Atrial fibrillation, the most common cardiac arrhythmia, is frequently disabling and drug resistant, and can be associated with major complications such as thromboembolic events. Non drug approaches, including surgery and catheter-based ablation, are used to treat the most severely symptomatic patients. These new treatment strategies have drastically improved our knowledge of thepathophysiology of this arrhythmia and, importantly, have shown that atrialfibrillation is curable. Since 1994, two main approaches have been used to modify the substrate responsible for AF maintenance, namely the creation of linear lesions, and ablation of triggers located within the pulmonary veins (about 90 % of cases). Most teams worldwide now use approaches centered on PV isolation, which, although imperfect, are sufficiently effective to be offered routinely to selected patients in experienced centers. The importance of P Vs in the initiation of AF has been clearly demonstrated, and there is also evidence of a role in AF maintenance. However, the existence of non venous foci or a prominent substrate for AF maintenance limits the success rate to about 70 %. We are now using a combination of PV isolation and a linear lesion delivered to the mitral isthmus from the mitral annulus to the ostium of the left inferior pulmonary vein. This more complex procedure carries a significantly higher success rate, about 82 % of patients being cured and drug-free. The main problem is to identify patients requiring mitral isthmus ablation in addition to PV isolation. At present, AF ablation is restricted to symptomatic patients in whom at least two antiarrhythmic drugs have failed, but future technical improvements are likely to broaden the indications of ablation therapy for AF.

Inappropriate Shocks Reduction by Remote ICD MonitoringIntroductionInappropriate shocks remain a highly challenging complication of implantable cardioverter defibrillators (ICD). We examined whether automatic wireless remote monitoring (RM) of ICD, by providing early notifications of triggering events, lowers the incidence of inappropriate shocks.Methods and resultsWe studied 433 patients randomly assigned to RM (n = 221; active group) versus ambulatory follow‐up (n = 212; control group). Patients in the active group were seen in the ambulatory department once a year, unless RM reported an event requiring an earlier ambulatory visit. Patients in the control group were seen in the ambulatory department every 6 months. The occurrence of first and further inappropriate shocks, and their causes in each group were compared.The characteristics of the study groups, including pharmaceutical regimens, were similar. Over a follow‐up of 27 months, 5.0% of patients in the active group received ≥1 inappropriate shocks versus 10.4% in the control group (P = 0.03). A total of 28 inappropriate shocks were delivered in the active versus 283 in the control group. Shocks were triggered by supraventricular tachyarrhythmias (SVTA) in 48.5%, noise oversensing in 21.2%, T wave oversensing in 15.2%, and lead dysfunction in 15.2% of patients. The numbers of inappropriate shocks delivered per patient, triggered by SVTA and by lead dysfunction, were 74% and 98% lower, respectively, in the active than in the control group.ConclusionRM was highly effective in the long‐term prevention of inappropriate ICD shocks.

Electrical Impact of the Left Ventricular Pacing Site in CRTIntroductionRecent studies have demonstrated that left ventricular (LV) pacing site is a critical parameter in optimizing cardiac resynchronization therapy (CRT). The present study evaluates the effect of pacing from different LV locations on QRS duration (QRSd) and their relationship to acute hemodynamic response in congestive heart failure patients.Methods and ResultsThirty‐five patients with nonischemic dilated cardiomyopathy and left bundle branch block referred for CRT device implantation were studied. Eleven predetermined LV pacing sites were systematically assessed in random order: epicardial: coronary sinus (CS); endocardial: basal and mid‐cavity (septal, anterior, lateral, and inferior), apex, and the endocardial site facing the CS pacing site. For each patient QRSd and +dP/dtmax during baseline (AAI) and DDD LV pacing at 2 atrioventricular delays were compared. Response to CRT was significantly better in patients with wider baseline QRSd (≥150 milliseconds). Hemodynamic response was inversely correlated to increase of QRSd during LV pacing (short atrioventricular [AV] delay: r = 0.44, P < 0.001; long AV delay: r = 0.59, P < 0.001). Compared to baseline, LV pacing at the site of shortest QRSd significantly improved +dP/dtmax (+18 ± 25%, P < 0.001) but was not superior to other conventional strategy (lateral wall, CS pacing, and echo‐guided) and was inferior to a hemodynamically guided strategy.ConclusionsIn our study, we have demonstrated that changes of QRSd during LV pacing correlated with acute hemodynamic response and that LV pacing location was a primary determinant of paced QRSd. Although QRSd did not predict the maximum hemodynamic response, our results confirm the link between electrical activation and hemodynamic response of the LV during CRT.

