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Figure 1 Technique used to insert the mapping and ablation catheter in the pericardial space. The needle used for epidural anesthesia (detailed in the left superior corner) being currently used for transthoracic pericardial puncture, according to the technique described by Kirkorian, to drain epicardial effusions (panel 1). A soft floppy-tip guidewire is introduced into the pericardial space (large arrow), where contrast is also present (black arrows) (panel 2). Then, an 8F introducer is advanced, the guidewire is removed and a quadripolar, 4-mm tip, 7F regular steerable catheter is gently introduced into the pericardial sac to perform epicardial mapping and/or ablation. Panel 3 demonstrates a right anterior oblique view at 60° obtained by fluoroscopy during epicardial mapping procedure. The epicardial catheter (arrow) is manipulated and placed in different locations of the epicardial space (A to F), where epicardial electrograms are obtained. RV = right ventricular apex catheter; CS = coronary sinus; 1 = coronary sinus catheter; 2 = endocardial left ventricular catheter; 3 = right apical endocardial catheter.