Triple-valve replacement in repaired tetralogy of fallot patients with mirror-image dextrocardia: a case report

BACKGROUND: The co-occurrence of mirror-image dextrocardia and tetralogy of Fallot (TOF) is a rare congenital condition. Reoperative multivalve surgery in such patients, especially after repaired TOF, presents exceptional challenges due to the mirrored cardiac anatomy and altered surgical field. This case highlights the surgical strategy for concomitant tricuspid, mitral, and pulmonary valve replacement in this unique setting. CASE PRESENTATION: A 14-year-old male patient with a history of corrected TOF and mirror-image dextrocardia presented with progressive heart failure due to severe regurgitation of the tricuspid, mitral, and pulmonary valves. Preoperative imaging confirmed the complex anatomy, with the atria positioned posteriorly, rendering the atrioventricular valve orifices near-vertical during surgery. The patient successfully underwent triple valve replacement under cardiopulmonary bypass. Key technical adaptations were made to select the valve model and position. The postoperative course was uneventful, with significant symptomatic and echocardiographic improvement at discharge and during the two-month and six-month follow-up. CONCLUSION: This case demonstrates that concomitant triple valve replacement is feasible in patients with mirror-image dextrocardia and a history of TOF repair, despite the profound technical challenges posed by the anatomical distortions. Success hinges on meticulous preoperative planning using advanced imaging and the development of an individualized surgical approach. This report provides a valuable reference for managing such complex, high-risk reoperations in the setting of congenital situs inversus.