A qualitative study exploring family caregivers' support needs in the context of medical assistance in dying.

OBJECTIVES: Family members are often involved in the provision of care to a relative at some point in their life. Their role becomes inherently complex when their care recipient is interested in seeking medical assistance in dying (MAID). As assisted death for "grievous and irremediable conditions" was legalized in Canada in 2016, the perspectives of family caregivers have received little attention. To best support caregivers to individuals seeking assisted dying, healthcare practitioners must first understand the perspectives of family caregivers in this context. The objective of this qualitative study was to explore the experiences and support needs of family caregivers who are or who have provided care to individuals who are seeking or have sought MAID. METHODS: This study employed a qualitative descriptive design. Family caregivers supporting individuals living with grievous and irremediable conditions were recruited through social media outlets and support organizations. Data were collected through semi-structured telephone interviews and online surveys. Data were transcribed and analyzed using thematic analysis. RESULTS: The study included 11 participants, comprising spouses, parents, and adult children. The research identified three prevalent themes: the caregiver experience including roles and responsibilities and the impact of their role; the MAID experience including the process and their thoughts and feelings about MAID; and caregiver insight into supports and services viewed as valuable or needed for the MAID process. SIGNIFICANCE OF RESULTS: Study findings may assist in the provision and development of best practice resources and guidelines to support healthcare professionals involved in the delivery of MAID. Specifically, caregivers need to be supported in the context of their caregiving responsibilities to minimize the impact on their own lives and optimize their MAID experience.

Rheological innovations for characterizing food material properties.

Rheological methods are continually evolving to encompass novel technologies and measurement methods. This review highlights novel techniques used to analyze the rheological properties of foods over the previous decade. Techniques reviewed include large amplitude oscillatory shear (LAOS) testing and rheological techniques coupled with other measurement methods, such as microscopy and nuclear magnetic resonance (NMR). Novel techniques are briefly overviewed and discussed in terms of advantages and disadvantages, previous use, and suggested future utilization.

Rheological properties and microstructure of Cheddar cheese made with different fat contents.

Reduced- and low-fat cheeses are desired based on composition but often fall short on overall quality. One of the major problems with fat reduction in cheese is the development of a firm texture that does not break down during mastication, unlike that observed in full-fat cheeses. The objective of this investigation was to determine how the amount of fat affects the structure of Cheddar cheese from initial formation (2 wk) through 24 wk of aging. Cheeses were made with target fat contents of 3 to 33% (wt/wt) and moisture to protein ratios of 1.5:1. This allowed for comparisons based on relative amounts of fat and protein gel phases. Cheese microstructure was determined by confocal scanning laser microscopy combined with quantitative image analysis. Rheological analysis was used to determine changes in mechanical properties. Increasing fat content caused an increase in size of fat globules and a higher percentage of nonspherical globules. However, no changes in fat globules were observed with aging. Cheese rigidity (storage modulus) increased with fat content at 10°C, but differences attributable to fat were not apparent at 25°C. This was attributable to the storage modulus of fat approaching that of the protein gel; therefore, the amount of fat or gel phase did not have an effect on the cheese storage modulus. The rigidity of cheese decreased with storage and, because changes in the fat phase were not detected, it appeared to be attributable to changes in the gel network. It appeared that the diminished textural quality in low-fat Cheddar cheese is attributed to changes in the breakdown pattern during chewing, as altered by fat disrupting the cheese network.

The effect of aging on low-fat, reduced-fat, and full-fat Cheddar cheese texture.

This study investigated the effects of aging and fat content on the texture of Cheddar cheese, both mechanical and sensory aspects, over a 9-mo aging period. Cheeses of 6, 16, and 33% fat were tested at 0.5, 3, 6, and 9 mo of aging. Cheeses were evaluated by a trained sensory panel using an established texture lexicon as well as instrumental methods, which were used to probe cheese structure. Sensory analysis showed that low-fat cheeses were differentiated from full-fat cheeses by being more springy and firm and this difference widened as the cheeses aged. In addition, full-fat cheeses broke down more during chewing than the lower fat cheeses and the degree of breakdown increased with aging. Mechanical properties were divided by magnitude of deformation during the test and separated into 3 ranges: the linear viscoelastic region, the nonlinear region, and fracture point. These regions represent a stress/strain response from low to high magnitude, respectively. Strong relationships between sensory terms and rheological properties determined in the linear (maximum compliance) and nonlinear (critical stress and strain and a nonlinear shape factor) regions were revealed. Some correlations were seen with fracture values, but these were not as high as terms related to the nonlinear region of the cheeses. The correlations pointed to strain-weakening behavior being the critical mechanical property. This was associated with higher fat content cheeses breaking down more as strain increased up to fracture. Increased strain weakening associated with an increase in fat content was attributed to fat producing weak points in the protein network, which became initiation sites for fracture within the structure. This suggests that fat replacers need to serve this functional role.

