The Murmur Pod

Transcatheter tricuspid valve replacement is quickly becoming a real option for patients with severe symptomatic TR, but the decision-making is still nuanced.

In this MurmurMD discussion, Dr. Aidan Raney speaks with Dr. Sameer Gafoor, about a Septuagenarian female with severe non-rheumatic tricuspid regurgitation, NYHA class III symptoms, prior mechanical mitral valve replacement, persistent AFib on warfarin, prior stroke, EF around 44%, RV dilation, moderately reduced RV function, TAPSE 1.1, and severe TR.

The case focuses on why Dr. Gafoor's team favored transcatheter tricuspid valve replacement over edge-to-edge repair, how they approached CT and echo sizing, and how they moved their program from TEE-guided TTVR toward ICE-only TTVR, including a pathway from general anesthesia with TEE and ICE to conscious sedation with ICE.

The discussion also covers key questions every TTVR program has to answer: surgical risk scoring, RV dysfunction, anticoagulation, pacemaker risk, working room, valve sizing, procedural imaging, fluid status matching, and what patients should expect after intervention.

KEY TOPICS

• Severe symptomatic non-rheumatic TR

• TTVR vs edge-to-edge repair decision-making

• Surgical risk vs tricuspid-specific risk scores

• RV dysfunction, TAPSE, and when to say no

• CT sizing vs TEE and ICE measurements

• Annular and basal RV oversizing

• Working room, RA height, RV height, and RV depth

• ICE-only TTVR workflow development

• Anchor position, commissures, and deployment assessment

• Matching fluid status between CT and procedure

• Anticoagulation requirements after TTVR

• Pacemaker risk and lifetime management questions

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CHAPTERS

00:00 – Introduction: TTVR case from Swedish Hospital

00:32 – Patient presentation: severe TR, AFib, MVR, stroke, and RV dysfunction

01:22 – Surgical consult, CT, TEE, and risk scoring

02:52 – Choosing intervention: repair vs replacement

03:52 – CT sizing, TEE discrepancy, and oversizing

04:53 – Working room: RA height, RV depth, and delivery space

05:35 – Moving from TEE-guided to ICE-only TTVR

07:54 – ICE setup, MPR views, and valve orientation

09:11 – Deployment assessment and anchor position

10:34 – Final result and key lessons learned

12:06 – Q&A: surgical risk scores and tricuspid-specific tools

13:56 – RV dysfunction and when to avoid TTVR

15:35 – Post-procedure support and Swan discussion

15:59 – ICE workflow as primary imaging strategy

17:28 – Closing thoughts

#TTVR #TricuspidValve #TricuspidRegurgitation #StructuralHeart #CardiacImaging #ICE #TEE #ValveReplacement #RightHeartFailure #TranscatheterValveReplacement #MurmurMD

Tricuspid regurgitation is no longer just a disease managed with diuretics and observation.

In this MurmurMD discussion, Matt Summers is joined by Dr. Josh Cohen, structural heart imaging director, to discuss the rapid growth of tricuspid valve intervention, the central role of imaging, and how teams are thinking through repair versus replacement strategies.

The conversation focuses on why TR has become such a major structural heart focus, how common and clinically impactful moderate-to-severe TR really is, and why imaging — especially 3D multiplanar reconstruction — is critical for deciding whether a patient should undergo edge-to-edge repair or be evaluated for transcatheter tricuspid valve replacement.

They also discuss the shift from treating advanced screen-fail patients to identifying patients earlier in the disease course, the safety profile of TriClip, the evolving role of EVOQUE, and why tricuspid programs need a structured workflow around volume optimization, TEE assessment, RV function, pulmonary pressures, and CT screening.