AIMS:The ECOST trial examined prospectively the long-term safety and effectiveness of home monitoring (HM) of implantable cardioverter defibrillators (ICD).METHODS AND RESULTS:The trial's primary objective was to randomly compare the proportions of patients experiencing ≥ 1 major adverse event (MAE), including deaths from all causes, and cardiovascular, procedure-related, and device-related MAE associated with HM (active group) vs. ambulatory follow-ups (control group) in a sample of 433 patients. The 221 patients assigned to the active group were seen once a year, unless HM reported an ICD dysfunction or a clinical event requiring an ambulatory visit, while the 212 patients in the control group underwent ambulatory visits every 6 months. The characteristics of the study groups were similar. Over a follow-up of 24.2 months, 38.5% of patients in the active and 41.5% in the control group experienced ≥ 1 MAE (P < 0.05 for non-inferiority). The overall number of shocks delivered was significantly lower in the active (n = 193) than in the control (n = 657) group (P < 0.05) and the proportion of patients who received inappropriate shocks was 52% lower in the active (n = 11) than in the control (n = 22) group (P < 0.05). At the end of the follow-up, the battery longevity was longer in the active group because of a lower number of capacitor charges (499 vs. 2081).CONCLUSION:Our observations indicate that long-term HM of ICD is at least as safe as standard ambulatory follow-ups with respect to a broad spectrum of MAE. It also lowered significantly the number of appropriate and inappropriate shocks delivered, and spared the device battery. Clinical trials registration NCT00989417.

AIMS:The Effectiveness and Cost of ICD follow-up Schedule with Telecardiology (ECOST) trial evaluated prospectively the economic impact of long-term remote monitoring (RM) of implantable cardioverter defibrillators (ICDs).METHODS AND RESULTS:The analysis included 310 patients randomly assigned to RM (active group) vs. ambulatory follow-ups (control group). Patients in the active group were seen once a year unless the system reported an event mandating an ambulatory visit, while patients in the control group were seen in the ambulatory department every 6 months. The costs of each follow-up strategy were compared, using the actual billing documents issued by the French health insurance system, including costs of (i) (a) ICD-related ambulatory visits and transportation, (b) other ambulatory visits, (c) cardiovascular treatments and procedures, and (ii) hospitalizations for the management of cardiovascular events. The ICD and RM system costs were calculated on the basis of the device remaining longevity at the end of the study. The characteristics of the study groups were similar. Over a follow-up of 27 months, the mean non-hospital costs per patient-year were €1695 ± 1131 in the active, vs. €1952 ± 1023 in the control group (P = 0.04), a €257 difference mainly due to device management. The hospitalization costs per patient-year were €2829 ± 6382 and €3549 ± 9714 in the active and control groups, respectively (P = 0.46). Adding the ICD to the non-hospital costs, the savings were €494 (P = 0.005) or, when the monitoring system was included, €315 (P = 0.05) per patient-year.CONCLUSION:From the French health insurance perspective, the remote management of ICD patients is cost saving.CLINICAL TRIALS REGISTRATION:NCT00989417, www.clinicaltrials.gov.

Catheter ablation has emerged as a realistic therapeutic option for symptomatic atrial fibrillation (AF). Young patients with AF are often more symptomatic and long-term taking medication is very demanding for their daily life. The aim of our study is to describe the safety and the long-term effectiveness of catheter ablation of AF in patients under 30 years of age. Twenty five consecutive patients < 30 years old (mean age: 26±3; 16-29) with paroxysmal (13 pts, 52%) or persistent AF (12 pts, 48%, AF duration 40±24 months) underwent catheter ablation of symptomatic atrial fibrillation refractory to at least one antiarrythmic drug (AAD), in our center. Only 3 patients had structural heart disease (hypertrophic cardiomyopathy). Patients were hospitalized and monitored at 3, 6 and 12 months, every 6 months thereafter and at the end of the follow up. Mean radio frequency duration was 51±29 min (39±14 for PAF and 65±40 for PsAF) for total procedure time of 176±91 min (128±55 for PAF and 224±100 for PsAF) and a fluoroscopic time of 52±33 min (38±20 for PAF and 62±36 for PsAF). In all procedures, no major complication occurred. After a mean follow up of 54 months ± 29; 21/25 (84%) patients remained arrhythmia-free (92% for PAF and 76% for PsAF) after a mean of 1.6 procedure per patient. 19 of the 21 arrhythmia free patients were also AAD free. Only 3 patients of these 21 patients were treated with warfarin. These finding suggest that catheter ablation of AF in patients under 30 years of age is safe, with good clinical long term outcome. Catheter ablation of AF can be first-line therapy in young people.

