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Cardiac resynchronization therapy (CRT) has become an important treatment for patients with heart failure and left ventricular dyssynchrony (Cazeau et al., 2001; Abraham et al., 2002; Auricchio et al., 2002; Cleland et al., 2005). For left ventricular (LV) pacing in CRT, transvenous placement of a lead into one of the posterolateral tributaries of the coronary sinus (CS) is the first choice. However, even with growing experience and improvement of available materials and tools placement of a lead into the coronary venous system may fail. Failures can be due to inability to engage the coronary sinus, absence of suitable side branches in the posterolateral area, coronary vein stenosis, lead instability, high stimulation threshold, phrenic nerve stimulation or a combination (Auricchio et al., 2004; Bentkover et al., 2003; Gras et al., 2002). As alternative for surgical epicardial lead implantation, in case of failed coronary sinus implant, atrial transseptal approaches with endocardial LV lead placement have been described, using a modified transseptal puncture technique from either the right jugular vein (Jais et al., 1998; Jais et al., 2000; Leclercq et al., 1999; Jais et al., 2006) or from the left axillary vein (Sen et al., 2004). We modified the atrial transseptal technique for endocardial LV lead placement by using a standard transseptal puncture from the femoral vein, dilatation of the atrial septum and subsequent passage of the lead through the septum via the subclavian vein (Van Gelder et al., 2007). Shortly after, a second alternative technique was described for LV endocardial implantation, using a limited lateral thoracotomy with transapical insertion of the lead (Kassai et al., 2009). We also used this transapical technique in a number of patients in whom the trans-atrial septum implant was unsuccessful or contraindicated due to the presence of an artificial valve in mitral position. Besides being an alternative for failed coronary sinus implants, the flexibility of lead positioning by both endocardial techniques also offers the possibility of an endocardial implant at a different LV site in patients not responding to CRT. The efficacy of the

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Left Ventricular Endocardial Pacing Techniques as an Alternative for Ineffective Cardiac Resynchronization Therapy and the Role of Acute Hemodynamic Evaluation