KEY TOPICS

• Why TR is becoming a major structural heart focus

• The clinical burden of moderate-to-severe TR

• Functional, lead-associated, and degenerative TR

• Why isolated surgical TR outcomes have been challenging

• Growth of TriClip, EVOQUE, and other tricuspid therapies

• 3D MPR and imaging-guided procedural planning

• Repair-first thinking in frail or advanced TR patients

• Repair vs replacement decision-making

• RV remodeling, symptoms, and heart failure admissions

• Volume optimization before intervention

• TEE as the pivot point for repair vs TTVR screening

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CHAPTERS

00:00 – Introduction: tricuspid intervention and imaging focus

03:10 – Why 3D imaging changes tricuspid planning

05:12 – How common and impactful TR really is

08:07 – Functional, lead-associated, and degenerative TR

09:45 – Why isolated surgical TR has been difficult

10:46 – Repair, replacement, and emerging device options

12:24 – TriClip, EVOQUE, safety, and patient selection

13:45 – Why a repair-first strategy may make sense

16:17 – Symptoms, RV remodeling, and heart failure reduction

18:23 – Real-world program experience and outcomes

20:26 – Workflow: inpatient consults, volume status, and TEE

22:25 – Choosing repair vs CT screening for TTVR

#TricuspidValve #TricuspidRegurgitation #StructuralHeart #TriClip #EVOQUE #TTVR #CardiacImaging #TEE #3DMPR #HeartFailure #ValveDisease #MurmurMD

LV pacing during TAVR can simplify workflow, reduce reliance on RV temporary pacing, and potentially avoid one of the most dreaded complications in the cath lab: RV perforation and tamponade.

In this MurmurMD discussion, Dr. Aidan Raney speaks with Dr. Thom Dahle, Director of the Valvular Heart Disease Program at St. Cloud Hospital, about LV pacing best practices and early experience with the SoloPace System.

The conversation reviews why LV pacing may offer advantages over traditional RV pacing, how operators can improve capture and wire positioning, and how a dedicated pacing platform may reduce variability during balloon valvuloplasty and valve deployment.

The discussion includes a live TAVR workflow using SoloPace, highlighting practical features such as capture check, operator-controlled pacing algorithms, backup pacing after deployment, and simplified room setup.

KEY TOPICS

• Why operators are moving from RV pacing to LV pacing

• RV pacing lead perforation and tamponade concerns

• Easy TAVI data and LV pacing rationale

• LV wire positioning and capture best practices

• Why capture can initially look “wonky” during LV pacing

• Using hemodynamics to confirm effective capture

• SoloPace Fusion wire as a workhorse TAVR wire

• Capture check and automated pacing workflows

• Balloon-expandable vs self-expanding pacing algorithms

• Backup pacing after valve deployment

• How SoloPace may improve lab efficiency and reduce communication errors

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Chapters:

00:00 – Why LV pacing may be safer and more efficient

00:57 – LV pacing rationale and Easy TAVI data

02:23 – Traditional LV pacing setup and capture challenges

04:11 – Wire positioning best practices in the LV

06:31 – St. Cloud’s experience moving toward SoloPace

09:05 – SoloPace Fusion wire and dedicated system setup

12:00 – Live case workflow and LV pacing setup

16:00 – Capture check, safety features, and valve deployment prep

20:19 – Fusion wire connection and automated backup pacing

22:11 – TAVR deployment using SoloPace

25:05 – What happens if heart block occurs after deployment?

27:04 – Pacing algorithms for balloon-expandable and self-expanding valves

29:28 – Efficiency, room setup, and final impressions

#TAVR #LVpacing #SoloPace

#StructuralHeart #AorticStenosis

#ValveReplacement #CathLab

#InterventionalCardiology #MurmurMD

Tricuspid intervention is not just a device procedure, it is an imaging-driven, two-person operation.

In this MurmurMD case discussion, Dr. Summers and Dr. Cohen walk through a series of tricuspid valve repair and replacement cases that highlight how procedural success depends on imaging precision, anatomy recognition, fluoroscopy correlation, and real-time teamwork between the imager and interventionalist.

