The Murmur Pod

In this MurmurMD discussion, Dr. Chetan Huded reviews the major trial data shaping modern LAA closure decision-making, including PROTECT AF, PREVAIL, PRAGUE-17, CLOSURE-AF, OPTION, and CHAMPION AF.

The conversation focuses on the real clinical question facing physicians today:

Can LAA closure match DOAC therapy for stroke prevention while reducing long-term bleeding risk?

Key topics include:

• LAA closure vs DOACs for stroke prevention

• PROTECT AF, PREVAIL, PRAGUE-17, OPTION, CLOSURE-AF, and CHAMPION AF

• Watchman FLX safety and modern outcomes

• Amulet data and peri-device leak discussion

• Stroke risk vs bleeding risk over time

• Device-related thrombus and leak as ongoing concerns

• Shared decision-making and patient selection

This discussion breaks down the nuance behind the headlines and offers a practical framework for counseling patients considering appendage closure.

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Chapters:

00:00 – Why LAA closure trials matter

02:17 – DOACs: effective, but bleeding risk persists

04:10 – Evolution of LAA closure devices

05:10 – PROTECT AF, PREVAIL, and early Watchman data

09:09 – Watchman FLX and improved procedural safety

11:01 – Amulet IDE and next-generation data

12:56 – LAAO vs DOACs: modern trial landscape

13:41 – PRAGUE-17 and CLOSURE-AF

16:53 – OPTION and CHAMPION AF

20:03 – Why trial results may appear conflicting

21:45 – Stroke, bleeding, DRT, and leak takeaways

26:41 – Ablation, rhythm control, and combined strategies

31:19 – Q&A: who should stay on medication?

40:42 – Practical clinic takeaways

49:31 – Risk buckets for shared decision-making

54:45 – Final thoughts on patient selection

#LAAO #LeftAtrialAppendageClosure #Watchman

#WatchmanFLX #Amulet #DOAC

#AtrialFibrillation #StrokePrevention

#CHAMPIONAF #CLOSUREAF #OPTIONTrial

#StructuralHeart #InterventionalCardiology #MurmurMD

Drug-coated balloons are creating new options in complex coronary intervention, but only when the lesion is prepared correctly.

In this MurmurMD discussion, Dr. Nyal Borges and Dr. Pratik Sandesara walk through a practical, case-based approach to contemporary DCB use, focusing on ISR, calcific neoatherosclerosis, underexpanded stents, and bifurcation disease.

The conversation starts with a severe LAD ISR case involving jailed diagonal branches and an under expanded stented segment. The operators discuss how imaging guides the diagnosis, why calcific atherosclerosis often requires atherectomy, when OPN and high-pressure balloons matter, and why DCB may be preferable to adding another layer of metal.

They then move into a challenging LAD/diagonal bifurcation case, where the strategy becomes a hybrid approach: DES for the main LAD and DCB for the diagonal branch.

Key topics include:

• A practical framework for treating ISR

• Differentiating tissue ISR, stent fracture, and mechanical under expansion

• Why calcific atherosclerosis is so difficult to treat

• Rotational atherectomy inside a stent

• OPN and high-pressure balloon optimization

• Imaging-guided vessel preparation before DCB

• When to avoid adding another stent layer

• DCB for jailed side branches and bifurcations

• Cutting balloon strategy for de novo vessel prep

• Using physiology to assess side branch stability after DCB

• Why DES and DCB may be complementary rather than competitive

This is a detailed, operator-level conversation on where DCB fits today — and why the success of DCB depends less on the balloon itself and more on diagnosis, imaging, and meticulous vessel preparation.

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Chapters:

00:00 – Introduction: DCB in contemporary complex PCI

00:51 – Case 1: Severe LAD ISR with jailed diagonal branches

01:48 – A practical framework for image-guided ISR treatment

02:25 – Calcific neoatherosclerosis vs neointimal hyperplasia

03:20 – Mechanical underexpansion and calcium behind the stent

04:20 – Why imaging matters before choosing a DCB strategy

06:00 – DCB after vessel prep: when another stent layer is avoidable

08:00 – Why this ISR lesion is high risk for recoil

10:17 – Why OPN or IVL may not be enough in dense ISR calcium

11:35 – Rotational atherectomy inside a stent

15:09 – Long NC balloons, OPN, and confirming expansion

16:26 – Wire strategy and practical OPN considerations

18:00 – Post-treatment imaging and deciding whether to use DCB

20:04 – Why DCB may be attractive in LAD ISR with jailed branches

21:30 – What if you need to extend the stent?

25:24 – Case 2: Complex LAD/diagonal bifurcation disease

30:07 – IVUS assessment of LAD/diagonal anatomy

31:09 – Hybrid strategy: LAD stent plus diagonal DCB

31:46 – Cutting balloon and vessel prep for de novo DCB

36:10 – Using pressure wire to assess side branch stability

40:05 – When DES still makes sense in high-jeopardy anatomy

42:00 – DCB timing in bifurcation workflows

45:06 – Should you evaluate the side branch after provisional stenting?

