Background Cardiac resynchronization therapy (CRT) with biventricular pacing has demonstrated cardiac function improvement for treating congestive heart failure (HF). It has been documented that the placement of the left ventricular lead at the longest contraction delay segment has the optimal CRT benefit. This study described follow-up to surgical techniques for CRT as a viable alternative for patients with heart failure. Methods Between April 2007 and June 2012, a total of 14 consecutive heart failure patients with New York Heart Association (NYHA) Class underwent left ventricular epicardial lead placements via surgical approach. There were eight males and six females, aged 36 to 79 years ((59.6 +/- 9.2) years). The mean left ventricular ejection fraction (LVEF) was (33.6 +/- 7.4)%. All patients were treated with left ventricular systolic dyssynchrony and underwent left ventricular epicardial lead placements via a surgical approach. Tissue Doppler imaging (TDI) and intraoperative transesophageal echocardiography were used to assess changes in left heart function and dyssynchronic parameters. Also, echo was used to select the best site for left ventricular epicardial lead placement. Results Left ventricular epicardial leads were successfully implanted in the posterior or lateral epicardial wall without serious complications in all patients. All patients had reduction in NYHA score from III-IV preoperatively II-III to postoperatively. The left ventricular end-diastolic diameter (LVEDD) decreased from (67.9 +/- 12.7) mm to (61.2 +/- 7.1) mm (P<0.05), and LVEF increased from (33.6 +/- 7.4)% to (42.2 +/- 8.8)% (P<0.05). Left ventricular intraventricular dyssynchrony index decreased from (148.4 +/- 31.6) ms to (57.3 +/- 23.8) ms (P<0.05). Conclusions Minimally invasive surgical placement of the left ventricular epicardial lead is feasible, safe, and efficient. TDI can guide the epicardial lead placement to the ideal target location.