BACKGROUND The efficacy of biventricular (BiV) pacing in patients with a narrow or moderately prolonged QRS duration remains questionable.OBJECTIVE To assess the hypothesis that electrical dyssynchrony is required to obtain hemodynamic benefit from BiV pacing by investigating the relationship between intrinsic QRS duration and hemodynamic response to BiV pacing in a patient population covering a broad spectrum of QRS duration.METHODS Eighty-two consecutive heart failure patients underwent cardiac resynchronization therapy implantation irrespective of their QRS duration. Thirty-four patients had a narrow QRS duration (<120 ms), whereas 11 patients had a moderately prolonged QRS duration (>= 120 to <150 ms) and 37 patients had a severely prolonged QRS duration (>= 150 ms). After implantation, invasive left ventricular (LV) dP/dt measurements were compared between intrinsic rhythm and simultaneous BiV pacing with an optimized atrioventricular delay.RESULTS A high correlation (r = .65; P < .001) was observed between baseline QRS duration and changes in LV dP/dt(max) induced by BiV pacing. BiV pacing was ineffective in patients with a narrow QRS duration (+0.4% +/- 6.1%; P = ns). No significant increase in LV dP/dt(max) was observed in patients with a QRS duration of >= 120 to <150 ms (+4.4% +/- 6.9%; P = .06), whereas patients with a QRS duration of >= 150 ms exhibited a significant increase in LV dP/dt(max) (+17.1% +/- 13.4%; P < .001). Only 9% of the patients with a narrow QRS duration exhibited a >= 10% increase in LV dP/dt(max).CONCLUSIONS Baseline QRS duration is linearly related to acute hemodynamic response to BiV pacing. Patients with a narrow QRS duration do not derive hemodynamic improvement. This improvement is also limited in patients with a moderately prolonged QRS duration, raising questions about the potential clinical benefit of this therapy in these patients.

Role of CS Occlusion for Mitral Isthmus Ablation. Objective: To evaluate the safety and outcomes of mitral isthmus (MI) linear ablation with temporary spot occlusion of the coronary sinus (CS).Background: CS blood flow cools local tissue precluding transmurality and bidirectional block across MI lesion.Methods: In a randomized, controlled trial (CS‐occlusion = 20, Control = 22), MI ablation was performed during continuous CS pacing to monitor the moment of block. CS was occluded at the ablation site using 1 cm spherical balloon, Swan–Ganz catheter with angiographic confirmation. Ablation was started at posterior mitral annulus and continued up to left inferior pulmonary vein (LIPV) ostium using an irrigated‐tip catheter. If block was achieved, balloon was deflated and linear block confirmed. If not, additional ablation was performed epicardially (power ≤25 W). Ablation was abandoned after ∼30 minutes, if block was not achieved.Results: CS occlusion (mean duration −27 ± 9 minutes) was achieved in all cases. Complete MI block was achieved in 13/20 (65%) and 15/22 (68%) patients in the CS‐occlusion and control arms, respectively, P = 0.76. Block was achieved with significantly small number (0.5 ± 0.8 vs 1.9 ± 1.1, P = 0.0008) and duration (1.2 ± 1.7 vs 4.2 ± 3.5 minutes, P = 0.009) of epicardial radiofrequency (RF) applications and significantly lower amount of epicardial energy (1.3 ± 2.4 vs 6.3 ± 5.7 kJ, P = 0.006) in the CS‐occlusion versus control arm, respectively. There was no difference in total RF (22 ± 9 vs 23 ± 11 minutes, P = 0.76), procedural (36 ± 16 vs 39 ± 20 minutes, P = 0.57), and fluoroscopic (13 ± 7 vs 15 ± 10 minutes, P = 0.46) durations for MI ablation between the 2 arms. Clinically uneventful CS dissection occurred in 1 patientConclusions: Temporary spot occlusion of CS is safe and significantly reduces the requirement of epicardial ablation to achieve MI block. It does not improve overall procedural success rate and procedural duration. Tissue cooling by CS blood flow is just one of the several challenges in MI ablation. (J Cardiovasc Electrophysiol, Vol. 23, pp. 489‐496, May 2012)

