Identifying the coronary branch that supplies the basal septum is the cornerstone for successful alcohol septal ablation (ASA). The basal septum is often supplied by septal perforator artery/arteries (SPA/SPAs) not originating from the left anterior descending (LAD) coronary artery. We aim to investigate the prevalence and significance of non-LAD septal "culprit" in patients undergoing ASA. A retrospective review of patients who underwent ASA from 2006 to 2014 was conducted. Procedural and midterm outcomes of patients who had ASA of LAD and non-LAD culprit SPA were reported. A total 89 patients were included in the analysis; 13 patients (15%) had ASA of non-LAD SPA. These patients were more likely to have a history of failed ASA, more than one SPA treated, more ethanol dose injected, longer procedures, and higher contrast use compared with those who had ASA of LAD-SPA. In-hospital outcomes, residual gradient, symptom improvement, and midterm mortality were similar in the 2 groups. In conclusion, in a cohort of patients undergoing ASA, 15% had ablation of SPA culprit that did not originate from the LAD. Half of these patients had previous unsuccessful ASA. Systematic screening for the ideal culprit SPA with nonselective coronary injection of echo contrast should be used to avoid incomplete or failed ASA.
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