Abstract: A method of perforating a tissue of a heart of a patient when an inferior approach to the heart is contraindicated. The method utilizes an electrosurgical apparatus having an energy delivery device which can function as an ECG measuring device at a distal end thereof and a delivery system comprising a dilator. Said method comprises the steps of (a) advancing the dilator through a superior vena cava into the heart of the patient, from a superior approach, until a distal end of the dilator is adjacent the tissue; (b) checking an ECG signal to confirm a position of the energy delivery device; (c) using the electrosurgical apparatus, which is positioned through the dilator, to create a perforation in the tissue by delivering electrical energy to the tissue; (d) advancing the distal end of the electrosurgical apparatus through the perforation; and (e) advancing the dilator over the electrosurgical apparatus.