Coronary venous dissection is a known complication of left ventricular lead placement during implantation of a cardiac resynchronization with defibrillator (CRT-D) system. A large-scale evaluation of the prevalence of coronary venous dissection and associated in-hospital clinical outcomes has not been performed. We sought to identify predictors of coronary venous dissection and evaluate subsequent in-hospital adverse events in those with the complication. We studied 140,991 first-time CRT-D recipients in the implantable cardioverter-defibrillator (ICD) Registry implanted between 2006 and 2011. Using hierarchical multivariable logistic regression adjusting for patient, implanting physician, and hospital characteristics, we examined predictors of coronary venous dissection and its association with other major complications, length of hospital stay, and in-hospital mortality. Coronary venous dissection occurred in 392 patients (0.28%). After multivariable adjustment, female gender and left bundle branch block were associated with greater odds of coronary venous dissection. Conversely, atrial fibrillation, previous coronary artery bypass graft, and higher implanter procedure volume were associated with lower odds of coronary venous dissection (all p values <0.05). After multivariable adjustment, CRT-D recipients with coronary venous dissection had greater odds of major complications (odds ratio [OR] 10.47, 95% confidence interval [CI] 6.75 to 16.24, p <0.0001), postprocedural hospital stays >3 days (OR 1.71, 95% CI 1.29 to 2.29, p <0.0001), but not in-hospital death (OR 0.78, 95% CI 0.12 to 5.25, p = 0.8012). In conclusion, in a large population of first-time CRT-D recipients, specific patient and implanter characteristics predicted coronary venous dissection risk. Coronary venous dissection was associated with major in-hospital complications and prolonged hospitalization, but not death.