The Murmur Pod

TAVR has come a long way—from a high-risk bailout procedure to a precision-driven, patient-specific therapy.

In this MurmurMD case discussion, Dr. Matt Summers (Sentara Heart Valve Center) joins Dr. Aiden Raney to explore how new data, AI modeling, and simulation tools like DASI are transforming how interventionalists choose between self-expanding and balloon-expandable valves. A real look into contemporary approaches to valve therapy decisions.

Key insights covered:

• The evolution from procedural survival to lifetime valve strategy

• How hemodynamics and durability data are reshaping valve selection

• Using predictive modeling (DASI) to prevent annular rupture and coronary occlusion

• Real-world lessons from redo TAVR and valve-in-valve procedures

• Why commissural alignment and cusp overlap have changed the game

• What next-generation AI tools mean for precision TAVR planning

• How large-volume centers are integrating data, imaging, and simulation into every case

This conversation bridges clinical intuition with digital precision, offering a glimpse into how the next era of TAVR will be designed—patient by patient, model by model.

Chapters:

00:00 – Introduction and evolution of TAVR therapy

01:00 – From high-risk to precision: how TAVR decision-making has evolved

02:30 – Valve selection: BEV vs SEV and the 16 decision factors

04:00 – Durability, hemodynamics, and small annulus data

06:00 – What the SMART and Notion trials revealed about performance

08:00 – Coronary access, explant, and the penalty of being wrong

10:00 – AI modeling and pre-procedural simulation (DASI)

12:00 – Predicting rupture, occlusion, and leaflet modification needs

14:00 – Impact of modeling on procedural planning and outcomes

16:00 – Planning for the second valve: true lifetime management

18:00 – Future vision: Precision TAVR through AI-guided design

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#TAVR #StructuralHeart #InterventionalCardiology #MurmurMD #PredictiveModeling #DASI #ValveSelection #HeartValve #CathLabInnovation

Physicians Building Devices: Powering the Next Wave of Cardiovascular Innovation

Not in boardrooms—but in cath labs, by operators sharing cases, data, and ideas in real time.

In this episode, Dr. David Daniels and Dr. Joe Walsh dive into how platforms like MurmurMD are connecting physicians, engineers, and startups to accelerate device innovation from the front lines of interventional cardiology.

Key themes and insights:

• Why innovation starts with operators identifying real problems in the lab

• How peer-to-peer case sharing is shortening the feedback loop between users and builders

• Turning complication management into product-development insight

• The role of data transparency and outcomes sharing in improving next-gen designs

• Collaborating across teams—engineers, industry, and interventionalists—without silos

• Why speed, iteration, and feedback now define modern cardiovascular innovation

• A preview on physician-built ecosystem for device advancement

This is essential viewing for clinicians, startups, and innovators who believe the future of medtech is built inside the cath lab, not outside it.

00:00 – Intro: Building devices from inside the cath lab

01:00 – Why innovation begins with frustration in the lab

02:15 – From case sharing to concept generation

03:30 – Turning complications into design opportunities

05:00 – The value of rapid feedback between operators and engineers

07:00 – Data as fuel: how shared outcomes guide better devices

09:00 – Creating a two-way bridge between clinicians and companies

11:00 – Vision: crowdsourced device evolution

12:30 – Real-time learning → real-time innovation

14:00 – How open conversation accelerates safe experimentation

15:30 – Next steps: empowering physician-engineer collaboration

🔔 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#MedTech #DeviceInnovation #MurmurMD #InterventionalCardiology #StructuralHeart

#CathLab #ClinicalInnovation #PhysicianEntrepreneur #MedicalDevices #MurmurMDLive

Can creating a shunt between the left atrium and the coronary sinus improve symptoms for patients with heart failure with preserved ejection fraction (HFpEF)?

In this in-depth discussion, Dr. Andrei Pop and Dr. Firas Zahr, PI of the ALT-FLOW II Trial, explore the science, physiology, and patient selection behind one of the most intriguing new frontiers in interventional heart failure.

Key takeaways:

What makes ALT-FLOW different from previous intra-atrial shunt devices

How shunt location, size, and flow patterns affect outcomes

Which heart failure patients respond best — HFpEF, HFrEF, or mixed phenotypes

Why resting wedge pressures don’t predict exercise hemodynamics

The importance of exercise right heart catheterization and PCWL measurement

Insights on stroke risk and why preserving the atrial septum may matter for lifetime procedures

How ALT-FLOW maintains procedural simplicity and safety through the coronary sinus approach

Expanding the field of interventional heart failure and device-based diastolic therapies

This conversation is essential for structural heart and heart failure specialists exploring new options for symptomatic HFpEF patients in the modern era of shunt-based therapy.

