Surgical LAA ligation is frequently incomplete. The similar incidence of incomplete ligation detected immediately postoperative and at various times thereafter suggest that this results from an intraoperative phenomenon rather than from gradual dehiscence of sutures over years. The incidence of incomplete left atrial ligation was unrelated to type of surgery, surgical approach, left atrial size or degree of mitral regurgitation. Residual communication between the incompletely ligated appendage and the left atrial body may produce a milieu of stagnant blood flow within the appendage and be a potential mechanism for embolic events.

Aims:We aimed to evaluate the effectiveness of excimer laser coronary angioplasty (ELCA) to treat instent restenosis (ISR) due to peri-stent calcium-related stent underexpansion as assessed by optical coherence tomography (OCT). Methods and results:We studied 81 patients (81 lesions with ISR, stent underexpansion, and peri-stent calcium >90°) who underwent OCT imaging both pre and post percutaneous coronary intervention and compared lesions treated with ELCA (n=23) vs. without ELCA (n=58). ELCA use was associated with more calcium fracture (ELCA: 61%, non-ELCA: 12%, p<0.01), larger final minimum lumen area (ELCA: 4.76 mm 2 [3.25, 5.57], non-ELCA: 3.46 mm 2 [2.80, 4.13], p<0.01), and a larger previously implanted stent area (ELCA: 6.15 mm 2 [4.83, 7.09], non-ELCA: 4.65 mm 2 [3.84, 5.40], p<0.01). In the multivariable model, ELCA use was associated with peri-stent calcium fracture (odds ratio 46.5, 95% confidence interval: 6.8, 315.9, p<0.001) that, in turn, was associated with final larger lumen and stent dimensions. Finally, contrast injection during ELCA was associated with multiple calcium fractures and fractures even in thicker calcium.Conclusions: ELCA is effective for treating ISR with underexpansion by disrupting peri-stent calcium, facilitating better expansion of the previously implanted stent.

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