The Murmur Pod

Choosing mechanical circulatory support in cardiogenic shock is not simply about picking the device that provides the most flow.

In this MurmurMD discussion, Dr. Aasim Afzal and Dr. Chris Brown break down how temporary MCS should be tailored to the patient’s shock phenotype and ultimate goal — whether that is myocardial recovery, stabilization, LVAD, or heart transplantation.

The discussion covers the different roles of balloon pump, Impella CP, Impella 5.5, and ECMO, including why oxygenation requirements may push a patient toward ECMO, why Impella may be preferred for myocardial unloading and recovery, and how teams can transition patients from ECMO to longer-term temporary support.

The conversation also explores axillary Impella 5.5, ambulation and prehabilitation, transplant listing strategy, protocolized MCS weaning, early intervention in deteriorating shock, and the importance of recognizing RV failure before venous congestion and renal dysfunction create a downward spiral.

KEY TOPICS

• Matching MCS to the shock phenotype

• Balloon pump vs Impella vs ECMO

• Bridge to recovery vs bridge to advanced therapy

• Transitioning from ECMO to Impella 5.5

• Impella 5.5 for transplant and LVAD evaluation

• Axillary access, ambulation, and prehabilitation

• When prolonged ECMO support becomes problematic

• Protocolized Impella weaning

• Lactate, pulse pressure, CPO, and native recovery

• Early intervention before ECPR is required

• RV failure, CVP, venous congestion, and kidney injury

• RP Flex and other right-sided support options

• Team-based decision-making in cardiogenic shock

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CHAPTERS

00:00 – MCS goals: recovery, LVAD, or transplant

07:23 – Choosing support for bridge to recovery

09:33 – Bridge to transplant and advanced therapies

12:15 – Axillary Impella 5.5 and longer-term support

12:47 – Ambulation and prehabilitation on MCS

14:22 – When and how to begin weaning

16:00 – Protocolized Impella weaning and recovery

18:35 – Why early MCS intervention matters

19:57 – RV failure, congestion, and renal dysfunction

21:39 – Right-sided MCS options

23:24 – Why shock decisions should be team-based

#MechanicalCirculatorySupport #MCS #Impella

#Impella55 #ECMO #CardiogenicShock

#HeartFailure #LVAD #HeartTransplant

#RVFailure #CriticalCareCardiology #MurmurMD

AFib stroke prevention is evolving quickly, but the hardest part may be translating the data into real conversations with patients.

In this MurmurMD discussion, Dr. Megan Coyle Wright, an interventional cardiologist, speaks with Dr. Emily Zeitler, an electrophysiologist, about how new data from CHAMPION AF, OPTION, CLOSURE-AF, OCEAN, and ALONE are changing the way clinicians counsel patients about stroke prevention, anticoagulation, ablation, and left atrial appendage occlusion.

The conversation focuses on patient care: what patients actually ask in clinic, how bleeding burden affects quality of life, why shared decision-making matters, and where WATCHMAN may fit for patients undergoing AFib ablation.

A major theme is the growing role of concomitant ablation + WATCHMAN. For EP patients already undergoing ablation, the marginal procedural and logistical burden of adding LAAO may be small in the right setting — but the decision still depends on stroke risk, bleeding risk, patient preference, local operator outcomes, and whether anticoagulation remains the best option.

This is a practical conversation about how to move beyond blanket statements and help patients choose the stroke-prevention strategy that fits their risk profile and priorities.

KEY TOPICS

• How CHAMPION AF and OPTION are changing clinic conversations

• Why patients increasingly ask about getting off anticoagulation

• Bleeding burden, bruising, cost, adherence, and quality of life

• Shared decision-making and asking what patients value most

• Why non-inferiority can be difficult to explain to patients

• Low-risk vs very high-risk patients and where more data are needed

• CLOSURE-AF confusion and why patient selection matters

• Local implant safety, operator outcomes, and patient counseling

• Concomitant ablation + WATCHMAN and why thresholds may be changing

• WATCHMAN referral “sweet spot” from the EP perspective

• Under-treatment of stroke prevention in real-world AFib care

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CHAPTERS

00:00 – Introduction: AFib stroke prevention data

00:28 – CHAMPION, OPTION, and guiding patients

01:15 – How patients and referrals are changing

03:21 – What AFib patients actually care about

05:46 – Stroke, bleeding, and trial endpoint nuance

07:18 – CHAMPION AF and offering patients a choice

08:33 – Where more data are still needed

10:08 – Explaining non-inferiority and “which is better?”

