The Murmur Pod

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

🔔 Subscribe for more insights from interventional experts and real-world program builders.

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#Mitr alValve #TEER #PASCAL #StructuralHeart

#TAVR #HeartTeam #EchoGuidedProcedures #InterventionalCardiology

#MitralRegurgitation #MurmurMD #SWAC

The common femoral artery has always been considered a surgical zone—but with today’s endovascular technology, should that dogma be challenged?

In this MurmurMD session, vascular surgeon Dr. Nick Mouawad joins Dr. Sameh Sayfo for a deep dive into how modern tools (IVUS, intravascular lithotripsy, advanced classification systems, and hybrid-OR workflow) are reshaping the way we evaluate and treat common femoral artery disease.

Using real-world experience and early data from investigative studies, the conversation covers:

• When to intervene on common femoral disease

• CTA vs duplex for pre-op planning

• How hybrid ORs change strategy and bailout options

• Key differences between acute limb ischemia vs chronic CLTI femoral exposure

• Why wound complications and groin integrity matter

• Which patients surgeons worry about most

• The rise of IVUS for sizing and anatomical confirmation

• How IVL (M5+, L6) is changing luminal gain and safety

• Why common femoral arteries are far larger than traditionally assumed

• Challenges: lack of large-bore DCBs, bifurcation disease, proximal spillover

• What future device platforms are still missing

• Early trial design lessons comparing IVL + DCB vs endarterectomy

A must-watch for anyone treating inflow disease, CLTI, or evaluating whether femoral interventions can be safely expanded beyond surgery alone.

Chapters:

00:00 – Introduction and setting the stage

01:00 – Why common femoral disease is a “sacred surgical zone”

02:00 – Indications for treating common femoral artery lesions

03:00 – Imaging workup: ultrasound vs CT

04:00 – When hybrid ORs become essential

05:00 – Acute limb vs chronic femoral disease: what changes surgically

06:30 – Groin complications and what surgeons fear most

08:00 – Patient types that raise surgical risk

09:00 – The durability of endarterectomy vs risks in fragile patients

10:00 – Why endovascular solutions matter for modern PAD demographics

11:00 – The biggest danger of early endovascular CFA therapy: dissection

12:00 – What technologies surgeons want when considering endovascular CFA work

13:00 – Calcification patterns and why IVL changed the game

14:00 – IVUS for femoral sizing: why CFA vessels are bigger than we thought

15:00 – Limitations: maximum DCB sizes and when they fall short

16:00 – L6 vs M5+: how the devices differ and when to use each

17:00 – European data on CFA stenting and bifurcation techniques

18:00 – Trial design: how to avoid bias when comparing endo vs open

19:00 – Classification systems (Ozema, Rapolino) and choosing appropriate patients

20:00 – Early lessons from IVL + DCB vs surgery investigation

21:00 – Future technologies needed for CFA therapy

22:00 – Closing thoughts: hybrid strategies and patient selection

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#PeripheralArteryDisease #CommonFemoralArtery #IVL #IVUS

#VascularSurgery #Endovascular #CLTI #PAD #HybridOR

#MurmurMD #L6 #M5Plus #DCB #CalciumModification

ADR (Antegrade Dissection and Re-Entry) has historically been viewed as unpredictable — but with a structured, IVUS-sighted approach, it becomes one of the most consistent and controllable CTO PCI techniques.

In this detailed case walkthrough, Dr. Robert Riley demonstrates how he performs an IVUS-Sighted ADR workflow during a complex RCA CTO. He explains how to select landing zones, create a controlled knuckle, prevent hematoma formation, orient the Stingray system correctly, and re-enter the true lumen with precision.

Topics you’ll learn:

• When ADR is the correct strategy for a long CTO

• Identifying a clean distal landing zone using IVUS

• How to form a stable knuckle with the Pilot 200

• The purpose of de-escalating to Mongo for safer advancement

• Hematoma prevention with guide extension support

• How retrograde angiography guides Stingray orientation

• Vacuum decompression (“straw technique”) for clearing the subintimal space

• Stick-and-drive vs stick-and-swap re-entry patterns

• Using IVUS to confirm true lumen passage and guide stent size

• Avoiding the most common ADR failure modes

This is a foundational training for operators refining modern ADR technique with IVUS guidance.

Chapters:

00:00 – Why ADR still matters in modern CTO PCI

01:00 – When ADR is favored over wire escalation

02:00 – Identifying the distal landing zone with IVUS

03:30 – RCA CTO setup and planning

05:30 – Bifemoral access and guide selection

06:30 – Creating a knuckle with the Pilot 200

08:30 – De-escalating the knuckle and reducing subintimal trauma

10:30 – Guide extension support and pressure control

11:30 – Stingray preparation and system orientation

12:30 – Selecting the correct projection angle

14:00 – Retrograde angiography for confirmation

15:00 – Vacuum decompression (“straw technique”)

17:00 – Stick-and-swap method to regain the true lumen

19:00 – IVUS confirmation and how to size stents correctly

21:00 – Final angiographic review and procedural takeaways

🔔 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/UCfrLYhAhliQ2ZvXinkDCZvA#CTO #ADR #IVUS #InterventionalCardiology #ComplexPCI #Stingray #Pilot200 #MongoWire #CathLab #MurmurMD

TAVR isn’t just a procedure anymore — it’s a lifetime management decision.

In this in-depth case discussion, Dr. Matt Summers and Dr. Aiden Raney dive into how hemodynamics, modeling tools, and device design are reshaping how operators approach valve selection, coronary access, and reintervention planning.

Key insights include:

• Real-world cases showing how valve selection has evolved since 2018

• Using DASI modeling to predict sinus sequestration and coronary risk

• How Shortcut has simplified bilateral leaflet modification and reduced procedure times

• Lessons learned from redo-TAVR failures, pannus formation, and HALT

• Why younger and bicuspid patients still favor surgical approaches

• How commissural alignment and annular eccentricity guide modern valve choice

• When and how to tackle coronary intervention through TAVR frames

• The importance of hemodynamics over “comfort” in valve selection

This is a must-watch for interventional cardiologists aiming to merge clinical intuition with device innovation and predictive modeling for long-term outcomes.

Chapters:

00:00 – Revisiting early valve-in-valve planning

01:00 – How modeling (DOSI) predicts coronary occlusion risk 02:20 – Shortcut vs. Basilica: evolution in leaflet modification 04:00 – Purpose-built devices reducing case time and risk 05:00 – When Shortcut changes your threshold for leaflet splitting

07:00 – Lessons from redo-TAVR and pannus formation 10:00 – Why bicuspid and young patients often need surgery 13:00 – The coronary access problem that taught a hard lesson

16:00 – Commissural alignment as the key to reintervention success

18:00 – Doing left main PCI through a fresh TAVR

20:00 – Horizontal aortas and catheter flexibility

22:00 – Hemodynamics as the foundation of valve choice 24:00 – Building a lifetime valve strategy for every patient

🔔 Subscribe for more insights from interventional experts and real-world program builders.

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

#TAVR #StructuralHeart #ValveInValve #LeafletModification #PredictiveModeling #CommissuralAlignment #InterventionalCardiology #DOSI #CoronaryAccess #MurmurMD