Left ventricular epicardial VVI pacing for a congenital complete heart block with severe myocardial dysfunction: shall epicardial pacing wires be positioned left?

We present the case of a patient with a congenital complete heart block (CHB) who developed a severe dilated hypokinetic cardiomyopathy whilst paced with a right-sided epicardial wire inserted by an anterior approach. She dramatically and rapidly improved both clinically and echocardiographically, once a single pacing wire was inserted on the left ventricular (LV) wall towards the apex by left thoracotomy. Based upon recent literature, attention is drawn to the fact that left-inserted epicardial pacing wires should probably be considered for pediatric patients in whom atrio-ventricular or inter-ventricular pacing might not be possible to achieve, or else as a consistent approach for small patients requiring VVI epicardial pacing.