Background: Coronary sinus lead placement for transvenous left ventricular (LV) pacing in cardiac resynchronization therapy (CRT) has a significant failure rate at implant and a considerable dislocation rate during follow-up. For these patients epicardial pacing lead implantation is the most frequently used alternative. Recent data support endocardial lead implantation through the atrial septum and the mitral valve, because this method provides further hemodynamic advantages. On the other hand transseptal CRT carries a significant risk for device related infective endocarditis of the mitral valve. The aim of this prospective, nonrandomized study was to demonstrate the feasibility of a fundamentally new approach for endocardial LV lead implantation. Methods: We performed 12 transapical LV lead implantations in 10 end-stage heart failure patients. In each operation an active fixation lead was placed into the LV cavity using standard Seldinger technique through the LV apex. By use of a J-shaped guide wire, the tip of the lead was positioned and fixed into the basal-lateral segment of the LV under fluoroscopy guidance. Pacing parameters were assessed and found to be optimal in all patients. The lead was conducted through the chest wall near the apex into a subcutaneous tunnel up to the pocket of the previously implanted device. After surgery the patients are anticoagulated with target anticoagulation level identical to mechanical valve prostheses. Results: In 8 patients there were no major or minor complications related to this new technique. During the follow-up period (mean 7.2 +/- 4.1 months) all patients responded favorably to the treatment. One lead dislocation and 1 pocket infection were detected; the lead repositioning and replacing could be performed without reopening of the pleural cavity. Conclusions: The potential advantages of this new technique are that it is minimally invasive, endocardial, and does not involve the mitral valve. LV lead repositioning can also be performed minimally invasively.