Iliac CTO interventions follow patterns — but recognizing them in real time is what separates a difficult case from a controlled one.

In this MurmurMD case discussion, Dr. Jay Mohan and Dr. Sameh Sayfo walk through two iliac CTO interventions, highlighting practical lessons in access strategy, crossing techniques, IVUS guidance, and covered stent deployment.

Key concepts discussed directly from the transcript include:

• Why ABI can appear normal despite severe inflow disease

• Using waveform analysis and CTA to guide planning

• When femoral access fails — and why radial R2P changes the game

• Recognizing the true stump and avoiding false lumen escalation

• Externalizing the wire and advancing destination-style sheaths

• IVUS (014 vs 018) for accurate vessel sizing

• Bilateral kissing covered stents in complex aorto-iliac anatomy

• Managing aneurysmal segments and knowing when to consider EVAR

• Using a misplaced wire as a roadmap instead of removing it too early

• Covered stent strategy to manage large dissections safely

Two real-world cases. One disciplined algorithm. A practical discussion for anyone treating complex iliac disease.

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Chapters:

00:00 – Introduction: Recognizing iliac CTO patterns

00:30 – Case 1 overview and waveform clues

01:10 – CTA review and identifying the true stump

01:40 – Femoral access failure → switching to radial R2P

02:20 – Crossing strategy and wire externalization

03:00 – IVUS sizing and covered stent selection

03:40 – Bilateral kissing stents and aneurysm considerations

04:20 – Case 2 overview: prior stent and new CTO

05:00 – False lumen wire as a landmark

05:40 – Radial crossing and externalization

06:10 – Managing dissection with covered stents

06:40 – Final results and key takeaways

#PeripheralIntervention #IliacCTO #IVUS

#CoveredStents #Endovascular #R2P

#PeripheralArteryDisease #MurmurMD

As TAVR expands into younger and lower-risk populations, TAVR explant is no longer a theoretical problem — it’s a real and growing clinical scenario.

In this MurmurMD discussion, Dr. Clinton Kemp and Dr. Matt Summers walk through the indications, technical challenges, and operative considerations involved in TAVR explant, emphasizing why early planning and multidisciplinary alignment are critical for patient outcomes.

Topics covered directly from the transcript include:

• Common indications for TAVR explant, including endocarditis, valve failure, and patient–prosthesis mismatch

• Why TAVR explant is fundamentally different from native SAVR

• Timing considerations: early vs late explant

• How valve type and frame design affect surgical strategy

• Annular, coronary, and aortic root risks during explant

• Managing adhesions and embolization

• When partial explant or valve-in-valve may be preferable

• The importance of preoperative imaging and surgical planning

• Why TAVR explant requires true heart team collaboration

• How explant considerations should influence initial TAVR valve selection

A must-watch discussion for structural heart teams navigating the long-term implications of TAVR therapy.

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Chapters:

00:00 – Why TAVR explant is becoming more common

01:00 – Indications that lead to explant consideration

02:00 – Early vs late TAVR explant: what changes technically

03:00 – Valve design and frame considerations

04:00 – Surgical risks to the annulus, coronaries, and root

05:00 – Managing endothelialization and adhesions

06:00 – When valve-in-valve is not the right answer

07:00 – Imaging and preoperative planning essentials

08:00 – Heart team decision-making for explant cases

09:00 – How explant risk should influence initial TAVR choice

10:00 – Key takeaways for structural programs

#TAVR #StructuralHeart #ValveExplant

#CardiacSurgery #HeartTeam #AorticValve

#InterventionalCardiology #MurmurMD

Iliac CTOs are among the highest-risk, highest-reward procedures in peripheral intervention. In this MurmurMD session, Dr. Jay Mohan joins Dr. Sameh Sayfo to break down their full approach — from diagnosis and CTA planning to crossing strategies, re-entry methods, IVUS, vessel prep, and stent selection.

This case-driven conversation is packed with pearls on how to handle complex iliac occlusions safely and predictably.