11:09 – Shared decision-making in real clinic conversations

13:48 – CLOSURE-AF, patient selection, and trial differences

15:38 – EP referral sweet spot for WATCHMAN

16:28 – Concomitant ablation + LAAO lowers the threshold

17:50 – Standalone WATCHMAN, access, adherence, and cost

18:50 – Final thoughts: getting therapy to the right patients

#WATCHMAN #LAAO #AFib

#StrokePrevention #AtrialFibrillation

#CHAMPIONAF #OPTIONTrial #CLOSUREAF

#Anticoagulation #SharedDecisionMaking

#Electrophysiology #InterventionalCardiology #MurmurMD

Left atrial appendage closure is entering a new phase.

In this MurmurMD discussion, Dr. Thomas Waggoner speaks with Dr. Jeremiah Depta about how LAA closure is evolving in the era of pulse field ablation, concomitant ablation + LAAO, CHAMPION AF, OPTION, structural heart clinics, and changing program economics.

The conversation centers on a practical question facing interventional cardiologists, electrophysiologists, and health systems:

Who owns the appendage now, and how should programs grow without losing focus on patient outcomes?

Dr. Depta and Dr. Waggoner discuss whether LAA closure should remain a structural heart procedure, shift toward EP-led concomitant workflows, or develop into a broader heart-team model where patient identification matters more than specialty ownership.

KEY TOPICS

• Growth of LAA closure and persistent under-penetration

• EP vs structural heart roles in appendage closure

• Concomitant ablation + LAAO after PFA and OPTION

• CHAMPION AF and possible future indication expansion

• Standalone LAAO vs concomitant procedural strategy

• Capacity, lab block time, reimbursement, and throughput

• Same-day discharge and workflow considerations

• Why valve clinics may be an underused LAAO funnel

• Screening AFib patients in TAVR, mitral, and tricuspid clinics

• Using existing valve CT imaging for LAAO planning

• Shared decision-making and patient counseling

• Coordinator-driven clinic scaling and program growth

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CHAPTERS

00:00 – Introduction: LAA closure in a changing landscape

01:07 – The shift: standalone, concomitant, and program growth

02:43 – PFA, OPTION, CHAMPION AF, and growth projections

05:16 – Who owns the appendage now?

08:23 – Does specialty change who gets identified?

12:06 – EP, PFA, and concomitant strategy

13:43 – Throughput: combined cases vs capacity limits

18:24 – EP block time and downstream program costs

23:20 – Standalone LAAO is not just leftover volume

28:33 – CHAMPION AF and the future playing field

34:31 – Broader indications and patient identification

38:22 – Shared decision-making and heart-team questions

41:52 – Why the valve clinic may be the hidden LAAO funnel

48:44 – Using valve CTs for appendage planning

52:31 – Screening workflows in valve clinic

58:08 – Scaling clinic capacity with coordinators

1:00:39 – Final takeaway: identification matters most

#LAAO #LeftAtrialAppendageClosure #Watchman

#StructuralHeart #Electrophysiology #AFib

#PulseFieldAblation #CHAMPIONAF #OPTIONTrial

#ValveClinic #HeartTeam #MurmurMD

The new TAVR National Coverage Determination brings some of the biggest changes structural heart programs have seen in years.

In this MurmurMD discussion, Dr. Andrei Pop, Dr. Jeremiah Depta, and Samantha Ramos break down the new CMS TAVR NCD and what it means for patients, operators, and valve programs.

The conversation covers the removal of Coverage with Evidence Development for symptomatic severe aortic stenosis, new requirements for asymptomatic patients, major changes to heart-team evaluation, single-operator TAVR, operator volume requirements, removal of prior hospital volume criteria, registry participation, quality improvement, and how programs should respond operationally.

