockwise rotation (cycle length, 242Ϯ43 ms). Eleven patients had structural heart disease. Cryo was performed with a 10F catheter with a 6-mm-tip electrode (CryoCor). Applications (3 to 5 minutes each) were delivered by use of a point-by-point technique to create the ablation line. The acute end point of the procedure was creation of bidirectional isthmus conduction block and noninducibility of AFL. A median of 14 applications (range, 4 to 30) at 10 sites (range, 4 to 19) was given along the CTI with a mean temperature of Ϫ80.0Ϯ5.0°C. Mean fluoroscopy and procedure times were 40Ϯ26 minutes and 3.2Ϯ1.3 hours, respectively. Of the 35 patients, 34 were acutely successfully ablated (97%). After a mean follow-up of 17.6Ϯ6.2 months (range, 9.6 to 26.1 months), 31 patients (89%) did not have recurrence of AFL. Three of the 4 patients with recurrence had a second successful procedure. One patient had transient ST elevation in the inferior leads during cryoapplication. Conclusions-Cryo produces permanent bidirectional isthmus conduction block of the CTI. Short-and long-term success rates are comparable to those for radiofrequency ablation.

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