What you’ll learn from this transcript-based discussion:

• Why PVR and waveform analysis matter more than ABI alone

• CTA essentials: calcium burden, aorto-iliac disease, access planning

• Jay’s preferred dual-access setup (radial + ipsilateral femoral)

• When to start anti-grade vs retrograde — and how to choose the correct cap

• Safe knuckling with microcatheter support through the CTO

• How to externalize the wire and complete the case through femoral access

• Why “every iliac should be IVUS”

• IVL in the iliac system: M5+, L6, Javelin, and how vessel size determines device choice

• Covered vs uncovered stents (VBX, ICAST, Lifestream, Visi-Pro)

• Why balloon-expandable covered stents dominate TASC C/D and CTO lesions

• When to use kissing stents and when to avoid self-expanding at the common iliac ostium

• Rescue toolkit: covered stents, bright-tip sheaths, alternative access, balloon tamponade

• Why Pioneer re-entry is less common now — and how R2P changed the game

A must-watch for operators who want to sharpen their iliac CTO algorithm and device selection.

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Chapters:

00:00 – Why iliac CTOs are high-risk, high-reward lesions

01:00 – Symptoms, ABI/PVR, waveform interpretation

02:00 – CTA planning: calcium, inflow disease, access strategy

03:00 – Choosing access: radial + ipsilateral femoral

04:00 – Anti-grade vs retrograde crossing strategy

05:00 – Knuckling technique and microcatheter support

06:00 – Re-entry options: R2P vs Pioneer

07:00 – IVUS: why “every iliac should be IVUS”

08:00 – Vessel prep: M5+, L6, Javelin, and when each matters

09:00 – Stent selection: covered vs uncovered, ostial precision

10:00 – Kissing stents and hybrid approaches

11:00 – Rescue toolkit: perforation, sheath size, balloon tamponade

12:00 – Final pearls for early operators

#PeripheralIntervention #IliacCTO #IVL #IVUS

#Endovascular #ComplexPCI #PeripheralArteryDisease #MurmurMD

#VBX #ICAST #R2P #CoveredStents

Not all cardiogenic shock after acute MI is left-sided — and treating it like it is can be fatal.

In this MurmurMD case discussion, Dr. Chris Brown walks through a young patient with acute MI, progressive shock, and severe right ventricular failure, highlighting how early recognition and biventricular mechanical support (Bipella physiology) stabilized the patient when inotropes and balloon support failed.

This transcript-based conversation focuses on real-time decision-making, including:

• Differentiating acute occlusion from chronic disease in an MI presentation

• Why rising troponins without washout suggested ongoing ischemia

• Recognizing RV failure as the primary shock driver

• Why balloon pump and escalating inotropes worsened physiology

• Early RV unloading with RP support as the first step toward BiPella

• Hemodynamic clues that mandated adding LV unloading

• Why RV support should precede LV support in evolving BiPella shock

• PCI strategy once full biventricular support is established

• Renal recovery after unloading both ventricles

• Using BiPella as a bridge to recovery, LVAD, or transplant decision-making

• Why unloading injured myocardium outperforms pharmacologic stimulation

A clear, real-world example of BiPella physiology saving a failing heart when revascularization alone isn’t enough.

Chapters:

00:00 – Acute MI with shock: LV vs RV failure dilemma

01:00 – Troponin trends and evidence of ongoing ischemia

02:00 – Recognizing RV failure as the dominant problem

03:00 – Why balloon pump and inotropes failed

04:00 – Decision to unload the RV first

05:00 – Transitioning toward BiPella physiology

06:00 – Hemodynamics that triggered LV unloading

07:00 – PCI strategy under biventricular support

08:00 – Renal recovery and early organ response

09:00 – Weaning strategy and support sequencing

10:00 – BiPella as bridge to recovery vs advanced therapies

11:00 – Final lessons: unload, don’t overstimulate

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#BiPella #BiventricularSupport #CardiogenicShock

#AcuteMI #MechanicalCirculatorySupport

#Impella #CriticalCareCardiology

#InterventionalCardiology #MurmurMD

A successful valve program isn’t built in the cath lab alone — it’s built in the clinic, the workflow, and the team structure behind the scenes.

In this MurmurMD discussion, Dr. Andrei Pop and Caitlin O'Callaghan Reen, CNP, FACC walk through how they’ve structured and scaled a high-functioning valve clinic, covering everything from referrals and imaging to staffing models and follow-up.