KEY TOPICS

• Why tricuspid repair is fundamentally imaging-driven

• Imager and interventionalist collaboration during TriClip

• Using TEE, 3D MPR, transgastric views, ICE, and fluoroscopy together

• Clip strategy near the anterior-septal commissure

• Leadless pacemakers near the septal leaflet

• ICD and CS lead interaction with the tricuspid valve

• Lead repositioning/corralling before clipping

• Lead extraction followed by persistent torrential TR

• Two-clip strategies that create an annuloplasty-like effect

• When TTVR may be favored over repair

• TTVR planning around leadless devices, flail leaflets, wire position, and leaflet capture

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Chapters:

00:00 – Why tricuspid repair is an imaging procedure

04:40 – Case 1: TriClip with a leadless pacemaker

10:00 – How TriClip reconstructs the tricuspid valve

11:20 – Case 2: CRT leads, lead interaction, and clipping strategy

19:14 – Case 3: Torrential TR after lead extraction

27:12 – Fluoroscopy, parallax, and clip orientation

28:01 – Case 4: Acute leaflet flail and TTVR planning

36:10 – Final takeaways on imaging, leads, and tricuspid strategy

#TricuspidValve #TriClip #TTVR #TricuspidRegurgitation #StructuralHeart #CardiacImaging #TEE #ICE #LeadRelatedTR #ValveRepair #InterventionalCardiology #MurmurMD

Successful valve programs are not built by procedures alone.

In this MurmurMD discussion, Dr. Andrei Pop speaks with Sandra Lauck, a valve specialist in British Columbia at the Center for Heart Valve Innovation, about the essential role of valve program clinicians in building efficient, patient-centered structural heart programs.

The conversation explores why the term “coordinator” often undersells the role, how these clinicians support patients and families from referral through discharge, and why their work is central to timely treatment, early discharge, communication, shared decision-making, and program growth.

KEY TOPICS

• Why valve program clinicians are not simply “coordinators”

• Clinical triage, urgency assessment, and patient education

• Early discharge planning and shared decision-making

• Benchmark, same-day discharge, and patient expectations

• Training, competencies, and career development for valve clinicians

• Standardized pathways, single referral systems, and avoiding silos

• Moving from procedure-focused clinics to disease-centered valve programs

• The future of nurse-led research and integrated mitral/tricuspid care

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

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Chapters:

00:00 – Introduction: Sandra Locke and the valve clinician role

01:08 – Why successful valve clinics depend on clinicians

02:34 – From coordinator to clinical heart-team member

04:02 – Patient expectations, discharge planning, and trust

06:05 – Three pillars: clinical care, communication, and program leadership

08:11 – Training, competencies, and growing the role

12:32 – How valve clinicians affect length of stay and efficiency

15:17 – Avoiding silos across competing valve teams

18:43 – Referral delays and the case for automatic valve clinic pathways

20:03 – Valve clinic vs TAVR clinic

21:45 – Moving toward disease-centered valve programs

23:31 – Longitudinal valve care and proactive planning

24:33 – What comes next: research, staffing, and integrated valve care

#StructuralHeart #ValveClinic #TAVR

#HeartTeam #ValveProgram #Benchmark

#NurseLedCare #PatientCenteredCare

#AorticStenosis #MurmurMD

What do you do when a calcified RCA CTO case stalls, your equipment will not deliver, and conventional reverse CART strategy becomes difficult?

In this MurmurMD discussion, Dr. Chris Brown and Dr. Eric Rothstein review a challenging CTO case involving a 57-year-old patient with five years of angina, a large ischemic RCA territory, prior LAD treatment without symptom improvement, and a heavily calcified RCA CTO.

The case evolves through several classic CTO decision points: upfront ADR consideration, side-branch anchoring, architectural knuckle formation, intralesional ambiguity, retrograde septal crossing, difficulty joining tissue planes, and ultimately the use of intravascular lithotripsy to modify calcified subintimal/extraplaque space and facilitate reverse CART.