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Chapters:

00:00 – Intro: The rise of interventional heart failure

00:45 – What makes the ALT-FLOW device unique

01:20 – Lessons learned from prior shunt trials

02:30 – Which patients may benefit most

04:00 – Persistent symptoms after valve repair and TAVR

05:00 – Stroke risk and shunt design safety

06:30 – Importance of preserving the interatrial septum

07:00 – Exercise right heart catheterization and PCWL

08:30 – What exercise reveals about true physiology

10:30 – When wedge pressures tell the real story

12:00 – Expanding tools for diastolic dysfunction

13:30 – Sham control and endpoint selection in ALT-FLOW II

15:30 – Heart failure specialists re-engaging with HFpEF

17:00 – Pacemaker leads and coronary sinus access

18:00 – Future of interventional heart failure

19:30 – Industry, innovation, and economics of device therapy

21:00 – Safety data and operator experience so far

23:00 – Future: Finding the right HFpEF subsets

24:30 – Closing reflections and next steps in research

#ALTFlow #HFpEF #HeartFailure #StructuralHeart #InterventionalCardiology #CoronarySinusShunt #HeartFailureDevice #CathLab #MurmurMD

How do surgeons decide when to place an Impella 5.5 before valve surgery?

In this discussion, Dr. Roland Hernandez walks through his operative approach with Dr. Chris Brown, covering:

Patient selection: when balloon pump isn’t enough support

Step-by-step technique for direct aortic Impella 5.5 insertion

How to tunnel and remove the graft safely

Technical pearls for cross-clamp position and avoiding flooding

Strategies for weaning from bypass to Impella

Common hazards: wire and catheter challenges for surgeons

Why mobilization is critical and when Impella CP isn’t enough

This case-based conversation offers a rare surgeon-to-interventionalist perspective on advanced mechanical circulatory support.

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

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Chapters:

00:00 – Intro & guest background

00:45 – Patient case: severe LV dysfunction, AI + MR

02:10 – Why Impella 5.5 over balloon pump

03:20 – Preemptive strategy & surgical planning

03:40 – Direct aortic Impella 5.5 implantation technique

04:45 – Graft tunneling, closure, and removal details

06:20 – Operative sequence & bypass setup

08:10 – Positioning, cross-clamp, and cannulation pearls

09:00 – Valve replacement + Impella insertion steps

10:20 – Weaning from bypass to Impella support

12:00 – Technical challenges: wires & catheters

13:20 – Axillary vs supraclavicular approach considerations

14:30 – Hazards of clamp position & LV flooding

15:45 – Manipulating the device intra-op

16:10 – Deciding level of support: index, EF, gestalt

17:20 – Post-op outcomes, shock scenarios, and red flags

18:40 – Mobilization benefits: why 5.5 beats CP

20:00 – Closing thoughts & key lessons

#Impella #MechanicalSupport #CardiacSurgery #AVR #InterventionalCardiology #TAVR #HeartFailure #MCS #Impella55 #MurmurMD

What really drives gradients after TAVR-in-TAVR—and do they actually matter?

In this conversation, Dr. Amr Abbas and Dr. Andrei Pop break down the nuances behind gradient measurements, patient-prosthesis mismatch (PPM), and valve expansion strategy in redo TAVR.

Key takeaways include:

• Why echo gradients differ from invasive gradients even under identical hemodynamics

• Understanding discordance between flow and pressure in post-TAVR assessment

• Why PPM is less concerning in normal-flow patients than previously believed

• How flow state—not gradient—drives outcomes after TAVR or SAVR

• The role of predicted vs measured PPM and valve-specific flow patterns

• Insights on undersizing vs overexpansion and how to optimize redo TAVR results

• Why well-expanded valves may outperform “bigger” but underexpanded ones

• How lifetime management means moving past numbers to patient-centered outcomes

This is a must-watch for interventional cardiologists and structural heart teams focused on redo TAVR planning, flow hemodynamics, and lifetime valve strategies.