Glycosylation and expanded utility of a modified whey protein ingredient via carbohydrate conjugation at low pH.

Whey protein, at one time considered a by-product of the cheese-making process, is now commonly used in foods for its thickening and emulsifying properties. Currently, approximately 30% of these proteinaceous resources remain under-utilized. Previously, an acidified, thermally treated whey protein concentrate (mWPC) was developed to produce a cold-set thickening ingredient. Mass spectroscopy revealed an approximate 2.5-fold decrease in the lactosylation of beta-lactoglobulin in mWPC starting materials compared with commercial whey protein concentrates, manufactured at a higher pH. Potentially, this should increase the number of reactive sites that remain available for carbohydrate attachment. With this study, the formation of glycoprotein complexes was demonstrated between the mWPC ingredient and lactose, naturally occurring in mWPC powders, or between mWPC protein components with dextran (35 to 45 and 100 to 200 kDa) materials at low pH. In fact, additional dry heating of mWPC powders showed a 3-fold increase in the amount of lactosylated beta-lactoglobulin. Evidence of Maillard reactivity was suggested using colorimetry, o-phthaldialdehyde assays, and sodium dodecyl sulfate PAGE followed by glycoprotein staining. Resultant glycoprotein dispersions exhibited altered functionality, in which case steady shear and small amplitude oscillatory rheology parameters were shown to be dependent on the specific reducing sugar present. Furthermore, the emulsion stability of mWPC-dextran fractions was 2 to 3 times greater than either mWPC or commercial WPC dispersions based on creaming index values. The water-holding capacity of all test samples decreased with additional heating steps; however, mWPC-dextran powders still retained nearly 6 times their weight of water. Scanning electron microscopy revealed that mWPC-dextran conjugates formed a porous network that differed significantly from the dense network observed with mWPC samples. This porosity likely affected both the rheological and water-binding properties of mWPC-dextran complexes. Taken together, these results suggest that the functionality of mWPC ingredients can be enhanced by conjugation with carbohydrate materials at low pH, especially with regard to improving the emulsifying attributes.

Molecular interactions and functionality of a cold-gelling soy protein isolate.

A soy protein isolate (SPI) was thermally denatured at a critical concentration of 8% protein for 3 h at 95 degrees C, resulting in a powder that was readily reconstituted at ambient temperature and that demonstrated improved heat stability and cold-set gel functionality when compared to a control SPI. When SPI was heated at 3% protein equivalently, prior to reconstitution to 8% protein, the final viscosity was about 3 orders of magnitude less than the original sample. The viscosity of SPI heated at 3% protein was still nearly 2 orders of magnitude less than the original sample after both samples were reheated at 8% protein. These results suggested that heat denaturation at low protein concentrations limited network formation even after the protein concentration and interaction sites increased, impacting the isolate's cold gelling ability. Gelation was prevented upon treatment of SPI with iodoacetamide, which carbaminomethylated the cysteine residues, establishing the role of disulfide bonds in network formation. The viscosity of the 8% protein dispersion was also reduced by 2 orders of magnitude when treated with 8 M urea, and when combined with 10 mM DTT the gel viscosity was decreased by another order of magnitude. These results suggested that hydrophobic interactions played a primary role in gel strength after disulfide bonds form. The need for a higher concentration of protein during the heating step indicated that the critical disulfide bonds are intermolecular. Ultimately, the functionality produced by these protein-protein interactions produced a powdered soy protein isolate ingredient with consistent cold-set and thermal gelation properties.

Factors regulating cheese shreddability.

