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After a median full sternotomy, cardiopulmonary bypass is installed in the usual manner. Apical ventriculotomy is performed through the infarcted myocardium. Polypropylene pledgeted mattress sutures are passed from the right to the left ventricular side through the ventricular septal defect, with the pledgets remaining on the right ventricle. Great care must be taken to place the suture on healthy myocardium and away from the edge of the ventricular septal defect; otherwise the chances of a recurrent postoperative ventricular septal defect would increase. The sutures are subsequently positioned through a heterologous patch, previously prepared to be appropriate for the ventricular septal defect closure. A collar of 3 to 4 cm is left on the external side of the patch. A 4-0 polypropylene running suture is placed through this collar and the left ventricle to further reinforce the ventricular septal defect closure. The left ventricular incision is closed with polypropylene 3-0 continuous sutures. For each ventricular edge, the running suture is passed through 2 polytetrafluoroethylene felts: one on the endoventricular side and the other on the epicardial side. Finally, the suture line is reinforced with a continuous 2-0 polypropylene suture, which is passed through the polytetrafluoroethylene felts, the ventricular wall, and the heterologous patch used to close the ventricular septal defect.

The use of artificial polytetrafluoroethylene (PTFE) chordae has been widely adopted in the setting of mitral valve repair. In this tutorial, we present a modified technique for neochordae placement using a semi-rigid complete ring, with a chordal sizing system. This ring was introduced with the aim of standardizing neo-chordae implantation and we introduce a modification of the implantation technique in the presence of myxomatous leaflets.

From early experience in cardiac surgery on the mitral valve, access was gained in different ways: through left and right antero-lateral extended thoracotomy for closed and correspondingly for open mitral commissurotomy, from right parasternal access with rib resection, and via median sternotomy. Median sternotomy remains the most common approach for mitral valve procedures, such as replacement or repair, allowing good visualisation, exposure and working field. Applying the largely spread access as median sternotomy, surgeons always wanted to overcome the necessity of large incisions, get a better surgical view, to dissect with better respect to structural integrity and have better aesthetic results. Enhanced understanding of surgical bases and technological development sourced a breakthrough in minimally-invasive approach for mitral valve surgery, offering several advantages such as less postoperative pain, lower morbidity and mortality, faster recovery and shorter hospital stay. In an effort to share the institutional experience in less invasive surgery, this article demonstrates our approach in mitral valve repair through a right minithoracotomy in the 3rd or 4th intercostal space.