We would like to thank the authors for their insightful and constructive comments regarding our manuscript. We appreciate the opportunity to clarify several important methodological and interpretative aspects of our study.

We fully acknowledge the conceptual concern that direct comparison between left main (LM) and non-LM intravascular lithotripsy (IVL) procedures may involve inherently different anatomical, procedural, and prognostic contexts. Our intention was not to imply procedural equivalence between these groups [1].

Although our cohort represents one of the larger real-world datasets reported to date in this specific setting, the study was not originally designed or powered to assess long-term clinical endpoints or to formally compare LM versus non-LM outcomes [1]. Rather, it reflects a prospective analysis of consecutive patients undergoing percuntaneous coronary intervention (PCI) with Shockwave C2 and C2+ IVL in a high-volume tertiary center. The inclusion of the non-LM cohort was intended to provide a broader clinical context and to situate LM IVL outcomes within contemporary daily practice. At the same time, we agree that these groups are inherently heterogeneous, as also reflected by differences in baseline characteristics, anatomical complexity (e.g., higher SYNTAX score), and procedural features in the LM cohort. This heterogeneity may have influenced the observed outcomes.

We appreciate the authors’ comment regarding the numerically higher 2-year all-cause mortality in the LM group (14.8% vs. 6.3%). We fully agree that the absence of statistical significance (p = 0.087) should not be interpreted as evidence of equivalence. Importantly, our study was not designed as a non-inferiority or equivalence trial, and the sample size – although relatively large for this clinical niche – remains insufficient for definitive comparisons of long-term clinical endpoints. The limited number of events further restricts statistical power.

We thank Kivrak et al. for highlighting the important issue of IVL balloon sizing in LM lesions. While it is correct that 3.5 mm balloons were most frequently used during IVL, this reflects a stepwise lesion preparation strategy rather than final vessel sizing. IVL was primarily used to facilitate calcium modification and improve lesion compliance. In all cases, IVL was followed by systematic optimization. Post-dilatation was performed in every patient, and proximal optimization technique (POT), as well as rePOT when appropriate, was routinely applied. Larger non-compliant balloons – most commonly 4.5 mm and 5.0 mm, or individually selected based on angiographic and intravascular imaging findings – were used to match the true reference vessel diameter. Moreover, intravascular imaging was performed in the vast majority of LM cases (over 90%), allowing for individualized sizing and optimization strategies. This comprehensive approach was intended to ensure adequate stent expansion and achieve satisfactory minimal stent area despite the initial use of smaller IVL balloons.

In summary, while we agree that LM PCI represents a distinct and complex clinical scenario, we believe that our analytical approach remains valid within the context of a real-world, exploratory study. The comparison with non-LM cases was intended to provide context rather than imply equivalence, and procedural details. We thank the authors again for their valuable contribution to the discussion.

Funding

No external funding.

Ethical approval

Not applicable.

Conflict of interest

The authors declare no conflict of interest.