Stent thrombosis is one of the most high-stakes complications in PCI — and getting the mechanism right is everything.

In this MurmurMD case discussion, Dr. Nyal Borges and Dr. Joe Walsh walk through a real-world case of stent thrombosis, focusing on how intravascular imaging (IVUS) guides diagnosis and how drug-coated balloons (DCB) fit into the treatment strategy.

Key discussion points from the transcript include:

• Identifying the underlying cause of stent thrombosis

• Why angiography alone is insufficient in these cases

• Using IVUS to detect under-expansion, malapposition, or mechanical issues

• Stepwise management of thrombus and lesion preparation

• When additional stenting may worsen outcomes

• The role of DCB in avoiding further metal layers

• Optimizing vessel expansion before definitive therapy

• Real-time decision making during a complex thrombotic case

This discussion highlights a critical principle:

stent thrombosis is not just treated — it is diagnosed and corrected with imaging.

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Chapters:

00:00 – Case introduction: stent thrombosis presentation

00:40 – Initial angiographic findings

01:20 – Why imaging is critical in stent thrombosis

02:10 – IVUS assessment and identifying the mechanism

03:10 – Lesion preparation and thrombus management

04:10 – Deciding against additional stenting

05:00 – Role of DCB in treatment strategy

05:50 – Final optimization and imaging confirmation

06:30 – Key lessons for managing stent thrombosis

#StentThrombosis #IVUS #DCB

#ComplexPCI #InterventionalCardiology

#CathLab #CoronaryIntervention #MurmurMD

Successful TAVR depends on precise positioning, controlled deployment, and a clear procedural strategy.

In this MurmurMD discussion, Dr. Nathan Frogge and Dr. Matthew Summers review key TAVR valve implantation techniques (highlighting Cusp Overlap), focusing on how to optimize positioning, manage deployment, and improve procedural outcomes.

Key discussion points from the transcript include:

• Planning valve positioning before deployment

• Understanding anatomy and fluoroscopic views

• Controlling implant depth during deployment

• Techniques for stable and controlled valve release

• Adjusting positioning during the procedure

• Managing procedural challenges during implantation

• Optimizing final valve position and function

• Lessons learned from real-world TAVR experience

This discussion provides practical insights into how experienced operators approach valve implantation to achieve consistent and safe outcomes.

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Chapters:

00:00 – Introduction to TAVR implantation techniques

00:40 – Pre-procedural planning and anatomy

01:30 – Fluoroscopic views and positioning

02:20 – Valve deployment strategy

03:10 – Controlling implant depth

04:00 – Managing positioning adjustments

04:50 – Handling procedural challenges

05:40 – Final valve position and optimization

06:30 – Key takeaways from implantation techniques

#TAVR #StructuralHeart #ValveImplantation

#AorticStenosis #HeartTeam

#InterventionalCardiology #CathLab

#MurmurMD

Ostial RCA disease can be one of the most unforgiving lesions in coronary intervention — especially when multiple layers of stent are already present.

In this MurmurMD case discussion, Dr. Nyal Borges and Dr. Joe Walsh review a challenging PCI involving two layers of stent at the ostial right coronary artery, focusing on how imaging and careful technique guide treatment decisions.

The discussion walks through the key procedural considerations in managing complex ostial stent anatomy, including:

• Evaluating restenosis and mechanical issues in previously stented segments

• Understanding the challenges of ostial RCA stent positioning

• Using intravascular imaging to assess stent expansion and vessel anatomy

• Managing overlapping or layered stent architecture

• Planning intervention when additional metal may worsen long-term outcomes

• Balancing lesion preparation with procedural risk

• Recognizing technical pitfalls unique to ostial coronary disease

This case provides practical insights into how experienced operators approach complex ostial PCI with prior stent layers.

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Chapters:

00:00 – Case introduction: ostial RCA with prior stents

00:40 – Angiographic review and lesion assessment

01:30 – Understanding the challenge of two stent layers

02:20 – Imaging evaluation and vessel sizing

03:20 – Strategy discussion for treating ostial restenosis

04:20 – Device and technique considerations

05:10 – Procedural outcome and imaging review

06:00 – Lessons from managing layered ostial stents

#OstialRCA #ComplexPCI #IVUS

#InStentRestenosis #InterventionalCardiology

#CathLab #MurmurMD

The cusp overlap technique has become an important strategy during TAVR with self-expanding valves to improve implant depth control and reduce conduction disturbances.

In this MurmurMD discussion, Dr. Nathan Frogge and Dr. Matthew Summers walk through how and why they use the cusp overlap technique, focusing on fluoroscopic positioning, implant depth control, and procedural workflow adjustments.

Key discussion points from the transcript include:

• Why implant depth is critical in self-expanding TAVR valves

• The relationship between implant depth and conduction system injury

• How the cusp overlap view improves visualization of the non-coronary cusp

• Fluoroscopic projection setup and imaging angles

• Deployment technique and depth control strategies

• Procedural workflow when using cusp overlap routinely

• Lessons learned from operators using cusp overlap in practice

This discussion provides practical insight into how cusp overlap helps operators control valve implantation and reduce conduction complications during TAVR.

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Chapters:

00:00 – Introduction to cusp overlap technique in TAVR

00:40 – Why implant depth matters for self-expanding valves

01:30 – Conduction disturbances and valve depth

02:20 – Setting up the cusp overlap fluoroscopic view

03:10 – Deployment technique and depth control

04:00 – Workflow adjustments using cusp overlap

05:00 – Imaging and positioning tips

06:00 – Lessons learned and key takeaways

#TAVR #StructuralHeart #CuspOverlap

#SelfExpandingValve #ConductionSystem

#InterventionalCardiology #CathLab

#MurmurMD

As TAVR expands into younger and lower-risk populations, valve durability has become a central question in structural heart care.

