Alcohol septal ablation has become an acceptable alternative to surgical myectomy in patients with hypertrophic obstructive cardiomyopathy who meet strict clinical and anatomic criteria. While the first septal perforator arising off the left anterior descending artery is the typical conduit for alcohol septal ablation, patients with hypertrophic cardiomyopathy and severe septal hypertrophy may present with unusual septal perforator anatomy, including anomalous origin. We present the case of a patient in whom the dominant basal septal perforator arose anomalously off the proximal right coronary artery. This anomaly has not previously been reported in patients without obstructive left coronary disease. Successful alcohol septal ablation was performed with the use of myocardial contrast echocardiography and optimum guide catheter and balloon support. Anomalous origin, when encountered, may be utilized successfully for alcohol septal ablation, and should not be considered a contraindication to the procedure.
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