Sternotomy. Sellors retractor.

Pericardiotomy. Roberts clamp on operator side of pericardium. Apply Cosgrove retractor.

Purse-strings to aorta, RA, IVC. Divide the lines. Cannulate AA, RA-SVC, IVC. Antegrade cardioplegia/vent. X-clamp. Cardioplegia (1.2l).

Divide behind Sondergaard’s groove, and around the SVC (taking care to not injure the phrenic nerve). The line of division is obliquely starting supero-anteriorly to postero-medially. If the incision is kept postero-anterior, then the RA is encountered.

A stab incision is made, and a pump sucked inserted into the LA while cardioplegia is being delivered. After CP delivery, use a small Ross retractor to allow full opening of the LA. Apply mitral retractors. Place sucker in the PV and use ethibond to keep it retracted.

Test valve with bladder syringe/tubing. Inject until LV is full to assess accurately.

If isolated ruptured chord, triangular resection and close wedge with 2 layers of 5-0 prolene.

Apply annuloplasty sutures.

Repair/replacement.

Rewarm. Closure with single layer 4-0 prolene. Not closed completely for de-airing later if another procedure.

Just before tying, fill the heart,  head down, blows on the lungs (allowing blood to circulate from right to left side and out of the LA incision for de-airing).

Remove cross-clamp.

Pacing wires.

Wean off bypass.

Haemostasis – check LA incision, check SVC/PA territory, any pleura open.

2 drains. Closure.

Post-op: keep sBP not too high.