Letter to the editor Quo vadis, coronary lithoplasty. Response

To the Editor,

We greatly appreciate the interest and comments expressed by Arroyo-Úcar et al. regarding our publication.¹ Calcified coronary lesions are a major challenge for interventional cardiologists, as they are associated with poor short- and long-term outcomes. The presence of calcium complicates the procedure by interfering with preparation of the lesion and restricting final expansion of the stent. An underexpanded stent in a patient with an acute coronary syndrome can have dramatic effects by favoring restenosis, and acute or late stent thrombosis. There are few available resources within this scenario, the most common and widespread being dilation with a noncompliant balloon at very high pressure or rotational stent atherectomy. Nonetheless, various complications have been associated with rotablation in these patients: stent deformation, dissection or perforation of the vessel, embolization with metallic material, slow-flow, and periprocedure infarction.² Furthermore, it is a technique that requires adequate training and a learning curve. Coronary lithoplasty is a novel, simple technique, with little reported experience as yet, but holds great promise. The available case series guided by optical coherence tomography have described its effects on calcified plaque and have reported a small percentage of complications.³ These studies have shown that the energy emitted with this technique interacts with atherosclerotic plaque and causes vibrations that fracture the calcium present in both the superficial and deep layers of the vessel wall.⁴ We believe that the effect of coronary lithoplasty on deep calcium may be its greatest advantage over other ablative techniques. In this line, we would like to underscore the importance of using optical coherence tomography to evaluate the extent of calcium and its depth and enable individualized treatment for each case. However, additional studies are needed to define the clinical effects of coronary lithoplasty and its impact on the stent structure.