Anomalous Origin of the Left Main Coronary Artery with an Intraseptal Course Identified by Transesophageal Echocardiography and Role of various diagnostic modalities

A 41year old male was seen in the cardiology clinic for risk assessment for a kidney and pancreatic transplant. Myoview stress test showed transient ischemic dilation and mild fixed anterior and inferior wall defects. Subsequent coronary angiography showed left main coronary artery arising from the right coronary cusp having an intra-septal course before bifurcating into anterior descending and left circumflex artery. The pre-operative transesophageal echocardiography confirmed the intra-septal course of the ectopic left main coronary artery. The intra-operative anatomy of this vessel also revealed a short pre-pulmonic course followed by an intraseptal course noted as the vessel dived into the septum.