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Objectives Optimal right ventricular lead placement remains controversial. Large studies investigating the safety and long-term prognosis of apical and septal right ventricular lead placement have been lacking.Methods Consecutive patients undergoing pacemaker insertion for high-degree atrioventricular block at Edinburgh Heart Centre were investigated. Periprocedural 30-day complications were defined (infection/bleeding/pneumothorax/tamponade/lead displacement). Long-term clinical outcomes were obtained from the General Register of Scotland and electronic medical records. The primary endpoint was a composite of all-cause mortality, new heart failure, hospitalisation for a major cardiovascular event, as per the CArdiac REsynchronization in Heart Failure trial. Secondary endpoints were all-cause mortality, new heart failure and their composite.Results 820 patients were included, 204 (25%) paced from the septum and 616 (75%) from the apex. All baseline variables were similar with the exception of age (septal: 73.2±1.1 vs apical: 76.9±0.5 years, p