Open Mitral Valvotomy :  Technique: A median stemotomy is done; peri cardium opened and stay sutures taken. After heparinisation ascending aorta is cannulated and then SVC and IVC cannulae inserted. If the left atrium is small, tapes arc passed around SVC and NC cannulae for Lola1 cardio pulmonary bypass. Cardioplegia cannulae arc inserted into the ascending aorta and coronary sinus. The inter atrial groove is developed. Dissection to separated RA from LA gives better exposure to the mitral valve in case the left atrium is very small. By dissecting under SVC and IVC more of left atrium will be available for atriotomy. Left atrium could also be approached through right abiotorny and incising the septum (trans septa! approac11) or through the roof of left atrium between ascending aorta and superior vena cava (superior approach).

Aorta is clamped, left atrium opened and cardioplegia is given. Left atrium is widely opened and a Cooley atrial retractor or the self-retaining atrial retractor is applied. The valve is inspected for calcification and mobility. Stay sutures using 40' prolene are taken on the anterior and posterior cusp margins. By traction on the sutures the anterolateral and postern medial commissures are

 identified. Stab incisions are made on the fused commissures close to the annulus and from there extended to the central orifice of the valve. The incision must be along the true commissure. Traction on the commissms using blunt hooks will help in identifying the chordae and papillary muscles. The fused chordae are separated by sharp dissection after identifying the ones going to

 either of the leaflets. It may require incision into the papillary muscles and at times fenestration of the fused chordae, the essential principle is to get a mobile valve.

Decalcification of the leaflets will be required in some cases. The valve competence is kited by injecting saline into the LV. LRCt atrial incision is closed and complete de-airing of the left side of the heart is done. Aortic clamp is removed and de-airing through the aortic root needle is continued till heart ejects well and good blood pressure is achieved. Trans oesophageal echo is done to make sure the valvotomy is adequate and mitral regurgitation is less than mild. The assessnlent of MR should be when blood pressure is good. Open valvotomy is the procedure of choice when patient is in AF and left atrium has clots. The clots are removed; left atrium is washed and sucked thoroughly. Left atrial appendage is obliterated by tying it off from outside or by sutuiing from inside using prolene sutures. If the atrial fibrillation has been present for more than one year or left atrium is larger than 50mrns, it is better to combine a COX 111 (Maze) procedure to reduce the chances of post-operative atrial fibrillation.