After the patient is asleep, a device called the Swan-Ganz catheter is often inserted into the jugular vein in the neck and threaded to the pulmonary artery (which goes from the heart to the lungs). The catheter can be used to give medication, measure the oxygen levels in the blood and measure pressures in the heart. A breathing tube (endotracheal tube) will also be inserted into the mouth and down the windpipe (trachea) to maintain an airway.

There are a variety of incisions the physician might use to gain access to the heart. The choice of incisions depends on the valve being operated on. The physician might use a:

• “J” incision, which is made just below the collarbone or near the manubrium, the upper part of the breast bone (sternum).
  
  
• “T” incision, which is made by partially separating the sternum and is often used for patients undergoing a second valve replacement or who have had bypass surgery previously.
  
  
• Partial rib removal, which involves removing the cartilage portion of the second or third ribs.
  
  
• Right thoracotomy, or small incision in the side of the chest.

In general, these incisions will be relatively small (3.5 to 6 inches long) as opposed to the 11- to 12-inch incision that is standard in traditional open-heart surgery.

The heart will be stopped for the surgery and drained of blood. However, working through smaller incisions, the physician may not be able to use the heart-lung machine in a conventional manner. In this case, a special port-access technique is available that was developed specifically for minimally invasive cardiac surgery. In this technique, the blood is routed through small “ports” in the skin, and the heart-lung machine is often utilized via the femoral artery in the leg or aorta in the chest. The heart is worked on through small “ports” with specialized instruments. The port-access technique may also be combined with endoscopic procedures, in which the physician performs the surgery with fiberoptic endoscopes that are inserted through small incisions in the chest to further reduce the size of the incisions.

Once the surgeon has gained access to the heart, the damaged valve can be replaced or repaired. After the procedure is completed, the heart incision is closed and the heart is restarted. When the surgical team is satisfied that the heart is beating strongly again, the heart-lung machine is removed and the chest incisions are closed. The patient will spend only about five nights in the hospital, and full recovery is expected within several weeks.