As the essentially palliative nature of many kinds of heart surgery becomes more fully recognized, secondary open heart procedures are being performed with increasing frequency. Reoperations most commonly involve replacement of malfunctioning prosthetic valves or insertion of new prosthetic devices where previous valvuloplastic precedures have failed. Additionally, reoperation is occasionally indicated in the face of progressive coronary atherosclerosis wherein previously placed grafts have occluded or new coronary lesions have developed. Numerous further special situations can occur in which a second operation becomes necessary. A certain amount of controversy surrounds the advisability of performing the second cardiac surgical procedure via the median sternotomy used for the earlier operation. Certainly, all agree the supine position on the operating table is far superior to the lateral for hemodynamic stability. Generally, objections to reoperating by vertical sternotomy have concerned safety, problems with intraoperative and postoperative hemostasia, and impatience with the sometimes tedious dissection. It