State-of-the-art pacing modalities are not readily utilized with conventional epicardial pacing lead implantation techniques. A transatrial implantation technique was developed combining a limited surgical approach with transvenous leads. Six patients who were poor candidates for transvenous implants have received DDD or DDDR pacemakers by this approach. The limited surgical approach includes resection of the third or fourth costal cartilage through a small skin incision, reflection of the pleura, and opening of the pericardium. The introducer and transvenous leads are inserted through a right atrial pursestring suture. The leads are positioned in the right ventricle and right atrium using standard fluoroscopic techniques. Through the incision, the subcutaneous tissue pocket is constructed on the right anterior chest wall. The leads are connected to the pacemaker without the need for adaptors or tunneling. There were no procedure-related complications. The magnitude of the surgery and postoperative morbidity are significantly less than for a standard thoracotomy, median sternotomy, and transdiaphragmatic epigastric or subcostal approach. The utility of the transatrial implantation technique is that it allows the use of state-of-the- art bipolar dual chamber pacemakers restoring access to all pacing modalities for those patients not candidates for transvenous implantation.