Right ventricular apical pacing remained the conventional pacing site for the cardiologists from beginning. But studies later on confirmed that long term right ventricular pacing is a cause of left ventricular dysfunction even in patients with pre pacemaker implantation normal LV ejection fraction. Some observational studies and small RCTs also analyzed the predictors of LV dysfunction. In current scenario main focus is on alternate more physiological pacing site, like RVOT pacing and to enable some special algorhythms that decrease the total percentage of the pacing. Thus it is Important to understand the mechanism of post RV apical pacing LV dysfunction, other predictors of LV dysfunction and how to treat/prevent the LV dysfunction.