A Road Less Traveled: Successful Alcohol Septal Ablation via an Aberrant Septal Coronary Artery in Hypertrophic Obstructive Cardiomyopathy.

Alcohol septal ablation (ASA) is a minimally invasive treatment option for patients with hypertrophic obstructive cardiomyopathy (HOCM) who remain symptomatic despite medical treatment and are either poor surgical candidates or prefer a less invasive approach. Evaluation of patient-specific pre-procedural anatomy is critical as selection of the correct coronary artery is key to successful ASA. The proximal first septal branches are the ideal target for ASA since they provide arterial supply to the basal septum associated with left ventricle outflow tract (LVOT) obstruction. While these arteries originate from the left anterior descending artery (LAD) in 90% of patients, unusual septal perforator anatomy, including anomalous or atypical origin, is encountered in patients with HOCM. We present a patient with HOCM who underwent successful ASA through an aberrant septal perforator originating from the ramus intermedius. This case highlights the complex coronary variability that necessitates a thorough assessment before ASA. Presence of non-LAD originating coronary vessels does not preclude ASA candidacy but does warrant further scrutiny to ensure procedural safety and success.