A variety of surgical approaches for pericardial drainage have been proposed. The choice of the best approach can be, therefore, oriented depending on the cause of the pericardial effusion. Recently a different approach, for neoplastic or post-traumatic pericardial effusion, has been proposed, in order to create a peritoneal-pericardial window avoiding the insertion of a tube. We report a case of late postoperative cardiac tamponade in a patient with a previous coronary surgery in which, due to extensive adhesion of the anterior wall a modified transperitoneal approach to the pericardium, was used.