After a complete annuloplasty ring has been introduced into the left atrium, the first suture (9–cm) is passed through the top left side of the ring and then through the left fibrous trigone. Thereafter, the suture is passed back through the ring and tied (Fig. 22.2). Thereafter, a second suture (14–cm) is passed through the top right end of ring and then through the right fibrous trigone. Thereafter, the suture is passed back through the ring and tied. Then, we “run” this suture counterclockwise (along the anterior ring) to the left fibrous trigone, where it is tied to the first suture tail. Similar to the initial placement of second suture, the third suture (16–cm) is passed through the top right end of ring, then through the right fibrous trigone, and finally back through the ring. Thereafter, we “run” this suture clockwise in a “mattress fashion” to the mid-point of the posterior ring, which should correspond to the annular mid-point at the medial posterior leaflet scallop (P₂). After removing the needle, excess suture material is left in the atrium for the next step. At the end of this suture line, a fourth suture (16–cm) is passed through the ring, then through the mid-annulus, and finally back through the ring. This suture is tied and the tail used to tighten and secure the third suture. The fourth suture is then continued clockwise to end at the left fibrous trigone, where it is tied tightly to the tail of the first suture.