The direct approach to the LVS provides access through the pericardial sac. This access also has a limitation because of thick epicardial adipose tissue and the coronary vessel density. The only reachable part of LVS via direct epicardial aspect is an accessible area. The superior portion of LVS is dangerous for pericardial penetration. It increases the risk of major and minor complications, such as intrapericardial bleeding, coronary artery stenosis, delayed tamponade and incidental right ventricle puncture [85–89]. Table 1 summarizes possible approaches to the LVS area.