Transcatheter aortic valve replacement in right aortic arch with mirror image branching

A right aortic arch withmirror-image branching is a rare congenital anomaly resulting from the abnormal regression ofthe embryonic left aortic arch. This variant, in which the aortic arch courses to the right of the trachea and gives rise to its branches in a mirrored configuration compared to the standard left-sided arch, can present unique challenges during cardiovascular interventions such as transcatheter aortic valve replacement (TAVR). We describe a 75-year-old male undergoing evaluation for TAVR who was incidentally found to have a right aortic arch with mirror-image branching. This anomaly, characterized by a mirrored branching pattern of the arch vessels, required tailored imaging and procedural considerations. The patient successfully underwent TAVR through the right aortic arch without complications, demonstrating the adaptability of contemporary structural heart interventions. This patient presented with an embryonic right aortic arch with mirror-image branching (RAA-MIB) and persistence of the left sixth arch. Given the potential technical challenges in catheter navigation that the unique anatomy of this aortic arch poses, it is critical to understand these embryological variations for successful procedural planning and execution. Clinical implications include a potentially increased risk of stroke and dissection. Advances in imaging modalities continue to enhance our ability to diagnose and manage rare aortic arch anomalies, ultimately improving patient outcomes.