The mitral valve is approached through the standard sternotomy approach, described above in earlier procedures, or through incisions in the right chest in select cases. The patient is placed on the heart lung machine during the procedure in order to allow the surgeon to provide himself with a near bloodless view of the inside of the heart when the mitral valve is replaced or in certain instances repaired. The heart incision is then suture repaired after the mitral valve replacement or repair. Temporary pacemaker wires are attached to an external pacemaker device and it is used if necessary, i.e.: patient's own heart beat too slow or heart block has developed. It can be determined in the days after surgery when it is safe to remove the temporary pacemaker wires or whether a separate procedure to insert a permanent pacemake is warranted, albeit rare.