Damage to the left internal mammary artery during anterior epicardial access for ventricular tachycardia ablation

Key Teaching Points•One of the complications of a pericardial puncture is laceration of the left internal mammary artery (LIMA).•An anterior approach is preferred to avoid right ventricular puncture.•An anterior approach may be related to a higher incidence of LIMA damage.•When approaching the pericardium, caution is needed during needle advancement to avoid a higher-than-usual puncture or needle take-off.•A very anterior puncture can be avoided when the puncture needle is aimed at a minimum angle of 20° toward the anterior right ventricle silhouette. A preprocedural computed tomography scan can aid in avoiding LIMA puncture in cases of difficult anatomy.•A pericardial drain with proximal side holes outside the pericardium is recommended to detect extrapericardial bleed that otherwise is left unnoticed. •One of the complications of a pericardial puncture is laceration of the left internal mammary artery (LIMA).•An anterior approach is preferred to avoid right ventricular puncture.•An anterior approach may be related to a higher incidence of LIMA damage.•When approaching the pericardium, caution is needed during needle advancement to avoid a higher-than-usual puncture or needle take-off.•A very anterior puncture can be avoided when the puncture needle is aimed at a minimum angle of 20° toward the anterior right ventricle silhouette. A preprocedural computed tomography scan can aid in avoiding LIMA puncture in cases of difficult anatomy.•A pericardial drain with proximal side holes outside the pericardium is recommended to detect extrapericardial bleed that otherwise is left unnoticed.