00:00 – Introduction: TAVR-in-TAVR and gradient anxiety

01:10 – Invasive vs echo gradients: why they don’t match

03:00 – Discordance and measurement error in post-TAVR gradients

04:25 – Understanding pre-discharge echo gradient increases

05:15 – When gradients are “nuisance” findings vs real issues

06:00 – PPM redefined: what echo really measures

07:30 – Flow-derived valve area and its pitfalls

09:00 – Flow vs gradient: the real driver of outcomes

10:00 – Lessons from the PARTNER and TVT data

12:30 – Predicted vs measured PPM in clinical context

14:00 – The role of ejection fraction and low-flow states

16:00 – Flow patterns: laminar vs turbulent impact on velocity

18:00 – Valve sizing: smaller expanded vs larger underexpanded

20:00 – Expansion optimization and stent analogy

22:00 – Valve labeling, true ID, and expansion limits

24:30 – Historical shift: from “biggest valve possible” to “best expansion possible”

26:30 – Oversizing risks, skirts, and modern generation valves

28:00 – The balance between PVL, pacemaker risk, and expansion

30:00 – Lifetime management: beyond numbers to patient outcomes

31:00 – Closing thoughts & takeaways

#TAVR #ValveInValve #TAVinTAV #InterventionalCardiology #StructuralHeart #Echocardiography #AorticValve #PPM #Hemodynamics #MurmurMD

How often do patients leave the cath lab with residual ischemia—and can physiologic guidance change outcomes?

In this discussion, Dr. Chris Brown and Dr. Christian McNeely review insights from the DEFINE GPS Trial, where PCI guided by pressure wire co-registration was compared with angiography alone.

Key highlights:

- Why 20% of patients left the lab with residual ischemia in DEFINE PCI

- How FFR/iFR pullback and co-registration create a physiologic roadmap for stenting

- Trial design, enrollment (2,100 patients), and endpoints: MACE at 1–2 years

- Surprising cases where physiology overturned angiographic impressions

- Calcium, long lesions, and the limits of angiography alone

- When to trust physiology vs imaging—IVUS/IVL integration

- The future role of co-registration software in routine PCI

This is a must-watch for interventional cardiologists looking to integrate objective physiologic data into daily practice.

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00:00 – Intro & guest background

00:39 – Define GPS trial design & objectives

01:17 – Residual ischemia: lessons from Define PCI

02:23 – Co-registration system explained

03:09 – Inclusion criteria & patient population

03:53 – Endpoints: MACE at 1–2 years

04:07 – Enrollment: 2,100 patients, top enrolling sites

04:25 – Why angiography alone misses physiology

05:12 – Standard PCI workflow vs physiologic pullback

06:30 – Case 1: circumflex calcification & LAD ischemia

07:41 – Co-registration mechanics step-by-step

09:12 – Post-PCI IFR goals & physiologic success

11:31 – IVUS co-registration and stent sizing pearls

12:46 – Calcium, long lesions & turbulence effects

13:43 – Taking subjectivity out of angiography

15:22 – Physiology + imaging: additive or redundant?

16:43 – Aggressive stent sizing & perforation risk

17:28 – Case 2: non-STEMI with PDA & focal circ lesion

18:51 – Pullback showing ischemia dots at stenosis

20:10 – Why physiology prevented unnecessary stenting

21:49 – Which lesions should we defer vs treat?

22:17 – Looking ahead: Define GPS trial results (2026–27)

#DefineGPS #PCI #InterventionalCardiology #FFR #iFR

#CoRegistration #CathLab #StructuralHeart #StentOptimization #MurmurMD

How is left atrial appendage closure (LAAC) evolving in 2025—and what’s the role of 3D ICE vs TEE?

In this SWAC session, Dr. Matthew Price and panelists share their real-world experiences and expert pearls:

• Why 3D ICE is becoming the standard for Watchman and Amulet procedures

• Key tips to avoid air embolism and manage sedation risks

• How to safely perform ICE-guided transseptal puncture and LAA imaging

• When TEE or mini-TEE probes remain the better option

• Cost, staffing, and program scaling strategies for high-volume centers

• Practical steps for single-operator workflows and nursing team integration

Whether you’re a structural heart imager, interventional cardiologist, or part of a valve clinic team, this discussion highlights the future of LAAC imaging and what it takes to safely scale programs as patient volumes grow.

