PMC10202565_01
Preoperative transesophageal echocardiograms.
Pseudoaneurysm (red arrow) and dehisced mitral ring (yellow arrow). Panels (A) to (D) Transesophageal echocardiograms 5 days prior to final surgical intervention.
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TEE at our institution further characterized the dehisced mitral ring as well as the LVPA contained by the posterolateral pericardium ( Fig. 1 ). The patient subsequently underwent redo sternotomy for repair of the LVPA repair along with MVR ( Fig. 2 ). 
Preoperative chest X-ray, preoperative coronary angiogram, and postoperative chest X-ray.
Pseudoaneurysm (red arrow). Panels (A) and (C) Improvement in cardiac maximal dimensions between preoperative day 12 (A) and postoperative day 23 (C) with a reduction in cardiomegaly. Panel (B) Left heart coronary angiogram with dashed line delineating pseudoaneurysm neck.
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TEE at our institution further characterized the dehisced mitral ring as well as the LVPA contained by the posterolateral pericardium ( Fig. 1 ). The patient subsequently underwent redo sternotomy for repair of the LVPA repair along with MVR ( Fig. 2 ). 
Intraoperative repair of the pseudoaneurysm.
Panel (A) Pseudoaneurysm neck (yellow arrow) and pseudoaneurysm sack (red arrow). Panel (B) Cut anterior leaflet of mitral valve (dashed yellow line). Panel (C) Bovine pericardial patch (blue stars). Panel (D) Surgeon's view: anterior annulus (dashed yellow line), patch (blue star), and noneverting pledgeted annular sutures (red arrows).
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The pseudoaneurysm wall was then carefully cleaned of all thrombi with high power suction with an open-ended tip ( Fig. 3A ). The neck of the pseudoaneurysm was patched on the posterior aspect of the heart using a bovine pericardium patch and sewn to the underside of the mitral annulus extending to the anterior and medial aspects of the ventricle ( Fig. 3C ). Pledgeted sutures in a noneverting manner were placed from the ventricular side to the atrial side at the level of the A3-P3 commissure ( Fig. 3D ).