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Physicians prefer traditional right ventricular apical pacing to right ventricular outflow tract pacing because of easy accessibility,short procedure time, stable lead function and a low incidence of complications. However, right ventricular apical pacing produce an abnormal pattern of ventricular activation compared with right ventricular outflow tract pacing. There is growing evidence that right apical pacing may have long-term detrimental effects on left ventricular function. The report of Kim et al. in this issue showed that ventricular dyssynchrony was commonly seen in patients with permanent pacemaker implantation. They suggested the role of paced QRS duration to predict ventricular dyssynchrony during the follow-up period in patients with permanent pacemaker. However, a large scaled prospective observational study is needed to assess the factors influencing ventricular dyssynchrony in Korean patients with permanent pacemaker.