Background Transvenous lead placement is the standard approach for left ventricular (LV) pacing in cardiac resynchronization therapy (CRT), while the open chest access epicardial lead placement is currently the most frequently used second choice. Our study aimed to compare the ventricular electromechanical synchronicity in patients with heart failure after CRT with these two different LV pacing techniques. Methods We enrolled 33 consecutive patients with refractory heart failure secondly to dilated cardiomyopathy who were eligible for CRT in this study. Nineteen patients received transvenous (TV group) while 14 received open chest (OP group) LV lead pacing. Intraand inter-ventricular electromechanical synchronicity was assessed by tissue Doppler imaging (TDI) before and one year after CRT procedure. Results Before CRT procedure, the mean QRS-duration, maximum time difference to systolic peak velocity among 12 left ventricle segments (LV Ts-12), standard deviation of time difference to systolic peak velocity of 12 left ventricle segments (LV Ts-SD), and inter-ventricular mechanical delay (IVMD) in OP and TV group were 166 +/- 17 ms and 170 +/- 21 ms, 391 +/- 42 ms and 397 +/- 36 ms, 144 +/- 30 ms and 148 +/- 22 ms, 58 +/- 25 ms and 60 +/- 36 ms, respectively (all P > 0.05). At one year after the CRT, the mean QRS-duration, LV Ts-12, LV Ts-SD, and IVMD in TV and OP group were 128 +/- 14 ms and 141 +/- 22 ms (P = 0.031), 136 +/- 37 ms and 294 +/- 119 ms (P = 0.023), 50 +/- 22 ms and 96 +/- 34 ms (P = 0.015), 27 +/- 11 ms and 27 +/- 26 ms (P = 0.86), respectively. The LV lead implantation procedure time was 53.4 +/- 16.3 min for OP group and 136 +/- 35.1 min for TV group (P = 0.016). The mean LV pacing threshold increased significantly from 1.7 +/- 0.6 V/0.5 ms to 2.3 +/- 1.6 V/0.5 ms (P < 0.05) in TV group while it remained stable in the OP group. Conclusions Compared to conventional endovascular approach, open chest access of LV pacing for CRT leads to better improvement of the intraventricular synchronization.