Two sets of cheeses were evaluated to determine factors that affect shred quality. The first set of cheeses was made up of 3 commercial cheeses, Monterey Jack, Mozzarella, and process. The second set of cheeses was made up of 3 Mozzarella cheeses with varying levels of protein and fat at a constant moisture content. A shred distribution of long shreds, short shreds, and fines was obtained by shredding blocks of cheese in a food processor. A probe tack test was used to directly measure adhesion of the cheese to a stainless-steel surface. Surface energy was determined based on the contact angles of standard liquids, and rheological characterization was done by a creep and recovery test. Creep and recovery data were used to calculate the maximum and initial compliance and retardation time. Shredding defects of fines and adhesion to the blade were observed in commercial cheeses. Mozzarella did not adhere to the blade but did produce the most fines. Both Monterey Jack and process cheeses adhered to the blade and produced fines. Furthermore, adherence to the blade was correlated positively with tack energy and negatively with retardation time. Mozzarella cheese, with the highest fat and lowest protein contents, produced the most fines but showed little adherence to the blade, even though tack energy increased with fat content. Surface energy was not correlated with shredding defects in either group of cheese. Rheological properties and tack energy appeared to be the key factors involved in shredding defects.

Valve replacement in patients with critical aortic stenosis and depressed left ventricular function: predictors of operative risk, left ventricular function recovery, and long term outcome.

OBJECTIVES: To identify predictors of operative and postoperative mortality and of functional reversibility after aortic valve replacement (AVR) in patients with aortic stenosis (AS) and severe left ventricular (LV) systolic dysfunction. METHODS AND RESULTS: Between 1990 and 2000, 155 consecutive patients (mean (SD) age 72 (9) years) in New York Heart Association (NYHA) heart failure functional class III or IV (n = 138) and with LV ejection fraction (LVEF) < or = 30% underwent AVR for critical AS (mean (SD) valve area index 0.35 (0.09) cm2/m2). Thirty day mortality was 12%. NYHA class (3.7 (0.6) v 3.2 (0.7), p = 0.004), cardiothoracic ratio (CTR) (0.63 (0.07) v 0.56 (0.06), p < 0.0001), pulmonary artery systolic pressure (63 (25) v 50 (19) mm Hg, p = 0.03), and prevalence of complete left bundle branch block (22% v 8%, p = 0.03) and of renal insufficiency (p = 0.001) were significantly higher in 18 non-survivors than in 137 survivors. In multivariate analysis, the only independent predictor of operative mortality was a CTR > or = 0.6 (odds ratio (OR) 12.2, 95% confidence interval (CI) 5.4 to 27.4, p = 0.002). The difference between preoperative and immediate postoperative LVEF (early-DeltaEF) was > 10 ejection fraction units (EFU) in 55 survivors. In multivariate analysis, CTR (OR 5.95, 95% CI 3.0 to 11.6, p = 0.006) and mean transaortic gradient (OR 1.05, 95% CI 1.0 to 1.1, p < 0.05) were independent predictors of an early-DeltaEF > 10 EFU. During a mean (SD) follow up of 4.6 (3) years, 50 of 137 (36%) 30 day survivors died, 31 of non-cardiac causes. Diabetes (OR 3.8, 95% CI 2.4 to 6.0, p = 0.003), age > or = 75 years (OR 2.6, 95% CI 2.1 to 4.5, p = 0.004), and early-DeltaEF < or = 10 EFU (OR 0.96, 95% CI 0.94 to 0.97, p = 0.01) were independent predictors of long term mortality. Among 127 survivors, the percentage of patients in NYHA functional class III or IV decreased from 89% preoperatively to 3% at one year. The decrease in functional class was significantly greater in patients with an early-DeltaEF > 10 EFU than patients with an early-DeltaEF < or = 10 EFU (p = 0.02). In addition, the mean (SD) LVEF at one year was 53 (11)% in patients with an early-DeltaEF > 10 EFU and 42 (11)% in patients with early-DeltaEF < or = 10 EFU (p < 0.001). CONCLUSIONS: Despite a relatively high operative mortality, AVR for AS and severely depressed LVEF was beneficial in the majority of patients. Early postoperative recovery of LV function was associated with significantly greater relief of symptoms and longer survival.

[Role of cardiac resynchronisation in the treatment of cardiac failure]. / Place de la resynchronisation cardiaque dans le traitement de l'insuffisance cardiaque.