Depression and Cardiac Resynchronization Therapy.Background: The relationship between depression and heart failure is neither coincidental nor trivial, since depression is a powerful predictor of re‐hospitalization and mortality. We prospectively studied the prevalence and impact of depression on the clinical outcomes of patients attending for cardiac resynchronization therapy (CRT). We specifically examined whether patients with depression have a different rate of response to CRT and whether CRT has an effect on depressive symptoms.Methods: Sixty‐eight recipients of CRT systems were included. The depressive status was evaluated before implant and after 6 months by a structured diagnostic interview measuring Diagnostic and Statistical Manual of Mental Disorders (DSM‐IV) criteria of major depression and by a self‐report questionnaire (Center for Epidemiological Studies Depression Scale, CES‐D). The CRT response was assessed at 6 months by a clinical composite score.Results: At inclusion, DSM‐IV criteria of major depression were identified in 41% of the population, while using the self‐report questionnaire 65% were observed to have mild to major depressive symptoms (CES‐D ≥ 16). Only 4 patients were taking antidepressants. At 6 months, 75% were considered responders to CRT. Response to CRT did not differ between those with and without depression at baseline. The rate of patients with depression at 6 months was significantly lower in responders to CRT compared with nonresponders.Conclusions: We found a high prevalence of depressive symptoms in patients receiving CRT systems. Patients with depression should not be excluded from CRT, because they demonstrate a similar rate of response than the persons without depression and the responders are less likely to be depressed at 6 months. (J Cardiovasc Electrophysiol, Vol. 23, pp. 631–636, June 2012)

Introduction Sosa et al, percutaneous pericardial access for mapping and ablation of ventricular tachycardia (VT) has been an important component of the successful management of patients with structural heart disease and refractory ventricular arrhythmias. Because catheter manipulation and ablation in the pericardial space is extremely painful, most electrophysiology (EP) centers perform the epicardial VT procedure under general anesthesia (GA). However, GA lowers blood pressure, may interfere with arrhythmia mapping, and the use of muscle relaxants precludes identification of phrenic nerve. We report our experience with epicardial VT ablation under conscious sedation (sufentanil + midazolam).

La cardiologie est un domaine où la télémédecine devrait connaître un essor rapide. L’application la plus avancée aujourd’hui est le télésuivi des stimulateurs et défibrillateurs cardiaques implantables, permettant de limiter les suivis en face à face au centre d’implantation et d’accéder plus facilement aux données mémorisées dans la prothèses. Après une phase de validation technologique, des larges études prospectives randomisées (TRUST, CONNECT, COMPAS, ECOST, EVATEL) ont démontré la sécurité d’utilisation du télésuivi sur des critères durs de morbi-mortalité avec une valeur ajoutée sous la forme d’une réduction du nombre des consultations, d’une détection anticipée des évènements et d’une réduction des thérapies inappropriées. Ce nouveau standard de suivi s’intègre parfaitement dans la loi française sur la télémédecine. Néanmoins, certains obstacles doivent encore être levés, notamment les aspects financiers de remboursement des actes pour les équipes médicales et de prise en charge d’un service pour les industriels, avant de passer dans la routine. L’acceptation par les patients et la communauté médicale ne devrait pas être un réel problème sous réserve de bien définir les objectifs cliniques et les modalités de partage de l’information. D’autres domaines de la cardiologie devraient à moyen terme s’ouvrir à la télémédecine.

Background— Catheter ablation of ventricular tachycardia (VT) is effective and particularly useful in patients with frequent defibrillator interventions. Various substrate modification techniques have been described for unmappable or hemodynamically intolerable VT. Noninducibility is the most frequently used end point but is associated with significant limitations, so the optimal end point remains unclear. We hypothesized that elimination of local abnormal ventricular activities (LAVAs) during sinus rhythm or ventricular pacing would be a useful and effective end point for substrate-based VT ablation. As an adjunct to this strategy, we used a new high-density mapping catheter and frequently used epicardial mapping. Methods and Results— Seventy patients (age, 67±11 years; 7 female) with VT and structurally abnormal ventricle(s) were prospectively enrolled. Conventional mapping was performed in sinus rhythm in all, and a high-density Pentaray mapping catheter was used in the endocardium (n=35) and epicardially. LAVAs were recorded in 67 patients (95.7%; 95% confidence interval, 89.2–98.9). Catheter ablation was performed targeting LAVA with an irrigated-tip catheter placed endocardially via a transseptal or retrograde aortic approach or epicardially via the subxiphoid approach. LAVAs were successfully abolished or dissociated in 47 of 67 patients (70.1%; 95% confidence interval, 58.7–80.1). In multivariate analysis, LAVA elimination was independently associated with a reduction in recurrent VT or death (hazard ratio, 0.49; 95% confidence interval, 0.26–0.95; P =0.035) during long-term follow-up (median, 22 months). Conclusions— LAVAs can be identified in most patients with scar-related VT. Elimination of LAVAs is feasible and safe and is associated with superior survival free from recurrent VT.

