Cardiac resynchronisation therapy is a well-established treatment for patients with heart failure. It, however, requires very experienced operators and can be time consuming. We present a case where, owing to anatomical difficulties in accessing the coronary sinus left ventricular lead positioning was not possible, but using an alternative site of pacing, the right ventricular outflow tract, improved left ventricular synchrony and ejection fraction were achieved. The benefits were demonstrated by 3D echocardiography, soon after implantation and at late clinic review.

A 70-year-old man was admitted electively for biventricular pacemaker implantation because of symptoms of dyspnoea on …