The conversation breaks down what actually works in day-to-day practice, including:

• Why valve clinics must be process-driven, not physician-dependent

• How referral pathways determine procedural volume and case quality

• Organizing clinic flow around echo, CT, and multidisciplinary review

• The role of APPs, nurses, coordinators, and administrators

• Avoiding bottlenecks between clinic, imaging, and procedure scheduling

• Managing TAVR, TEER, and surgical referrals in a single ecosystem

• Pre-visit planning to reduce wasted clinic visits

• Post-procedure follow-up models that prevent patients from being lost

• How data tracking and communication improve outcomes and efficiency

• Common mistakes programs make when scaling too quickly

A practical guide for anyone building, optimizing, or expanding a structural heart valve clinic.

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Chapters:

00:00 – Why valve clinic structure matters

01:00 – Referral pathways and patient intake

02:00 – Clinic workflow and visit organization

03:00 – Imaging coordination: echo, CT, and review

04:00 – Multidisciplinary decision-making

05:00 – Staffing models and role definitions

06:00 – APPs and coordinators as the backbone of the clinic

07:00 – Scheduling procedures without bottlenecks

08:00 – Managing multiple valve therapies in one clinic

09:00 – Pre-visit planning to improve efficiency

10:00 – Post-procedure follow-up and continuity of care

11:00 – Tracking outcomes and operational metrics

12:00 – Common pitfalls when scaling a valve program

13:00 – Final lessons for sustainable growth

#StructuralHeart #ValveClinic #TAVR #TEER

#HeartTeam #HealthcareOperations #Cardiology

#ProgramBuilding #MurmurMD

In this MurmurMD discussion, Dr. Raghava Gollapudi and Dr. Arvin Narula break down how the Watchman TruSteer sheath changes left atrial appendage occlusion (LAAO) workflows — from transeptal access to final device deployment.

The conversation focuses on real-world use, and highlights when TruSteer adds value, how it improves coaxiality, and why many operators are moving toward using it routinely.

Topics covered in this transcript-based discussion include:

• Why earlier Watchman sheaths limited depth and stability

• How TruSteer allows four-directional control (superior, inferior, anterior, posterior)

• Using the device body and sheath as complementary anchoring mechanisms

• Improving coaxial alignment without repeating transeptal puncture

• Why TruSteer reduces redeployments and manipulation

• Large anterior chicken-wing, flat, and posterior appendage anatomy

• Efficiency gains vs cost considerations

• Why some operators now use TruSteer in nearly every case

• Safety pearls: avoiding steering with the dilator in place

• Minimizing air and bubble risk by reducing sheath exchanges

• Achieving zero-leak goals in the Watchman FLX era

A practical discussion for operators looking to improve precision, safety, and efficiency in LAAO.

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Chapters:

00:00 – Introduction to Watchman TruSteer

00:40 – Limitations of earlier Watchman sheaths

01:40 – Four-directional steering and coaxial control

03:00 – Using the sheath vs the device body for positioning

04:10 – Challenging appendage anatomy: chicken-wing and posterior LAA

05:30 – Improving depth without repeating transeptal

06:40 – Efficiency, safety, and air management

08:00 – Cost vs value: when TruSteer adds benefit

09:20 – Zero-leak mindset in the FLX era

10:40 – Safety tips and final takeaways

#LAAO #LAAC #Watchman #TruSteer #StructuralHeart

#InterventionalCardiology #CathLab #MurmurMD

#WatchmanFLX #LeftAtrialAppendage

Redo groins, radiation injury, prior infection, and failed bypasses make common femoral artery disease some of the most difficult decisions in vascular care.

In this case-based discussion, Dr. Nick Mouawad and Dr. Sameh Sayfo walk through two challenging common femoral artery cases where traditional open surgery carried high risk.

Topics covered include:

• Managing CFA bifurcation disease after prior radiation and surgical complications

• Why the profunda femoris artery must always be protected

• Radial-to-peripheral access to avoid hostile groins

• Intravascular imaging to guide vessel sizing and therapy

• When to use IVL, atherectomy, serration balloons, and DCB

• Avoiding stents in the common femoral whenever possible

• Multidisciplinary decision-making for durable outcomes

A practical, honest discussion focused on patient selection, technique, and long-term durability in modern peripheral intervention.