In this MurmurMD discussion, Dr. Curtiss Stinis and Dr. Andrei Pop review current understanding of TAVR valve durability, focusing on how clinicians interpret available data and apply it to real-world patient decisions.

The conversation highlights key themes from the transcript, including:

• How durability data for TAVR has evolved over time

• The challenges of comparing surgical and transcatheter valve longevity

• Structural valve degeneration and how it is defined and measured

• The role of patient age and lifetime management strategy

• Imaging and follow-up approaches to monitor valve performance

• Valve-in-valve considerations as transcatheter valves age

• The importance of long-term data as TAVR indications expand

This discussion provides a practical perspective on how clinicians are thinking about durability today while planning for the future of valve therapy.

Chapters:

00:00 – Introduction to TAVR durability discussion

00:40 – Why durability matters more in lower-risk patients

01:30 – Current data on TAVR valve performance

02:30 – Defining structural valve degeneration

03:20 – Surgical vs transcatheter durability considerations

04:10 – Imaging and long-term follow-up

05:10 – Valve-in-valve strategy and future planning

06:00 – Patient selection and lifetime valve management

07:00 – Key takeaways from the discussion

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#TAVR #StructuralHeart #ValveDurability

#AorticStenosis #HeartTeam

#InterventionalCardiology #MurmurMD

Complex coronary PCI often requires careful planning, imaging, and stepwise escalation of technique to achieve a safe and durable result.

In this MurmurMD case discussion, Dr. Chris Brown and Dr. Eric Rothstein review a challenging coronary intervention and walk through the decision-making process used throughout the procedure.

The conversation highlights key aspects of managing difficult coronary anatomy, including:

• Assessing lesion complexity and procedural risk

• Planning the intervention strategy before device escalation

• Using imaging and angiography to guide treatment decisions

• Selecting appropriate wires, balloons, and stent strategy

• Managing resistance during device delivery

• Recognizing when to modify the approach mid-procedure

• Achieving optimal stent expansion and final procedural result

This case review provides practical insight into how experienced operators approach complex coronary interventions in the cath lab.

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Chapters:

00:00 – Introduction to the coronary intervention case

00:40 – Patient presentation and angiographic findings

01:30 – Assessing lesion complexity and procedural planning

02:20 – Initial device strategy and lesion preparation

03:20 – Device escalation and procedural adjustments

04:20 – Stent placement and expansion strategy

05:10 – Imaging review and final optimization

06:00 – Final result and procedural takeaways

#ComplexPCI #CoronaryIntervention

#InterventionalCardiology #CathLab

#CoronaryDisease #PCI

#MurmurMD

Structural heart interventions increasingly involve patients with severe ventricular dysfunction, valvular shock, or limited hemodynamic reserve. In these cases, maintaining stability throughout the procedure can be the biggest challenge.

In this MurmurMD discussion and case review, Dr. Gennaro Giustino and Dr. Andrei Pop review how LAVA ECMO (Left Atrial Veno-Arterial ECMO) can be used to support patients undergoing complex structural heart interventions.

The conversation walks through practical considerations around the use of LAVA ECMO, including:

• Why traditional support strategies can be insufficient during certain structural interventions

• How LAVA ECMO provides effective hemodynamic support in unstable patients

• The physiologic advantages of left atrial drainage

• Procedural setup and access considerations

• How ECMO support can stabilize patients during high-risk valve procedures

• Integrating mechanical circulatory support into structural heart workflows

• Lessons learned from real-world cases using LAVA ECMO

This discussion highlights how advanced support strategies are becoming an important tool for managing high-risk structural heart patients.

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Chapters:

00:00 – Introduction to LAVA ECMO support

00:40 – Why hemodynamic support is needed in structural procedures

01:30 – Physiologic rationale for left atrial drainage

02:20 – How LAVA ECMO differs from traditional ECMO support

03:10 – Procedural setup and access strategy

04:10 – Use of ECMO during structural interventions

05:10 – Managing hemodynamics throughout the procedure

06:00 – Clinical outcomes and lessons learned

06:50 – Key takeaways for structural heart teams

#ECMO #LAVAECMO #StructuralHeart

#MechanicalCirculatorySupport

#CardiogenicShock #InterventionalCardiology

#CathLab #MurmurMD

Cardiogenic shock cases demand rapid recognition, structured thinking, and decisive escalation of support.

In this MurmurMD case discussion, operators review a complex patient presentation with cardiogenic shock and walk through the clinical reasoning that guided management decisions.

The conversation focuses on practical decision-making during shock physiology, including:

• Recognizing early signs of cardiogenic shock

• Interpreting hemodynamics and clinical presentation

• Understanding when medical therapy is insufficient

• Deciding when to escalate mechanical circulatory support

• Balancing revascularization strategy with hemodynamic stability

• Team communication during rapidly evolving cases

• Learning from real-world shock management

This case discussion provides a practical look at how experienced operators approach cardiogenic shock in the cath lab and critical care setting.

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Chapters:

00:00 – Case introduction and patient presentation

00:40 – Recognizing cardiogenic shock physiology

01:20 – Initial management and stabilization strategy

02:10 – Hemodynamic interpretation and decision points

03:10 – Escalating support and procedural considerations

04:00 – Revascularization strategy during shock

05:00 – Clinical course and procedural outcome

06:00 – Key lessons from the case discussion

#CardiogenicShock #MechanicalCirculatorySupport

#InterventionalCardiology #CriticalCareCardiology

#CathLab #MurmurMD

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