For 10 years cardiac resynchronisation has seen considerable development, as much on the technological side as at the level of its scientific validation. Several prospective studies have shown the functional benefits of cardiac resynchronisation in a selected population of refractory cardiac failure patients with improvement in symptoms, exercise tolerance and quality of life. Equally, cardiac resynchronisation allows a significant reduction in hospital episodes for cardiac failure and also has a beneficial effect on left ventricular inverse remodelling. Finally, the first results of morbidity/mortality trials are very encouraging with a significant reduction in overall mortality at one year in the COMPANION study with the biventricular defibrillator. However, numerous important, unresolved questions remain such as the problem of non-responders and thus patient selection, or such as the place of cardiac resynchronisation in patients with permanent atrial fibrillation. The choice of the type of implantable prosthesis (pacemaker or biventricular defibrillator) and the choice of the mode of pacing (biventricular or solely left ventricular) are still under discussion. New indications for cardiac resynchronisation could be seen next, for example such as the optimisation of stimulation mode in already paced patients or "systematic" biventricular pacing in patients with a conventional indication for pacing..... In 2004, cardiac resynchronisation must be considered as an effective adjuvant therapy in cardiac failure patients refractory to optimal medical treatment with left ventricular dysfunction and intraventricular conduction disorders.

Kinetics of rennet casein gelation at different cooling rates.

A mathematical model was developed to quantitatively analyze the rheological data of rennet casein gelation at different cooling rates. Kinetic parameters were estimated and correlated with the microstructure development of the protein network. The kinetic model identified structure development upon cooling to be first order, and the network forming energies were estimated for four protein concentrations cooled at four rates. A lower energy for network formation was observed for a slower cooling rate and a higher protein concentration. This observation resulted from the availability of more flocs at a slower cooling rate and a higher casein concentration, simplifying floc cross-linking. By analyzing the kinetics during the aging process of casein gels, no difference in the reaction mechanism was observed. This study illustrated that structure formation resulted from the addition of flocs into the protein network: not all flocs were part of the network at a defined gel point. The incubation period following cooling integrated idle flocs into the network, thereby strengthening the gel. By understanding the gelation mechanism during cooling of rennet casein gels, the structure and thus quality of dairy products, such as processed cheese, may be better controlled.

Relationships among rheological and sensorial properties of young cheeses.

This study investigated the sensory and rheological properties of young cheeses in order to better understand perceived cheese texture. Mozzarella and Monterey Jacks were tested at 4, 10, 17, and 38 d of age; process cheese was tested at 4 d. Rheological methods were used to determine the linear and nonlinear viscoelastic and fracture properties. A trained sensory panel developed a descriptive language and reference scales to evaluate cheese texture. All methods differentiated the cheeses by variety. Principal component analysis of sensory texture revealed that three principal components explained 96.1% of the total variation in the cheeses. The perception of firmness decreased as the cheeses aged, whereas the perception of springiness increased. Principal component analysis of the rheological parameters (three principal components: 87.9% of the variance) showed that the cheeses' solid-like response (storage modulus and fracture modulus) decreased during aging, while phase angle, maximum compliance, and retardation time increased. Analysis of the instrumental and sensory parameters (three principal components: 82.1% of the variance) revealed groupings of parameters according to cheese rigidity, resiliency, and chewdown texture. Rheological properties were highly associated with rigidity and resiliency, but less so with chewdown texture.

Isolated left main coronary artery stenosis: long term follow up in 106 patients after surgery.

OBJECTIVE: To analyse the long term prognosis in patients with isolated stenoses of the left main coronary artery (LMCA) following surgical revascularisation. PATIENTS: 106 patients (71 men and 35 women, mean age 61 years) were operated on between 1982 and 1998. Before surgery, 103 patients presented with angina pectoris and only 10 had a history of myocardial infarction. Their mean left ventricular ejection fraction was 62%. Stenoses were localised on the LMCA ostium in 19 patients, a subgroup characterised by a high proportion of women (68%). Three patients presented with chronic LMCA occlusion. Forty six patients were operated on as an emergency. The mean (SD) number of grafts per patient was 2.0 (0.5), and only one patient had no left anterior descending (LAD) coronary artery bypass. Bypass of the LAD using the internal thoracic artery was performed in 88 cases. RESULTS: Early postoperative mortality was 4.7% and the five year survival was 86.8%. Late mortality occurred in nine cases, and in three of these it was linked to a coronary condition. Of the 92 long term survivors, 81.5% were totally symptom-free and 77% of those of working age were able to resume work. The postoperative outcome of patients with isolated ostial LMCA stenosis did not differ significantly from that of the other patients. CONCLUSIONS: The postoperative prognosis of isolated LMCA stenosis appears good in terms of mortality and symptoms.