46:02 – Final angiogram and optimization

47:10 – Future role of hybrid DES + DCB strategies

#DCB #ComplexPCI #DrugCoatedBalloon

#ISR #InStentRestenosis #CoronaryCalcium

#BifurcationPCI #IVUS #RotationalAtherectomy

#InterventionalCardiology #MurmurMD

For years, the biggest limitation of coronary IVL wasn’t its ability to modify calcium- it was deliverability.

In this MurmurMD discussion, Dr. Yousif Ahmad and Dr. Chris Brown review early real-world experience with Aero, ⁨@ShockwaveMedical⁩ IVL platform designed to improve crossability, flexibility, rewrap, and treatment efficiency in calcified coronary anatomy.

The discussion focuses on how Aero changes day-to-day decision-making around calcium modification, including:

• Why deliverability has historically limited IVL use

• How Aero’s tapered tip, redesigned shaft, flexible balloon material, and longer hydrophilic coating improve performance

• Why 120 pulses matter for longer calcified segments

• Delivering Aero through tortuous LAD/diagonal anatomy

• Using Aero in heavily calcified distal left main bifurcation anatomy

• When atherectomy is still needed before IVL

• Why rewrap performance may be one of Aero’s biggest advantages

• Treating multiple vessels with the same IVL balloon

• Reduced need for guide extension, repeat balloons, and device exchanges

• How Aero may shift IVL earlier in the calcium-modification algorithm

This is a practical device-focused discussion on how a seemingly incremental design change may meaningfully change how operators approach complex coronary calcium.

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Chapters:

00:00 – Why Aero matters: IVL’s deliverability limitation

01:00 – What changed: tip, shaft, coating, and balloon design

02:00 – Tortuous LAD/diagonal anatomy and Aero deliverability

04:00 – When Aero may reduce the need for atherectomy

04:30 – Distal left main bifurcation calcium: atherectomy plus Aero

06:30 – Rewrap performance and multivessel treatment

08:00 – Fewer guide extensions, fewer exchanges, fewer ruptures

09:30 – How Aero may change the coronary calcium algorithm

11:00 – Final thoughts: why this upgrade surprised operators

#Aero #IVL #IntravascularLithotripsy #CoronaryCalcium

#CalcifiedLesions #LeftMain #Atherectomy

#InterventionalCardiology #MurmurMD

What happens when a patient has critical limb-threatening ischemia, severe calcification, no distal targets, and has failed traditional endovascular therapy?

In this MurmurMD discussion, Dr. Andres Vargas Estrada and Dr. Sameh Sayfo explain the evolution of Deep Vein Arterialization (DVA/TADV) and why it has become a powerful option for patients previously considered "no-option" candidates.

The conversation explores the changing landscape of peripheral artery disease, the rise of small artery disease and medial arterial calcification, and why conventional therapies often fail in advanced CLTI patients.

Key topics include:

• Why today's CLTI patients are different than those of the past

• The impact of diabetes, dialysis, and severe calcification

• Understanding the MAC score and predicting treatment failure

• Why traditional tibial interventions often fall short

• The role of vessel preparation before advanced therapies

• How Javelin, IVL, and bioresorbable scaffolds fit into modern limb salvage

• The history and evolution of Deep Vein Arterialization

• How DVA reroutes blood flow to preserve limbs when no arterial options remain

This discussion highlights one of the most innovative shifts in peripheral intervention: when arteries can't be reopened, use the veins.

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Chapters:

00:00 – Why CLTI remains one of the biggest challenges in vascular care

03:00 – The shift from large artery disease to small artery disease

05:00 – Using the MAC score to identify no-option patients

07:00 – Modern tools: Javelin, IVL, and bioresorbable scaffolds

10:00 – The origins and evolution of Deep Vein Arterialization

13:00 – How DVA works and why it can salvage limbs

18:00 – Patient selection and practical considerations

22:00 – Future directions in limb salvage

#DeepVeinArterialization #DVA #CLTI

#LimbSalvage #PeripheralArteryDisease

#Endovascular #PeripheralIntervention

#CriticalLimbIschemia #MurmurMD

Intracardiac masses have traditionally meant high-risk surgery — but transcatheter approaches are changing what’s possible in structural and endovascular intervention.

In this MurmurMD discussion, Dr. Abdallah El Sabbagh and Dr. Andrei Pop review the evolving role of transcatheter removal of intracardiac masses, focusing on procedural planning, imaging guidance, device strategy, and patient selection.

Key discussion points from the transcript include:

• Types of intracardiac masses considered for transcatheter removal

• Imaging strategies for procedural planning and guidance

• Access considerations and device positioning

• Managing embolic risk during extraction

• Technical challenges unique to intracardiac mass removal

• Patient selection and procedural decision-making

• Real-world lessons from complex intracardiac cases

• The expanding role of minimally invasive intracardiac intervention

This discussion provides a practical look at how transcatheter techniques are creating new options for managing intracardiac masses without open surgery.