KEY TOPICS

• Symptomatic severe AS no longer under CED

• Asymptomatic severe AS covered only through CMS-approved CED studies

• Coverage gap before the asymptomatic protocol is approved

• One in-person operator evaluation instead of two separate specialty visits

• Heart-team decision-making still required

• Single-operator TAVR now allowed

• New operator volume requirements

• Removal of prior hospital volume thresholds

• On-site surgical and ICU infrastructure requirements

• TAVR registry no longer specifically mandated

• Registry participation vs broader CQI requirements

• Aortic regurgitation and moderate AS coverage questions

• How programs should interpret and implement the new flexibility

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CHAPTERS

00:00 – What changed in the new TAVR NCD

02:23 – Heart-team evaluation and single-operator TAVR

05:23 – Asymptomatic severe AS and CED coverage

14:28 – One visit, one operator, and program workflow

28:32 – New TAVR operator volume requirements

36:41 – New program and satellite-site possibilities

37:58 – Registry requirements and quality improvement

45:30 – Aortic regurgitation and moderate AS coverage

50:25 – Low-flow, low-gradient AS and heart-team judgment

52:18 – What TAVR programs should do now

55:18 – Why thoughtful CMS comments mattered

58:01 – Closing thoughts

#TAVR #TAVRNCD #CMS #StructuralHeart #AorticStenosis #HeartTeam #TAVRProgram #Medicare #Reimbursement #ValveProgram #InterventionalCardiology #MurmurMD

Cardiology is changing: clinically, operationally, financially, and politically.In this MurmurMD discussion, Dr. Andrei Pop speaks with Cathleen Biga, past president of the American College of Cardiology and former president of Cardiovascular Management of Illinois, about the forces reshaping cardiology practice.The conversation covers Cathie’s path from bedside nursing to practice management, hospital leadership, cardiovascular service line growth, MedAxiom leadership, and becoming the first non-physician president of the ACC.But the core of the discussion is bigger than one career. It is about how cardiologists can better understand the business, policy, and team-based systems that shape daily practice.Cathie and Andrei discuss why private practice voices need to be involved in professional societies, why local ACC chapters and legislative advocacy matter, how MedAxiom helps practices learn from data and peers, how APPs can improve access and sustainability, and why physicians must understand site neutrality, fee schedules, technical fees, professional fees, and coverage decisions.The biggest takeaway:Physicians cannot expect the system to represent them if they are not involved in shaping it.KEY TOPICS• Cathie Biga’s path from bedside nursing to ACC president• Why leadership can come from many backgrounds• Private practice representation in the ACC• Getting involved locally through chapters and advocacy• Legislative conference and understanding policy• MedAxiom, practice data, and dyad leadership• APPs, access, training, and team-based care• Nocturnal APP coverage and reducing call burden• The possible return of independent cardiology practice• Physician autonomy, governance, and professionalism• Site neutrality and why it matters financially• Coverage decisions, RUC surveys, and physician engagement🔔 Subscribe for more insights from interventional experts and real-world program builders.📱 Download the app: https://apps.apple.com/app/apple-store/id1586692687📺 Follow us on YouTube: https://www.youtube.com/channel/UCfrLYhAhliQ2ZvXinkDCZvACHAPTERS00:00 – Introduction: Cathie Biga’s career and ACC leadership04:16 – Why private practice voices matter in the ACC09:43 – How cardiologists can get involved locally12:01 – Legislative conference and physician advocacy14:42 – MedAxiom, practice data, and dyad leadership18:43 – APPs, access, training, and team-based care23:01 – Nocturnal APP coverage and reducing call burden29:03 – Is private practice cardiology coming back?36:09 – Why independent practice can bring joy back to medicine39:34 – Site neutrality and why cardiologists should care46:03 – Coverage decisions, RUC surveys, and getting a voice53:37 – Why constructive engagement matters56:21 – Closing thoughts#Cardiology #CardiologyPractice #ACC #MedAxiom #PrivatePractice #TeamBasedCare #APPs #HealthcarePolicy #SiteNeutrality #PhysicianAdvocacy #CardiovascularCare #MurmurMD

Coronary IVL has changed how many operators treat calcified coronary disease, but the technology is still evolving.

In this MurmurMD discussion, Dr. Nyal Borges speaks with Dr. Matthew Price from Scripps about SEISMIQ, Boston Scientific’s investigational IVL catheter, and where it may fit in the coronary calcium-modification toolkit.

The discussion breaks down how SEISMIQ differs from current IVL platforms. Instead of using electrical energy, SEISMIQ uses laser energy delivered through fiber optics to strike tungsten emitters, creating a plasma event that generates acoustic pressure waves inside the balloon. The device uses a quad-pole emitter design intended to deliver energy in a more circumferential 360-degree pattern.

