Background: Cardiac resynchronization therapy by Biventricular pacing has emerged as a novel therapeutic option for patients with heart failure who continue to be symptomatic despite optimal medical therapy. The left cephalic – axillary – subclavian venous route is commonly used for left ventricular pacing but is not always accessible.
Case Report: A 61-year-old Afro-American female with a known history of NYHA [New York Heart Association] class 4 heart failure, wide QRS complex continued to be symptomatic despite being on maximal medical treatment making her a suitable candidate for cardiac resynchronization therapy. Previous attempt to implant a left ventricular (LV) pacing lead during implantable cardioverter defibrillator was unsuccessful due to unexpected diffi culty associated with accessing the coronary sinus so coronary sinus was cannulated using right internal jugular approach.
Conclusions: In technically impossible right sided coronary sinus cannulation right internal jugular approach is a reasonable alternative before opting for more invasive epicardial approach.

Keywords: biventricular pacing, Electrophysiologic Techniques, Cardiac, Internal jugular vein