KEY TOPICS

• RCA CTO with long-standing angina and ischemia

• Hybrid CTO strategy and switching approaches mid-case

• Side-branch anchor technique for guide support

• Large architectural knuckle vs small knuckle strategy

• Intralesional ambiguity and how to define the vessel course

• Retrograde septal crossing strategy

• Why guide extension delivery can fail in calcified CTOs

• IVL use in the subintimal/extraplaque space

• Shockwave to facilitate reverse CART

• Trapping, microcatheter delivery, and externalization

• IVUS interpretation after CTO crossing

• Conservative sizing in the subintimal space

• Why IVL may be preferable to atherectomy in this setting

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Chapters:

00:00 – Key concept: microcatheter delivery and externalization

00:22 – Case introduction

00:44 – Patient presentation: 57-year-old with five years of angina

01:45 – RCA CTO anatomy, J-CTO score, and initial strategy

02:46 – Failed knuckle formation and need for more guide support

03:28 – Side-branch anchor technique in the conus

04:44 – Large architectural knuckle strategy

05:54 – Intralesional ambiguity and CTO decision-making

06:54 – Options: bigger knuckle, BASE, Carlino, or retrograde definition

07:55 – Switching to retrograde strategy

08:57 – Septal surfing and retrograde crossing

11:00 – Retrograde support, guide extension limits, and plaque modification

12:16 – Balloons fail to expand in the subintimal space

14:00 – Shockwave IVL to modify calcified CTO architecture

15:00 – Anchor technique to deliver larger equipment

15:39 – Retrograde wire choice for reverse CART

17:07 – Moving the reverse CART strategy proximally

19:01 – Wiring the guide vs snaring

19:50 – Balloon trapping to deliver the microcatheter

20:50 – Externalization with R350 or RG3

21:13 – IVUS: true lumen, subintimal space, and hematoma

22:10 – Ballooning, stent sizing, and conservative expansion

22:49 – Final IVUS and result

23:27 – Why IVL may be safer than atherectomy in the extraplaque space

24:23 – Closing thoughts and key learning points

#CTO #ComplexPCI #IVL #IntravascularLithotripsy #ShockwaveIVL #ReverseCART #RCACTO #CoronaryCalcium #InterventionalCardiology #CathLab #MurmurMD

TAVR explant was once viewed as a procedure to avoid almost at all costs. Early national data showed very high mortality, creating fear among both physicians and patients.

In this MurmurMD discussion, Dr. Andrei Pop speaks with Dr. Shinichi Fukuhara, from the University of Michigan, about how the field has evolved, and why newer data may change the conversation around TAVR explant, redo TAVR, and lifetime management of aortic stenosis.

The discussion explores why TAVR explant outcomes have improved, how patient selection has changed, what the latest STS data suggest, and why isolated TAVR explant may now be far more reasonable in carefully selected patients than many clinicians assume.

KEY TOPICS

• Why early TAVR explant mortality created fear

• Improved outcomes in more recent STS data

• Isolated TAVR explant vs more complex explant cases

• Tall-frame vs short-frame explant considerations

• Why high-volume centers may matter

• Hidden surgical findings after valve removal

• TAVR-first as a possible strategy in selected younger patients

• What a “perfect” index TAVR result should include

• Coronary access, commissural alignment, and tissue ingrowth

• Why lifetime management requires strong heart-team decision-making

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Chapters:

00:00 – Introduction: why TAVR explant matters

01:03 – Early STS data and why explant was feared

02:52 – Why outcomes have improved over time

03:57 – Isolated TAVR explant and recent mortality data

06:11 – New STS risk prediction for post-TAVR surgery

07:24 – Tall-frame vs short-frame explant considerations

08:44 – Can TAVR explant outcomes be democratized?

11:16 – Why center experience may matter

12:05 – Unexpected findings after TAVR explant

12:58 – Lifetime management and risk modeling

14:19 – TAVR-first as a possible strategy

15:32 – Which younger patients may fit a TAVR-first approach?