BACKGROUND The report from the 2nd Consensus Committee on BrS suggests that all patients with syncope without a "clear extracardiac cause" should have an implantable cardioverter-defibrillator (ICD). However, a clear extracardiac cause for syncope may be difficult to prove.OBJECTIVE The purpose of this study was to characterize syncope in patients with Brugada syndrome (BrS).METHODS All patients diagnosed with BrS at our institution between 1999 and 2010 were enrolled in a prospective registry. Patients with suspected arrhythmic syncope (group 1) were compared to patients with nonarrhythmic syncope (group 2) and to patients with syncope of doubtful origin (group 3).RESULTS Of 203 patients with BrS, 57 (28%; 44 male, age 46 +/- 12 years) experienced at least 1 syncope. Group 1 consisted of 23 patients, all of whom received an ICD. In group 2 (17 patients), 3 received an ICD because of a positive electrophysiologic study. In group 3 (17 patients), 6 received an implantable loop recorder and 6 received an ICD. After mean follow-up of 65 +/- 42 months, 14 patients in group 1 remained asymptomatic, 4 had recurrent syncope, and 6 had appropriate ICD therapy. In group 2, 9 patients remained asymptomatic and 7 had recurrent neurocardiogenic syncope. In group 3, 7 remained asymptomatic and 9 had recurrent syncope. One patient from each group died from a noncardiac cause.CONCLUSION In the present study, syncope occurred in 28% of patients with BrS. The ventricular arrhythmia rate was 5.5% per year in group 1. In 30%, the etiology of the syncope was questionable. No sudden cardiac death occurred in groups 2 and 3.

OBJECTIVES:This study describes 5-year follow-up results of catheter ablation for atrial fibrillation (AF). BACKGROUND:Long-term efficacy following catheter ablation of AF remains unknown. METHODS:A total of 100 patients (86 men, 14 women), age 55.7 ± 9.6 years, referred to our center for a first AF ablation (63% paroxysmal; 3.5 ± 1.4 prior ineffective antiarrhythmic agents) were followed for 5 years. Complete success was defined as absence of any AF or atrial tachycardia recurrence (clinical or by 24-h Holter monitoring) lasting ≥ 30 s. RESULTS:Arrhythmia-free survival rates after a single catheter ablation procedure were 40%, 37%, and 29% at 1, 2, and 5 years, respectively, with most recurrences over the first 6 months. Patients with long-standing persistent AF experienced a higher recurrence rate than those with paroxysmal or persistent forms (hazard ratio [HR]: 1.9, 95% confidence interval [CI]: 1.0 to 3.5; p = 0.0462). In all, 175 procedures were performed, with a median of 2 per patient. Arrhythmia-free survival following the last catheter ablation procedure was 87%, 81%, and 63% at 1, 2, and 5 years, respectively. Valvular heart disease (HR: 6.0, 95% CI: 2.0 to 17.6; p = 0.0012) and nonischemic dilated cardiomyopathy (HR: 34.0, 95% CI: 6.3 to 182.1; p < 0.0001) independently predicted recurrences. Major complications (cardiac tamponade requiring drainage) occurred in 3 patients (3%). CONCLUSIONS:In selected patients with AF, a catheter ablation strategy with repeat intervention as necessary provides acceptable long-term relief. Although most recurrences transpire over the first 6 to 12 months, a slow but steady decline in arrhythmia-free survival is noted thereafter.

