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The best strategy for device implantation has always been debated. It is generally believed that the transvenous approach is associated with a greater complication rate than the epicardial one, even if the latter may be associated with more difficult lead positioning and subsequent transvenous lead dislodgement. We report a series of 489 consecutive, "ideal" patients who underwent either a transvenous (n = 303) or an epicardial (n = 186) approach for pacemaker implantation. A total of 98% of the patients underwent device implantation using the transvenous approach. The transvenous approach was preferred in patients with paroxysmal atrial fibrillation, high right atrial and ventricular voltages, a long and small oval-shaped left atrium, and subvalvular lead positioning (70%). The epicardial approach was preferred in patients with chronic atrial fibrillation and a short and thick atrial wall (61%). No significant difference in the overall complication rate was observed between the two approaches (14% vs 13.5%, p = 0.8). A high rate of lead dislodgement, late pocket infection, and rhythm disturbances were observed with the transvenous approach (12%, 7%, and 9%, respectively). In contrast, only 5% of the epicardial patients experienced lead dislodgement, pocket infection, and/or rhythm disturbances. In conclusion, the choice of implantation approach is of paramount importance. A transvenous approach should be used in patients with specific characteristics, such as paroxysmal atrial fibrillation, a high right atrial and ventricular voltages, a long and small oval-shaped left atrium, and subvalvular lead placement. The epicardial approach should be used in patients with chronic atrial fibrillation, a short and thick atrial wall, and a high left atrial and ventricular voltage 1a423ce670 Free File Opener 5.18.1 Crack Free [Win/Mac] keymacro is a macro recorder. 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