Left Antero Lateral Thoracotomy Approach :  Arterial and central venous pressure monitoring lines are placed. A left antero lateral thoracotomy is done through the 5th or 4th space. Left phrenic nerve is isolated as a pedicle and retracted. Pericardium away from calcified area is selected over the left venlricle. An incision is deepened and deepened 'till the myocardium bulges and it is pulsating. By sharp dissection, flaps are raised in the correct plain. Care is taken not to go into the myocardium as well as injure coronary vessels on the epicardium. Dissection is done with a sharp knife and the left ventricle is first released. Dissection is extended posterior to the phrenic have and the thickened peiicardium is removed. The left ventricle is freed first as freeing right ventricle first can lead to pulmonary congestion and oedema.

Similarly the right ventricle and its outflow are released and freed. From a left thoracotomy no attempt is made to free the SVC and IVC as they are inaccessible. When classify plaques are densely adherent, islands of these can be left on the ventricles.

When dissection and rising of the flaps are completed they are excised along with part of the pericardium over the diaphragm. Haeomostasis is achieved and chest closed with two pleural drains. It is a good idea to monitor arterial, left and right atrial pressures post-operatively.