Background: The "sequential ablation" strategy for persistent AF is aimed at progressive organization of AF until the rhythm converts to sinus rhythm or atrial tachycardia ( AT). During ablation of an AT, apparently seamless transitions from one organized AT to another occur. The purpose of our study was to quantify the occurrence and the mechanism of this transition.Methods and Results: Twenty-nine of 90 patients undergoing ablation for persistent AF had multiple AT during the procedure and constitute the study group. Thirty-nine direct transitions from one AT to another during ablation were observed classified in four types: type I (79.4%), i.e., a direct transition of a faster to a slower tachycardia without significant intervening pause; type II (7.69%)-transition after intervening ectopy or longer pause; type III (10.26%)-A slower AT accelerated; type IV (2.56%)-alteration of activation sequence but with no change on CL.Conclusions: Transition to a second AT occurs frequently in the midst of ablation of AT in persistent AF patients. This transition occurs most commonly abruptly within the range of a single cycle length of the original AT. This is best explained by a continuation of AT that was "present" simultaneously with the pretransition tachycardia, being "entrained" (for a reentrant tachycardia) or "overdriven" for an automatic focal tachycardia. The presence of multiple tachycardia mechanisms active simultaneously would be consistent with the eclectic pathophysiology of persistent AF. (J Cardiovasc Electrophysiol, Vol. 22, pp. 506-512 May 2011).

BACKGROUND: Left atrial appendage (LAA) is implicated in maintenance of atrial fibrillation (AF) and atrial tachycardia (AT) associated with persistent AF (PsAF) ablation, although little is known about the incidence and mechanism of LAA AT.OBJECTIVE: The purpose of this study was to characterize LAA ATs associated with PsAF ablation.METHODS: In 74 consecutive patients undergoing stepwise PsAF ablation, 142 ATs were encountered during index and repeat procedures. Out of 78 focal-source ATs diagnosed by activation and entrainment mapping, 15 (19%) arose from the base of LAA. Using a 20-pole catheter, high-density maps were constructed (n = 10; age 57 +/- 6 years) to characterize the mechanism of LAA-AT. The LAA orifice was divided into the posterior ridge and anterior-superior and inferior segments to characterize the location of AT.RESULTS: Fifteen patients with LAA AT had symptomatic PsAF for 17 +/- 15 months before ablation. LAA AT (cycle length [CL] 283 +/- 30 ms) occurred during the index procedure in four and after 9 +/- 7 months in 11 patients. We could map 89% +/- 8% AT CLs locally with favorable entrainment from within the LAA, which is suggestive of localized reentry with centrifugal atrial activation. ATs were localized to inferior segment (n = 4), anterior-superior segment (n = 5), and posterior ridge (n = 6) with 1:1 conduction to the atria. Ablation targeting long fractionated or mid-diastolic electrogram within the LAA resulted in tachycardia termination. Postablation, selective contrast radiography demonstrated atrial synchronous LAA contraction in all but one patient. At 18 +/- 7 months, 13/15 (87%) patients remained in sinus rhythm without antiarrhythmic drugs.CONCLUSION: LAA is an important source of localized reentrant AT in patients with PsAF at index and repeat ablation procedures. Ablation targeting the site with long fractionated or mid-diastolic LAA electrogram is highly effective in acute and medium-term elimination of the arrhythmia.

Right heart failure is a common feature in patients with repaired tetralogy of Fallot (TOF), right ventricular (RV) dysfunction and right bundle branch block (RBBB). Biventricular pacing (BVP) has been described as a potentially useful therapeutic in some cases. We aimed to investigate the clinical outcome and dyssynchrony echocardiographic characteristics of patients with repaired TOF and BVP. A systematic retrospective study of all of the patients of CHU de Bordeaux with repaired TOF and BVP was realized. Clinical NYHA status and exercise test performance were retrieved before and 6 months after BVP. All patients benefited from an echocardiography with dyssynchrony measures in spontaneous rhythm, RV pacing and BVP. 10 patients (7 male, 36,6 ± 13 years old) were retrieved from our database. Surgical repair had occurred at the age of 7,4 ± 5,8 years. BVP was effective since 18 ± 10 months. After 6 months of BVP were noted a significant improvement in NYHA class (1,3 ± 0,4 vs 1,8 ± 0.6, p = 0.05) and exercise test capacity (93 ± 22 W vs 78 ± 14 W, p<0,05). In spontaneous rhythm (SR), a significant inter-ventricular dyssynchrony was found (41 ± 13 ms, p<0,01) as well as late activation of RV lateral wall (electrosystolic delay: 42 ± 22 ms vs lateral LV wall and 49 ± 30 ms vs interventricular septum; p<0,01 for both). This dyssynchrony is corrected in biventricular pacing (inter-ventricular delay 8,6 ± 6,4 ms electrosystolic delays repectively 25,5 ± 13 ms and 12 ± 9 ms, p<0,01 vs SR). RV pacing is responsible for late activation of LV lateral wall (36,5 ± 30 ms) BVP pacing in selected patients with repaired TOF, BVP significantly improves dyssynchrony parameters. This is associated with significative improvement of clinical status.