Dr. Price also walks through a severe calcified RCA case from the trial experience, including lesion selection, angiographic calcium, OCT assessment, balloon delivery, IVL treatment, stenting, post-dilatation, OCT-guided optimization, and management of a proximal edge dissection.

The broader conversation focuses on where SEISMIQ may fit alongside Shockwave, Aero, rotational atherectomy, orbital atherectomy, and other calcium-modification strategies.

KEY TOPICS

• SEISMIQ as an investigational coronary IVL platform

• Laser-generated acoustic pressure waves

• Fiber optic energy delivery and tungsten emitters

• Quad-pole emitter design and 360-degree energy delivery

• Potential advantages in eccentric calcium and nodules

• Pulse capacity and selective emitter control

• Severe calcified RCA trial case

• OCT-guided lesion assessment and final optimization

• Deliverability compared with current IVL platforms

• Pressure monitoring during IVL therapy

• IVL-first calcium modification strategy

• Where rotational atherectomy still fits

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CHAPTERS

00:00 – Introduction: SEISMIQ and calcium modification

02:24 – Trial background and severe calcified RCA case

04:24 – Defining severe coronary calcification

06:38 – IVL-first strategy vs rotational atherectomy

08:12 – How SEISMIQ works: laser, fiber optics, and tungsten emitters

10:13 – Quad-pole emitters and 360-degree energy delivery

12:08 – Selective emitter control and pulse capacity

15:36 – Device delivery and visible emitter positioning

17:23 – Balloon prep, pressure monitoring, and treatment workflow

20:44 – Treating the full lesion and avoiding missed calcium

22:36 – OCT, stenting, edge dissection, and final result

24:16 – Deliverability and next-generation device considerations

25:58 – Where SEISMIQ may fit in the IVL toolkit

28:22 – Why atherectomy still matters

30:02 – Final thoughts

#SEISMIQ #IVL #IntravascularLithotripsy #CoronaryCalcium #CalciumModification #ComplexPCI #ShockwaveIVL #Aero #RotationalAtherectomy #OCT #InterventionalCardiology #MurmurMD

Mechanical circulatory support in cardiac surgery is not just a bailout strategy- it can be a way to prevent the shock cascade before it becomes difficult to reverse.

In this MurmurMD discussion, Dr. Chris Brown speaks with Dr. Robert Farivar about how he uses mechanical support before, during, and after cardiac surgery.

Dr. Farivar explains why the EACTS-STS guidance reinforces a practice pattern he has followed for years: identify patients early, intervene before low-output states spiral, and avoid relying too long on escalating inotropes when mechanical support may better protect end-organ function.

The conversation compares balloon pump support, Impella CP, Impella 5.5, ECMO, and biventricular Impella strategies. It also goes deep on Dr. Farivar’s direct aortic Impella 5.5 technique, when axillary placement makes sense, how he manages support during surgery, and why right-sided recovery often requires patience.

KEY TOPICS

• Preventing shock before the cascade starts

• Balloon pump limitations and select use cases

• Impella CP vs Impella 5.5 support levels

• Impella 5.5 vs ECMO tradeoffs

• ECMO venting, limb, bleeding, and Harlequin concerns

• Direct aortic Impella 5.5 placement technique

• Axillary Impella stability and device migration risk

• EF less than 35% in major cardiac surgery

• Rising lactate as a low-output warning sign

• Avoiding prolonged inotrope escalation

• Escalating from CP to 5.5 before surgery

• Managing Impella 5.5 during cardiopulmonary bypass

• Echo-guided weaning and myocardial recovery

• Biventricular Impella support and RV recovery timeline

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CHAPTERS

00:00 – Introduction: mechanical support in surgery

01:03 – Preventing shock before it spirals

02:40 – Balloon pump limitations

04:04 – Impella CP, Impella 5.5, and ECMO

05:26 – Impella 5.5 vs ECMO tradeoffs

08:01 – Impella 5.5 placement options

08:41 – Direct aortic Impella 5.5 technique

11:07 – Who should get perioperative MCS?

