Biventricular pacing (resynchronization therapy) improves the duration and quality of life in a subset of patients with congestive heart failure, but this technique has received little attention in the cardiac surgery literature. This report presents some preliminary ideas about its rationale and technique, and some likely indications for this procedure during the performance of cardiac operations.We briefly summarize the theory and the results of the randomized clinical trials of resynchronization therapy that led us to consider biventricular pacing for high-risk cardiac surgery patients. We present s ome techniques for using temporary and permanent biventricular pacing in the operating room. We review the hospital records and present early results of the first 25 patients in whom we implanted permanent left ventricular free wall pacing electrodes with the intent of implanting biventricular pacing devices.Biventricular pacing has great potential to simplify the management and improve the outcomes of some cardiac surgical patients.