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Chapters:

00:00 – Case setup and goals of discussion

00:45 – Prior pelvic radiation and failed CFA surgery

02:05 – Risks of redo open CFA endarterectomy

03:10 – Why the profunda femoris must be protected

04:20 – Radial access strategy to avoid hostile groins

05:05 – IVUS-guided sizing and IVL preparation

06:00 – Serration balloons and DCB for CFA disease

07:15 – Avoiding stents in the common femoral artery

07:55 – Second case: prior fem-fem bypass and claudication

09:10 – Crossing strategy and imaging uncertainty

10:05 – Orbital atherectomy near bypass anastomosis

11:45 – IVUS, gradients, and confirming success

12:45 – Durability vs redo surgery discussion

14:00 – Multidisciplinary collaboration and MurmurMD

#CommonFemoralArtery #PeripheralArteryDisease #IVL #IVUS #Endovascular #VascularSurgery #RedoGroin #RadialToPeripheral #MurmurMD #MultidisciplinaryCare

Leaflet modification has rapidly evolved from niche innovation to a cornerstone of lifetime TAVR management.

In this discussion, Dr. Toby Rogers joins Dr. Andrei Pop to explore the latest data, device advances, and clinical decision-making behind Basilica, Shortcut, and emerging techniques like Telltale, Unicorn, and leaflet excision.

Key topics covered:

• History of leaflet modification — from LAMPOON to BASILICA and now device-guided procedures

• How Shortcut and Telltale are changing training and access

• Why leaflet modification is still primarily for TAV-in-SAV but expanding to redo-TAVR

• Balancing risk, complexity, and informed consent for lower-risk patients

• Role of CT simulation, FEops, and DASI modeling for lifetime valve planning

• When to err on the side of leaflet modification vs risking coronary obstruction

• Coronary height and valve-to-coronary distance — why those 2–4mm cutoffs aren’t gospel

• Future directions: routine modification, improved washout, and potential HALT reduction

• Access routes (carotid, transcaval, axillary) and practical tips for operators

• Comparing BASILICA, Shortcut, Unicorn, and Telltale—safety, mechanism, and learning curve

• Why new devices need structured trials before widespread use

This is essential viewing for structural heart operators refining TAVR-in-TAVR safety, coronary access strategies, and the future of leaflet modification.

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Chapters:

00:00 – Introduction: The evolution of leaflet modification

00:40 – From LAMPoon to BASILICA: history of electrosurgery

02:00 – Off-label origins and why it mattered

03:00 – Shortcut and Telltale: first commercial systems

05:00 – Who qualifies? High-risk vs lower-risk considerations

06:30 – Lifetime management and early valve planning

08:00 – Simulation tools (3Mensio, FEops, DASI) in valve strategy

09:30 – Challenges in coronary height and valve-to-coronary measurement

12:00 – Surgical perspective: root enlargement and small annuli

13:00 – Rethinking the “risk-based” TAVR vs SAVR decision

15:00 – When to err toward leaflet modification

17:00 – New benefits beyond obstruction: access & flow dynamics

19:00 – Routine modification in the future?

20:00 – Cerebral protection data and operator practices

23:00 – Access routes: transfemoral vs transcarotid approaches

25:00 – Comparing BASILICA, Shortcut, Unicorn & Telltale

28:00 – Risks of balloon-tear methods and lack of validation

30:00 – Data-driven advancement vs anecdotal adoption

31:00 – Future of device design and mitral implications

33:00 – Closing remarks and next frontier: mitral leaflet work

#LeafletModification #BASILICA #Shortcut #Telltale #TAVRinTAVR #ValveinValve

#StructuralHeart #CoronaryProtection #AorticValve #MurmurMD

LIMA interventions are rare, high-risk, and technically unforgiving. In this MurmurMD case session, Dr. Arvin Narula and Dr. Joe Walsh walk through an extremely challenging LIMA-to-LAD lesion involving heavy calcification, tortuosity, failed prior PCI, device entrapment, rotational atherectomy, Shockwave IVL, and management of unexpected graft thrombus.

This discussion delivers real-world strategy, troubleshooting, and device thinking you won’t find in textbooks.

