Cardiac resynchronization therapy (CRT) has been shown to improve survival and symptoms in patients with severe left ventricular (LV) dysfunction, congestive heart failure, and prolonged QRS duration. LV lead placement is achieved by placing the lead in the coronary sinus, an endovascular approach, or by a minimally invasive robotic-assisted thoracoscopic epicardial approach. There are no data directly comparing the 2 methods. Patients eligible for CRT were randomized to the endovascular and epicardial arms. Coronary sinus lead placement was achieved using the standard technique, and epicardial leads were placed using a minimally invasive robotic-assisted thoracoscopic approach. The primary end point was a decrease in LV end-systolic volume index at 6 months. The secondary end points included 30-day mortality rate, measures of clinical improvement, 1-year electrical lead performance, and 1-year survival rate. The relative improvement of LV end-systolic volume index from baseline to 6 months was similar between the arms (28.8% for the transvenous [n = 12] vs 30.5% for the epicardial (n = 9) arm, p = 0.93). There were no significant differences in the secondary end points between the 2 groups. In conclusion, there were no differences in echocardiographic and clinical outcomes comparing a conventional endovascular approach versus robotic-assisted surgical epicardial LV lead placement for CRT in patients with heart failure. Surgical approaches are still a viable alternative when a transvenous procedure has failed or is not technically feasible.