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Chapters:

00:00 – Why transcatheter intracardiac mass removal is evolving

01:30 – Imaging and procedural planning

03:30 – Access strategy and device positioning

05:30 – Managing embolic risk and technical challenges

07:30 – Patient selection and case considerations

09:00 – Key lessons and future direction

#StructuralHeart #IntracardiacMass

#TranscatheterIntervention

#InterventionalCardiology #CardiacImaging

#Endovascular #MurmurMD

Building a successful LAAO program requires more than procedural skill — it depends on workflow efficiency, team coordination, and scalable systems.

In this MurmurMD discussion, Dr. Vijay Iyer and Dr. Joe Walsh break down the key drivers behind LAAO program efficiency and growth, focusing on how high-performing programs optimize patient flow, referrals, procedural planning, and long-term expansion.

Key discussion points from the transcript include:

• Improving workflow efficiency in LAAO programs

• Referral pathways and program growth strategies

• Streamlining patient evaluation and scheduling

• Building coordination across the heart team

• Procedural efficiency and lab workflow optimization

• Managing follow-up and longitudinal patient care

• Identifying bottlenecks that slow program growth

• Lessons learned from scaling successful LAAO programs

This discussion provides practical insights into how structural heart teams can grow LAAO programs while improving efficiency and patient care.

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Chapters:

00:00 – Why LAAO program efficiency matters

01:30 – Referral pathways and program growth

03:30 – Streamlining workflow and patient evaluation

05:30 – Team coordination and procedural efficiency

07:30 – Managing follow-up and long-term care

09:00 – Lessons learned from scaling LAAO programs

#LAAO #StructuralHeart #Watchman

#LeftAtrialAppendageClosure

#ProgramGrowth #HeartTeam

#InterventionalCardiology #MurmurMD

As TAVR expands into younger and lower-risk patients, one question continues to drive decision-making: how durable are transcatheter valves over time?

In this MurmurMD discussion, Dr. Robert W. Yeh reviews his late-breaker at CRT26, the Evolut valve durability data, focusing on long-term outcomes and what they mean for real-world clinical practice with Dr. Matthew Summers.

Key insights from the transcript include:

• Long-term performance of self-expanding Evolut valves

• How durability is assessed and measured over time

• Structural valve degeneration and clinical relevance

• Comparing durability expectations in TAVR vs surgical valves

• Patient selection and lifetime management considerations

• What durability data means for younger TAVR patients

• How evolving evidence may shape future practice

This discussion provides a focused look at how durability data is influencing TAVR decision-making today and into the future.

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Chapters:

00:00 – Why valve durability matters in TAVR

01:00 – Overview of Evolut durability data

02:30 – Structural valve degeneration and outcomes

04:30 – Comparing TAVR vs surgical durability

06:00 – Clinical implications for patient selection

07:30 – Key takeaways and future direction

#TAVR #Evolut #ValveDurability

#StructuralHeart #AorticStenosis

#InterventionalCardiology #MurmurMD

High-risk PCI isn’t just about technique — it’s about protecting the patient while you fix the artery.

In this MurmurMD discussion, Dr. Chris Brown and Dr. Yousif Ahmad walk through the role of left ventricular (LV) support in complex PCI, focusing on when to escalate, how to think about hemodynamics, and why support can change the entire strategy.

Key insights from the discussion include:

• Identifying patients who qualify as high-risk PCI

• Recognizing when hemodynamics may deteriorate during intervention

• Deciding when to use LV support devices

• How support changes procedural planning and execution

• Balancing complete revascularization with patient stability

• Real-time decision-making during complex cases

• Lessons learned from managing high-risk coronary interventions

This discussion highlights a critical shift in mindset:

in high-risk PCI, success depends as much on support strategy as it does on technical skill.

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Chapters:

00:00 – What defines high-risk PCI

01:00 – Hemodynamic risk and patient selection

02:30 – When to escalate to LV support

04:00 – How support changes PCI strategy

06:00 – Procedural decision-making under support

07:30 – Outcomes and key takeaways

#HighRiskPCI #LVSupport #ComplexPCI

#MechanicalCirculatorySupport

#InterventionalCardiology #CathLab #MurmurMD

The Champion AF trial is one of the most important studies in structural heart — directly comparing left atrial appendage closure (LAAC) to DOAC therapy in patients with atrial fibrillation.

In this MurmurMD discussion, Dr. Saibal Kar and Dr. Thomas Waggoner break down the Champion AF data, focusing on what the results actually mean for clinical practice and how they may shift long-term management strategies.

Key themes from the transcript include:

• The rationale behind comparing LAAC to DOAC therapy

• Trial design and patient population

• Key outcomes and how to interpret them

• Safety and efficacy considerations

• Where LAAC fits in the treatment algorithm today

• How these results may impact future guidelines and patient selection

This discussion offers a practical, real-world interpretation of a pivotal trial — and what it means for stroke prevention in atrial fibrillation moving forward.

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Chapters:

00:00 – Overview of Champion AF and why it matters

01:00 – Trial design and patient selection

03:00 – Key outcomes and results interpretation

05:30 – Safety and procedural considerations

07:00 – LAAC vs DOAC: how to think about it clinically

08:30 – What this means for practice and future direction

#ChampionAF #LAAClosure #AtrialFibrillation

#StrokePrevention #StructuralHeart

#Watchman #InterventionalCardiology #MurmurMD

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