Key insights from the case:

• Why left distal transradial can provide safer LIMA engagement

• The moment a Corsair microcatheter is “chewed up” — and why that signals severe calcium

• How to decide between more support, downsizing, or plaque modification

• When rotational atherectomy is safe in a LIMA graft — and when it’s not

• Why starting the burr in the native LAD, not the graft, may reduce risk

• How dual preparation (Rota + Shockwave) improves expansion

• DCB strategy for distal LAD disease

• Managing LIMA thrombus: ACT troubleshooting, lytics, aspiration, and stent “tattooing”

• Tricks for keeping thrombus from embolizing distally

• How to avoid dissecting the LIMA ostium during exchanges

• What to do if ACT remains subtherapeutic despite multiple boluses

This is an advanced case with invaluable pearls for anyone treating heavily calcified coronaries, bypass graft disease, or LIMA interventions.

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Chapters:

00:00 – Why LIMA interventions are challenging

00:40 – Patient background and LIMA access strategy

01:20 – Tortuosity, calcium, and microcatheter difficulty

02:00 – Deciding to escalate to rotational atherectomy

02:40 – Rota technique and safety considerations in LIMA

03:30 – Adding Shockwave for dual preparation

04:10 – DCB strategy for distal LAD disease

04:50 – Managing sudden LIMA thrombus and low ACT

05:40 – Final result and key takeaways

#ComplexPCI #LIMAIntervention #RotationalAtherectomy #ShockwaveIVL

#DCB #Atherectomy #CoronaryCalcium #InterventionalCardiology

#BypassGraftPCI #CathLab #MurmurMD

Complex mitral valve anatomy continues to challenge even the most experienced TEER operators. In this month's SWAC conference, Dr. Sergio Garcia, Dr. Tom Waggoner, Dr. Mark Bieniarz, and Dr. Aidan Raney walk through how to approach PASCAL therapy in anatomies where leaflet length, clefts, stenosis, and calcification make decision-making difficult.

Using multiple real patient examples, they break down:

• How PASCAL’s separatable clasps change strategy in short posterior leaflets

• When to choose PASCAL vs Pascal Ace based on anatomy

• Managing posterior leaflet restriction, clefts, and deep scallop gaps

• How clasping technique differs from MitraClip

• Imaging keys for procedural success on transesophageal echo

• When to attempt independent clasping—and when not to

• Avoiding iatrogenic mitral stenosis

• What to do when coaptation depth is low or leaflet mobility is asymmetric

• Real-world case outcomes, lessons, and clinical pearls from each scenario

A must-watch for operators training in PASCAL or managing anatomies that push TEER beyond standard degenerative or functional mitral regurgitation.

Chapters:

00:00 – Introduction: Why complex mitral anatomy requires a different strategy

01:00 – Case review overview and PASCAL system fundamentals

01:40 – Leaflet length, calcium, clefts: deciding if TEER is feasible

02:20 – When to choose PASCAL vs Pascal Ace

03:00 – Understanding PASCAL’s independent clasping advantage

03:40 – Case 1: Short posterior leaflet and how to secure a durable grasp

04:20 – Using TEE to confirm leaflet insertion and avoid chordal entanglement

04:50 – Maneuvering around a cleft and choosing the correct landing zone

05:20 – Case 2: Posterior leaflet restriction and reduced mobility

05:50 – Why independent clasping helps unequal coaptation

06:20 – Residual MR strategies: reposition, reclasp, or add a second device

06:50 – Case 3: When coaptation depth is too shallow for a central grasp

07:20 – Recognizing when stenosis risk outweighs TEER benefit

07:45 – Procedural adjustments when leaflet tissue is limited

08:10 – Case 4: Complex functional MR with tenting and asymmetric jets

08:45 – TEE markers for good versus poor grasping zones

09:10 – Post-grasp evaluation: gradients, residual jets, and stability

09:40 – Final thoughts: how PASCAL expands TEER into anatomies once avoided

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#Mitr alValve #TEER #PASCAL #StructuralHeart

#TAVR #HeartTeam #EchoGuidedProcedures #InterventionalCardiology

#MitralRegurgitation #MurmurMD #SWAC