Rheological and physical properties of derivitized whey protein isolate powders.

Pregelatinized starch is employed in many food applications due to the instantaneous nature of thickening and stability imparted by modification. Proteins, however, have been excluded as a viscosifying agent due to requisite thermal treatments required to create structure. Whey protein isolate gels were produced while manipulating heating time, pH, and mineral type/content, producing a variety of gel types/networks. Gels were frozen, freeze-dried, and ground into a powder. Once reconstituted in deionized water, gel powders were evaluated based on solubility studies, rotational viscometry, and electrophoresis. The protein powder exhibiting the largest apparent viscosity, highest degree of hydrolysis, and greatest solubility was selected for pH and temperature stability analyses and small amplitude oscillatory rheology. This processing technique manipulates WPI into a product capable of forming cold-set weak gel structures suitable for thickening over a wide range of temperature and pH food systems.

Junctional rhythm during slow pathway radiofrequency ablation in patients with atrioventricular nodal reentrant tachycardia: beat-to-beat analysis and its prognostic value in relation to electrophysiologic and anatomic parameters.

INTRODUCTION: Junctional rhythm usually is considered a sensitive but nonspecific marker of successful ablation of the slow pathway in AV nodal reentrant tachycardia. Nevertheless, this junctional rhythm has been little studied, and its relations to recognized predictors of successful radiofrequency (RF) application were never established in any study. METHODS AND RESULTS: Thirty-nine patients underwent RF ablation of the slow pathway for AV nodal reentrant tachycardia. Ninety RF applications were delivered, and each ablation site was determined using three different fluoroscopic projections. Six anatomic zones were defined from low posterior septum to the site of distal His-bundle recording (P1, P2, M1, M2, A1, and A2). Characteristics of junctional rhythm during RF applications were analyzed. Atrial electrogram characteristics at the ablation sites also were studied. All patients had successful slow pathway ablation, without any complication. The ablation sites were located as follows: 41 at P1, 26 at P2, 20 at M1, and 3 in M2. Forty RF applications were successful: 14 of 41 attempts at P1, 7 of 26 at P2, 16 of 20 at M1, and 3 of 3 at M2. Mid-septal ablation site (M1 and M2) was associated with higher occurrence of junctional rhythm (P < 0.0001), earlier first junctional beat (P = 0.008), and earlier occurrence of the longest junctional burst (P = 0.03) compared with posterior ablation site (P1 and P2). The combination of a mid-septal ablation site and a first junctional beat occurring < or = 3 seconds after onset of RF application identified successful RF application with 100% accuracy. Using multivariate analysis, the ablation site, duration of atrial electrogram (including slow pathway potential when present), and occurrence of junctional rhythm were independent predictors of success. CONCLUSION: Successful slow pathway ablation depends on many factors. Junctional rhythm characteristics are related to the site of RF delivery and can be helpful in assessing successful slow pathway ablation.

Comparative effects of permanent biventricular pacing for refractory heart failure in patients with stable sinus rhythm or chronic atrial fibrillation.

This study aimed to compare the long-term benefit of biventricular pacing in drug-refractory heart failure in patients with dilated cardiomyopathy who were in stable sinus rhythm or had persistent atrial fibrillation. The results showed that permanent biventricular pacing in such patients significantly improves exercise tolerance in both groups of patients; however, the benefit tended to be greater in patients with atrial fibrillation.

The interdependency of protein-energy malnutrition, aging, and dysphagia.

Advancing age is increasingly associated with confounding chronic and acute ailments, predisposing elderly individuals to conditions such as malnutrition and swallowing dysfunction. This enhanced susceptibility to malnutrition and dysphagia in this aging demographic lends itself to exacerbating, disabling conditions that may result in increased morbidity and mortality in the event of an aspiration episode. Early identification of substandard nutritional status and subsequent interventiion in the elderly dysphagic population may circumvent the deleterious effects of malnutrition.

Significant improvement of quality of life following atrioventricular synchronous pacing in patients with hypertrophic obstructive cardiomyopathy. Data from 1 year of follow-up. PIC study group. Pacing In Cardiomyopathy.