13:20 – Rising lactate and limits of inotropes

15:39 – Rescue support when patients cannot come off bypass

17:24 – Direct aortic vs axillary stability

20:59 – Pre-surgical shock and CP-to-5.5 escalation

23:12 – Managing Impella 5.5 during surgery

24:53 – Echo assessment, pulsatility, and weaning support

27:51 – Biventricular Impella support and RV recovery

30:19 – Closing thoughts

#MechanicalCirculatorySupport #Impella55 #Impella #ECMO #CardiacSurgery #CTsurgery #CardiogenicShock #HeartFailure #MCS #ShockPrevention #MurmurMD

Below-the-knee disease remains one of the most difficult areas in vascular intervention: small vessels, severe calcification, acute recoil, aggressive restenosis, and patients who often present with CLTI, diabetes, CKD, wounds, and limited surgical options.

In this MurmurMD discussion, Dr. Sameh Sayfo speaks with Dr. S Jay Mathews about the evolution of below-the-knee disease treatment — from plain balloon angioplasty to IVUS-guided therapy, laser, atherectomy, scoring and cutting balloons, IVL, drug therapy, and emerging scaffold technologies.

The conversation focuses on why BTK intervention is different from other vascular beds, why durable outcomes have historically been difficult, and how newer calcium-modification tools may help operators achieve better acute results while setting up more effective definitive therapy.

The discussion also includes real-world cases showing how IVL and combination therapy can be used across challenging vascular territories, including BTK disease, common femoral disease, profunda protection, and subclavian occlusion.

KEY TOPICS

• Why below-the-knee vessels are uniquely challenging

• CLTI vs claudication indications for BTK intervention

• Angiosome-directed revascularization and inline flow

• IVUS for morphology, sizing, calcium, and device selection

• Acute recoil, dissection, restenosis, and intimal hyperplasia

• Evolution from PTA to atherectomy, laser, IVL, and scaffolds

• When IVL is a standalone prep tool vs adjunctive therapy

• Javelin, E8, M5 Plus, and other IVL platform considerations

• Laser plus IVL in complex fibrocalcific disease

• Common femoral IVL and profunda preservation

• Subclavian occlusion, body floss, and focal stenting strategy

• Future IVL platforms and the changing role of atherectomy

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CHAPTERS

00:00 – Introduction: evolution of below-the-knee disease treatment

00:52 – Why BTK vessels are so challenging

01:49 – CLTI vs claudication: when to treat below the knee

03:16 – Choosing the target vessel and angiosome strategy

05:28 – What IVUS has taught us about BTK disease

07:10 – Recoil, dissection, and why acute results may not last

08:32 – Evolution of tools: atherectomy, laser, balloons, and scaffolds

10:39 – Retrievable and drug-eluting scaffold concepts

12:23 – Matching lesion prep to definitive therapy

14:58 – Why IVL became attractive for BTK disease

15:56 – IVL adoption and platform differences

17:26 – Javelin, E8, and IVL as adjunctive therapy

19:28 – Case 1: CLTI, CKD, wounds, laser, and IVL

25:02 – Case 2: Common femoral disease and M5 Plus

28:58 – Case 3: Subclavian occlusion and IVL-assisted strategy

33:00 – Future IVL platforms and expanding applications

36:15 – How IVL is changing atherectomy use

36:55 – Conference discussion and closing thoughts

#BelowTheKnee #BTK #CLTI #LimbSalvage #PeripheralIntervention #IVUS #IVL #IntravascularLithotripsy #Javelin #E8 #Atherectomy #PeripheralArteryDisease #MurmurMD

As TAVR moves into younger patients, the first implant is no longer just about getting a good result today, it may determine every future option.

In this MurmurMD discussion, Dr. Nathan Frogge and Dr. Andrei Pop review the concept of optimizing the index TAVR implant, using the CODE framework: coaxiality, orientation, depth, and expansion.

The conversation is a candid look at where TAVR technique is headed, and where the evidence still has gaps. They discuss whether the field is standardizing true best practice or simply codifying expert opinion, how much optimization is worth pursuing, and when a technically “suboptimal” result may actually be the safest choice for the patient.

The discussion covers commissural alignment, coronary access, cusp overlap, implant depth, pacemaker risk, valve expansion, pre- and post-dilatation, underexpansion, TAV-in-TAV planning, and a practical case example showing how these tradeoffs come together in real time.