17:25 – What a “perfect” index TAVR result requires

19:04 – Heart-team decision-making

19:19 – Tissue ingrowth, coronary access, and future risk

21:10 – What surgeons see during explant

#TAVR #TAVRExplant #StructuralHeart

#AorticStenosis #RedoTAVR #LifetimeManagement

#HeartTeam #CardiacSurgery #InterventionalCardiology

#MurmurMD

Some complex PCI cases are difficult because of the anatomy. Others are difficult because the margin for error is almost zero.

In this MurmurMD discussion, Dr. Chris Brown and Dr. Christian McNeely walk through a high-risk NSTEMI case involving an elderly Jehovah’s Witness patient with severe multivessel coronary disease, heavily calcified distal left main disease, reduced EF, anemia, elevated filling pressures, and an occluded RCA.

The central issue is not just how to treat the lesion, it is how to think through risk when both options are dangerous: surgery is preferred but not feasible, while PCI requires hemodynamic support and large-bore access in a patient who cannot receive blood products.

KEY TOPICS

• High-risk NSTEMI with severe multivessel disease

• Unprotected calcified distal left main disease

• Low EF, high EDP, anemia, and occluded RCA

• Jehovah’s Witness status and refusal of blood products

• Why CABG was not feasible at the time

• Impella-supported PCI and large-bore access risk

• Counseling when bleeding may be fatal

• Limits of current complex PCI risk calculators

• Shockwave IVL in the distal left main

• Ostial left main recognition and stent positioning

• Provisional circumflex strategy

• Closure technique after large-bore access

• Planning for staged RCA intervention

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Chapters:

00:00 – Case introduction and risk stratification

00:41 – High-risk NSTEMI and severe multivessel disease

01:33 – Calcified distal left main and limited RCA options

02:20 – Jehovah’s Witness status and why CABG was not feasible

03:02 – Why hemodynamic support was needed

04:30 – Anemia, no blood products, and surgical thresholds

05:15 – Why this anatomy is truly complex

06:34 – Counseling around bleeding risk and large-bore access

08:25 – The need for better complex PCI risk calculators

10:18 – Operator risk tolerance and institutional support

11:44 – Femoral access, Impella support, and high EDP

12:16 – Shockwave IVL and loss of pulsatility

13:30 – LAD/left main stenting with circumflex preservation

14:35 – Ostial left main positioning and cusp view

15:34 – Final optimization and provisional circumflex access

16:25 – Large-bore closure with no bleeding

17:08 – Planning the staged RCA intervention

18:33 – Final thoughts on risk, consent, and complex PCI

#ComplexPCI #HighRiskPCI #LeftMainPCI

#Impella #MechanicalCirculatorySupport

#ShockwaveIVL #CoronaryCalcium

#InterventionalCardiology #CathLab #MurmurMD

Below-the-knee CLTI is rarely straightforward especially in patients with diabetes, dialysis, medial arterial calcification, toe wounds, gangrene, and misleading ABIs.

In this MurmurMD discussion, Dr. Sameh Sayfo is joined by Dr. Michael Siah, vascular surgeon at UT Southwestern, to review real-world vascular cases using intravascular lithotripsy, including Javelin and E8 strategies for tibial and pedal disease.

The conversation focuses on how IVL-based therapy fits into a modern limb-salvage algorithm, especially when conventional balloons, support catheters, or crossing tools do not behave the way operators expect.