AIMS: Atrioventricular synchronous pacing exerts beneficial effects, including reduction of left ventricular outflow tract gradients, in patients with hypertrophic obstructive cardiomyopathy. The Pacing in Cardiomyopathy study was initiated to explore the effects of pacing in a double-blind randomized crossover fashion. The aims were to ascertain the beneficial effects of pacing in a controlled study and to rule out a placebo effect by pacing. This paper deals with the outcome of pacing on quality of life during 1 year of follow-up. METHODS: Quality of life was evaluated with the Karolinska questionnaire, validated for patients paced for bradyarrhythmias and ischaemic heart disease. Drug-refractory patients with hypertrophic obstructive cardiomyopathy were recruited for the study and after a temporary pacing procedure implanted with permanent pacemakers. Patients were randomized to two study arms defining the sequence of pacemaker programming. In one arm the pacemaker was inactive, in the other active. After 3 months the pacemaker was reprogrammed to the alternate mode and a further 3 months followed. After this period subsequent pacemaker programming corresponded to the mode preferred by the patient. A last assessment was made 1 year after baseline examinations. RESULTS: Eighty patients completed the first crossover period and 75 completed the full 1 year of follow-up. Active pacing induced significant quality of life improvements, in the order of 9-44%, regardless of programming sequence. Discontinuation of pacing after a first active period resulted in the return of symptoms. Fourteen patients requested early reprogramming after having been programmed to inactive pacing after a first period of active pacing. Seventy-six patients preferred active pacing after the crossover period. A further 6 months of pacing induced progressive improvement in symptoms already favourably influenced. CONCLUSION: Atrioventricular synchronous pacing has a profound beneficial effect on most domains of quality of life in patients with hypertrophic obstructive cardiomyopathy refractory to drug treatment.

Pacemaker lead infection: echocardiographic features, management, and outcome.

OBJECTIVE: To compare transthoracic and transoesophageal echocardiography (TTE, TOE) in patients with permanent pacemaker lead infection and to evaluate the safety of medical extraction in cases of large vegetations. METHODS: TTE and TOE were performed in 23 patients with definite pacemaker lead infection. Seventeen patients without previous infection served as a TOE reference for non-infected leads. RESULTS: TTE was positive in seven cases (30%) whereas with TOE three different types of vegetations attached to the leads were visualised in 21 of the 23 cases (91%). Of the 20 patients with vegetations and lead culture, 17 (85%) had bacteriologically active infection. Left sided valvar endocarditis was diagnosed in two patients. In the control group, strands were visualised by TOE in five patients, and vegetations in none. Medical extraction of vegetations >/= 10 mm was performed in 12 patients and was successful in nine (75%) without clinical pulmonary embolism. After 31.2 (19.1) months of follow up (mean (SD)), all patients except one were cured of infection; three died from other causes. CONCLUSIONS: Combined with bacteriological data, vegetations seen on TOE strongly suggest pacemaker lead infection. Normal TTE examinations do not exclude this diagnosis because of its poor sensitivity. Medical extraction of even large vegetations appeared to be safe.

Optimal right ventricular pacing site in chronically implanted patients: a prospective randomized crossover comparison of apical and outflow tract pacing.

OBJECTIVES: To evaluate the long-term functional and hemodynamic effects of right ventricular outflow tract (RVOT) pacing by comparison with right ventricular apical (RVA) pacing. BACKGROUND: Acute studies have suggested that RVOT pacing could significantly improve cardiac performance in comparison with RVA pacing but no data are available in chronically implanted patients. METHODS: Sixteen patients with chronic atrial tachyarrhythmia and complete AV block were included. Left ventricular ejection fraction (LVEF) was > or =40% in ten and <40% in six. Patients were implanted with a standard DDDR pacemaker connected to two ventricular leads. A screw-in lead was placed at the RVOT and connected to the atrial port. A second lead was positioned at the RVA and connected to the ventricular port. Right ventricular outflow tract and RVA pacing was achieved by programming either the AAIR or the VVIR mode respectively. Four months later patients were randomized so as to undergo either RVOT or RVA pacing for three months according to a blind crossover protocol. Apart from the pacing mode, programming remained unchanged throughout the study. At the end of each period, NYHA class, LVEF, exercise time and maximal oxygen uptake were assessed. RESULTS: No significant difference was observed between the two modes for all the parameters analyzed. These identical results were observed in all patients globally, in patients with LVEF > or =40% as in those with LVEF <40%. CONCLUSIONS: Within the limits of this study, no symptomatic improvement or hemodynamic benefit was noted after three months of RVOT pacing, by comparison with RVA pacing.