Successful Replication of the Transconal Repair Technique for Anomalous Aortic Origin of the Left Main Coronary Artery

Background: Anomalous aortic origin of the left main coronary artery (AAOLCA) with a transseptal course is an exceptionally rare anomaly associated with myocardial ischemia and sudden cardiac death. Surgical management has traditionally required complex repair. Case Summary: A 41-year-old man presented with acute chest pain and ST-segment elevations. Angiography revealed no obstructive coronary disease but identified an AAOLCA from the right coronary sinus with a transseptal course. Physiologic testing demonstrated ischemia under dobutamine stress. The patient underwent successful transconal unroofing and right ventricular outflow tract reconstruction through replication of a novel transconal approach. Discussion: This case highlights the importance of multimodality imaging and physiologic assessment in diagnosing high-risk AAOLCA variants. Careful unroofing and patch reconstruction can relieve compression while avoiding conduction injury or obstruction of the right ventricular outflow tract. Take-Home Message: Transconal unroofing for AAOLCA with extended transseptal course is safe, reproducible, and provides favorable early outcomes.