KEY TOPICS

• Why the index TAVR implant matters more as patients live longer

• CODE framework: coaxiality, orientation, depth, and expansion

• Limits of consensus guidance and the need for better data

• Minimalist TAVR vs “perfectionist” TAVR

• Commissural alignment and future coronary access

• Implant depth, pacemaker risk, and redo TAVR options

• Cusp overlap and radiolucent-line techniques

• Pre-dilatation and post-dilatation tradeoffs

• Underexpansion, pinwheeling, HALT, and valve durability

• TAV-in-TAV and lifetime management planning

• Case example: balancing valve size, calcium, coronary access, and pacemaker risk

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CHAPTERS

00:00 – Introduction: optimizing the index TAVR implant

01:44 – CODE framework: coaxiality, orientation, depth, and expansion

03:57 – Consensus vs data: how much do we really know?

06:15 – Why optimization always involves tradeoffs

09:02 – Minimalist vs perfectionist TAVR

15:39 – CODE recommendations and operator concerns

18:53 – Implant depth, pacemakers, and redo TAVR planning

23:20 – Pre-dilatation, post-dilatation, and expansion

30:16 – Cusp overlap, radiolucent line, and deployment technique

39:32 – Valve clinic planning and future redo scenarios

42:03 – Underexpansion, double tap, and durability concerns

52:49 – Case example: sizing, calcium, and high implant strategy

1:03:27 – The need for more predictable TAVR deployment

1:05:03 – Final thoughts on volume, data, and lifelong planning

#TAVR #StructuralHeart #AorticStenosis #TAVRinTAVR #RedoTAVR #ValveDurability #CuspOverlap #CommissuralAlignment #LifetimeManagement #InterventionalCardiology #MurmurMD

This MurmurMD case discussion features Dr. Chris Brown and Dr. Christian McNeely walking through a high-risk PCI case where the hardest part was not just the calcium, it was deciding when and how to intervene safely.

The patient was an 82-year-old frail female who presented with chest pain and NSTEMI. Angiography showed heavily calcified distal left main disease, proximal circumflex disease, a tight calcified mid-LAD, moderate LV dysfunction, and an occluded RCA. She was transferred for surgical evaluation, but then developed neurologic changes while on heparin and was found to have a small amount of bleeding in a prior meningioma resection bed.

That created a difficult clinical problem: surgery was no longer feasible, anticoagulation and antiplatelet therapy carried real neurologic risk, and the coronary anatomy still needed treatment.

The discussion focuses on practical decision-making in a case with limited bailout options: waiting for stable neuro imaging, rechallenging heparin, checking rapid CYP2C19 genotype to support a short-DAPT plan, using Impella support, planning access with CTA, modifying severe calcium with rotational atherectomy and Shockwave IVL, preserving the circumflex with a nano-crush style strategy, and carefully managing closure and anticoagulation reversal.

KEY TOPICS

• Frail elderly NSTEMI patient with severe calcified left main/LAD/circ disease

• Neurologic complication after heparin in prior meningioma resection bed

• Timing PCI after stable serial neuro imaging

• Short-DAPT planning and rapid CYP2C19 testing

• Why hemodynamic support was used

• CTA planning for calcified tortuous iliac access

• Rotational atherectomy to facilitate equipment delivery

• IVUS delivery challenges and imaging limitations

• Shockwave IVL for distal left main/LAD/circumflex calcium

• Rewrap advantage when moving IVL from LAD to circumflex

• Nano-crush style left main bifurcation strategy

• Deciding whether to treat the remaining RCA CTO

• Hybrid closure strategy and partial protamine reversal

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CHAPTERS

00:00 – Case setup: frail NSTEMI patient with limited options

01:16 – Neuro bleeding complication and why surgery became high risk

02:18 – Waiting, serial scans, and timing high-risk PCI

03:08 – Short-DAPT planning and rapid CYP2C19 testing

04:18 – Why Impella support was chosen

04:46 – CTA planning for calcified iliac access

06:09 – PCI plan: LAD priority with circumflex involvement

06:31 – Rotational atherectomy to start the case

07:05 – IVUS delivery challenges and calcium assessment

09:02 – Shockwave IVL for severe calcified disease

09:37 – Rewrap performance and treating the circumflex

10:09 – Nano-crush style bifurcation strategy and final result

10:31 – What to do with the RCA CTO?

12:11 – Closure strategy, ACT control, and protamine reversal

13:18 – Outcome and final takeaways

#ComplexPCI #HighRiskPCI #LeftMainPCI #NSTEMI #Impella #ShockwaveIVL #RotationalAtherectomy #CoronaryCalcium #IVUS #BifurcationPCI #MurmurMD