Intramyocardial left anterior descending unroofing using a minimally invasive off-pump approach

A 50-year-old male had been suffering from angina pectoris functional class III/IV for the past 9 years. Initially, medical therapy was attempted, but the patient continued to experience disabling angina. The coronary angiogram revealed an intramyocardial left anterior descending artery (LAD) extending from the second diagonal branch to the apex (Fig. 1a). Echocardiography indicated normal ventricular function. The patient was accepted for minimally invasive unroofing surgery. During the procedure, a left-sided mini-thoracotomy was performed and the LAD course was identified. The entire intramyocardial course could be unroofed using minimally invasive off-pump techniques (Fig. 1b, and see Video 1 in Electronic Supplementary Material). The LAD diameter was significantly larger than initially suspected. When we compared the pre- and postoperative coronary angiograms, we noticed the LAD diameter had increased 2–3 times (Fig. 1). The postoperative course was uneventful and the patient was discharged after 3 days. Follow-up assessments revealed complete remission of chest pain. Minimally invasive unroofing surgery can be a solution for selected patients with this complex disease [1].