Cardiac resynchronization therapy (CRT) has been increasingly performed in patients having heart failure with dyssynchrony. We report a successful case of total thoracoscopic left ventricular (LV) lead implantation in CRT. A 77-year-old man with marked dyssynchrony of the LV wall motion and a low ejection fraction (EF17%) due to pacemaker-mediated cardiomyopathy was referred to us. CRT was planned, but percutaneous LV lead implantation proved difficult owing to anatomical variations. The LV lead was placed in the post-lateral wall of the LV base using a total thoracoscopic procedure. Preoperative dyspnea and dyssynchrony were clearly improved. In CRT, the LV wall stimulation site is important. The LV lead should be implanted in the latest activation area, which can be detected using speckle tracking echocardiography. Surgical lead implantation can be performed in the ideal area, and this procedure may play a new role as a hybrid CRT.
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