Open chest ablation of a right anterior epicardial accessory pathway

Key Teaching Points•If standard endocardial ablation is not successful, the examiner should initiate further diagnostic steps to locate an epicardial location of accessory pathways.•Further diagnostic steps must be coordinated meticulously between participating specialties to yield maximum diagnostic output, such as merging computed tomographic and mapping scans.•Open chest ablation is an alternative, safe therapeutic approach, especially in cases of epicardial accessory pathways close to the coronary artery given the risk of coronary injury during epicardial ablation. •If standard endocardial ablation is not successful, the examiner should initiate further diagnostic steps to locate an epicardial location of accessory pathways.•Further diagnostic steps must be coordinated meticulously between participating specialties to yield maximum diagnostic output, such as merging computed tomographic and mapping scans.•Open chest ablation is an alternative, safe therapeutic approach, especially in cases of epicardial accessory pathways close to the coronary artery given the risk of coronary injury during epicardial ablation.