The right ventricular apex (RVA) has been the elective site for placing endocardial pacing leads since 1959 when Furman described the use of the transvenous route for pacemaker implantation. This site was used because it is easily accessible, readily identified, and associated with a stable position and reliable chronic pacing parameters. It was recognised however, that pacing from the RVA did not reproduce normal ventricular conduction or contraction. With the advent of reliable active fixation leads, alternative right ventricular sites became accessible and began to be explored. In this review, we will outline the detrimental effects of RVA pacing, define the right ventricular outflow tract, and discuss the evidence for selective site pacing.
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