KEY TOPICS

• CLTI patients with gangrene, toe wounds, diabetes, ESRD, and MAC

• Why ABIs can be misleading in below-the-knee disease

• Using x-ray and MAC burden to anticipate difficulty

• Javelin for proximal cap modification, even when it does not fully cross

• E8 for tibial, plantar, and below-the-ankle calcium modification

• Balloon sizing philosophy with low-pressure IVL

• Avoiding embolization and perforation concerns compared with atherectomy

• Pedal loop access, body floss, and long posterior tibial CTO treatment

• IVL after inadequate PTA to avoid or optimize scaffolding

• Wound blush, toe pressure improvement, and limb-salvage endpoints

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Chapters:

00:00 – Introduction: vascular IVL experience and case series

00:56 – Case 1: Hallux gangrene and anterior tibial target

02:35 – Angiography, failed support catheter delivery, and Javelin

04:37 – Javelin as proximal cap modification when it does not cross

07:05 – Final result: wound blush and an E8-like outcome

07:38 – Why avoid atherectomy in discrete BTK disease?

09:26 – Case 2: Non-healing toe amputation and high MAC burden

10:16 – Distal PT occlusion and plantar perfusion strategy

10:50 – E8 below the ankle with strong wound blush

12:28 – Why larger IVL balloons can be safe at low pressure

15:12 – Case 3: Normal ABI but low toe pressure and tibial CTOs

17:36 – Failed antegrade PT crossing and pedal loop strategy

18:32 – Javelin for long PT and plantar treatment

19:32 – Final result: flow through the pedal loop and toe pressure improvement

20:58 – Case 4: Prior failed crossing and no clear AT origin

22:32 – Retrograde pedal access and subintimal angioplasty

23:38 – E8 after inadequate PTA result

24:27 – IVL as vessel prep before deciding on scaffolding

25:30 – Closing thoughts

#PeripheralIVL #IntravascularLithotripsy #CLTI

#LimbSalvage #BTK #BelowTheKnee

#Javelin #E8 #PeripheralIntervention

#VascularSurgery #PAD #MurmurMD

Coronary IVL has changed the way operators approach calcified coronary disease, but the mechanism is often underappreciated because the device is so simple to use.

In this MurmurMD discussion, Dr. Chris Brown and Dr. Yousif Ahmad walks through a complex calcified coronary case and then breaks down the mechanism of action behind coronary intravascular lithotripsy.

The conversation focuses on Aero: improved deliverability, rewrap, and multivessel treatment in heavily calcified anatomy.

Key topics include:

• Severe calcified coronary disease in a high-risk patient

• Using IVL with minimal lesion preparation

• Deliverability through tortuous, calcified anatomy

• Re-advancing a used IVL balloon after treatment

• Why rewrap performance matters

• Treating multivessel calcified disease more efficiently

• Practical cautions around shorter pause times

• How IVL fractures calcium while limiting vessel injury

• Circumferential 360-degree energy delivery

• Deep calcium penetration and broader energy distribution

• Why coronary IVL has become a major calcium-modification tool

This is a practical discussion for operators who want to understand not just that IVL works, but why it works, and how device iteration may change day-to-day calcium strategy.

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📺 Follow us on YouTube: https://www.youtube.com/channel/UCfrLYhAhliQ2ZvXinkDCZvA

Chapters:

00:00 – Introduction: coronary IVL case and mechanism discussion

00:17 – High-risk calcified coronary case presentation

01:47 – Minimal lesion prep and Aero IVL deliverability

02:34 – Moving, re-advancing, and reusing the IVL balloon

04:41 – Why rewrap performance changes workflow

06:04 – Final treatment strategy and angiographic result

07:06 – When IVL may replace default atherectomy

08:33 – Aero design changes: tip, coating, balloon material, and rewrap

09:08 – Practical caution: shorter pauses and ischemic time

10:45 – How IVL changes multivessel calcium treatment

11:32 – Mechanism of action: pressure waves and calcium fracture

12:32 – Consistent energy delivery and 120 pulses

13:31 – Circumferential 360-degree energy delivery

14:06 – Deep calcium penetration and broader treatment effect

15:13 – Why IVL is simple to use but complex underneath

16:01 – Closing thoughts

#CoronaryIVL #IntravascularLithotripsy #Aero

#CoronaryCalcium #CalcifiedLesions

#CalciumModification #ComplexCoronary

#InterventionalCardiology #MurmurMD