Cardiac resynchronization therapy (CRT) improves cardiac function in many patients with ventricular dyssynchrony. The optimal use of imaging for pre-implantation assessment remains a subject of debate. Here, we review the literature to date on the utility of echocardiography and cardiac MR, as well as conventional ECG, in choosing the best site for LV lead implantation. Prior to the use of imaging for pre-implantation evaluation, LV leads were placed empirically, based on average responses from population-level studies. Subsequently, patient-specific approaches have been used to maximize response. Both echocardiography and cardiac MR allow determination of areas of latest mechanical activation. Some studies have found improved response when pacing is applied at or near the site of latest mechanical activation. Similarly, both echocardiography and cardiac MR provide information about the location of any myocardial scar, which should be avoided when placing the LV lead due to variable conduction and high capture thresholds. Alternative approaches include targeting the region of latest electrical activation via measurement of the QLV interval and methods based on intraoperative hemodynamic measurements. Each of these modalities offers complementary insights into LV lead placement, so future directions include multimodality pre-implantation evaluation, studies of which are ongoing. Emerging technologies such as leadless implantable pacemakers may free implanting electrophysiologists from the constraints of the coronary sinus, making this information more useful and making non-response to CRT increasingly rare.