00:00 – Welcome & panel introduction

00:18 – Why imaging is critical for LAAC in 2025

00:37 – Matthew Price: 3D ICE is the future for Watchman and Amulet

01:03 – Boston Scientific advisory on air emboli

01:50 – Why 3D ICE outperforms 2D ICE for moderate sedation

02:11 – NCDR registry data on ICE vs TEE outcomes

02:40 – Learning curve and case volume to master ICE

03:42 – Practical workflow: efficient 3D ICE case steps

05:42 – Pre-procedure CT planning and AI sizing tools (FEOPS, DASHI)

07:11 – Tips for safe transseptal puncture with ICE guidance

09:04 – Balloon dilation vs delivery sheath crossing strategies

13:14 – Using fluoro as a backup for ICE alignment

18:08 – Aligning the ICE view to the LAA axis for accurate deployment

28:12 – Preventing air embolism during sedation-only cases

31:18 – Hydration, LA pressure checks, and sheath management

35:17 – When to choose TEE: obesity, severe OSA, or complex mitral work

40:17 – Mini-TEE probes: workflow advantages under MAC

47:01 – Pre-procedural imaging vs on-table imaging debate

52:09 – High-volume GA workflows and 4-minute deployment case

53:08 – Panel takeaways: scaling LAAC imaging programs

#LAAC #Watchman #3DICE #TEE #InterventionalCardiology

#StructuralHeart #CathLab #LAAO #ModerateSedation #MurmurMD

Can you safely perform left atrial appendage occlusion (LAAO) without TEE, anesthesia, or an echo doc?

In this episode, Dr. Raghava Gollapudi (San Diego Cardiac Center) and colleagues break down how they built a conscious sedation, ICE-only LAAO program in private practice. They cover:

- Why traditional TEE + anesthesia models slow scheduling and add variability

- Evidence from Europe showing ICE-only Watchman is safe

- How to transition from TEE support to ICE-only workflow

- Practical pearls for ICE catheter handling, transeptal crossing, and imaging

- Patient selection: absolute and relative contraindications

- The role of nursing staff and team buy-in

- Why 3D/4D ICE makes device visualization easier

This is a must-watch for operators and program builders looking to simplify workflows and improve access to LAAO.

⏱️ Chapters

00:00 – Intro & program overview

01:00 – Why conscious sedation for LAAO?

02:00 – Limitations of TEE + anesthesia model

02:45 – Evidence for ICE-only Watchman safety

03:30 – Becoming a solo-operator with ICE

04:45 – Transition: 20 cases with TEE + ICE

06:00 – Patient selection: contraindications & risks

08:00 – Screening tools & nursing involvement

09:00 – Step-by-step ICE technique & home views

10:30 – Transeptal crossing: tips, 3-minute rule

12:00 – Biggest barrier: ICE-only septal crossing

14:00 – Imaging the appendage: mid & low angle views

15:45 – Benefits of 3D/4D ICE vs 2D ICE

16:30 – Final pearls for solo-operator LAAO

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

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#LAAO #Watchman #ConsciousSedation #ICEImaging #InterventionalCardiology #StructuralHeart #CathLab #AtrialFibrillation #SoloOperator #murmurmd

A look into how Dr. Waggoner took a new TAVR program and transformed it into a top-tier research hub from scratch!

Dr. Tom Wagner, Director of Structural Heart at Tucson Medical Center, shares his journey in building a research-first culture from scratch. In this conversation, he discusses:

• Why research is a differentiator in regional cardiology

• How he grew from zero research to 70+ active clinical trials

• The inflection point when a program takes off (around year 5)

• The importance of volume, outcomes, and clean data for sponsor trust

• Practical insights on staffing: from one CRC to a full research hierarchy

• Why perseverance, weekends, and attention to detail are the real “secret sauce”

• How research fuels both patient access to novel devices and institutional reputation

Whether you’re a structural cardiologist, program director, or part of a valve team, this discussion offers a roadmap to building research infrastructure that benefits both patients and institutions.

Chapters:

00:00 – Intro & guest background

01:10 – Starting with zero research & 50 TAVRs/year

02:00 – Why research matters for program growth

03:30 – Research as a differentiator in regional markets

04:10 – Perseverance: the real “secret sauce”

05:30 – Balancing call, STEMI, and research demands

06:20 – The 5-year inflection point of growth

07:00 – From 2 trials to 70: scaling the research portfolio

07:45 – Importance of high volume and outcomes

08:15 – Why clean data builds sponsor trust

09:30 – Don’t overreach: starting with the right trial

10:20 – Building staff: from one CRC to a full hierarchy

12:00 – Lessons learned from early trial missteps

13:00 – Closing insights on building lasting programs

#StructuralHeart #CardiologyResearch #TAVR #HighRiskPCI #InterventionalCardiology #ClinicalTrials #CathLab #ValveTeam #ResearchProgram #MurmurMD

Once considered niche, the Ross procedure is making a strong comeback. With improved techniques and long-term outcomes, it’s becoming a first-line option for younger patients with aortic valve disease.

In this episode, Dr. Chris Malaisrie (Northwestern Memorial, Chicago) joins Dr. Andrei Pop to discuss:

• Why the Ross procedure is resurging in high-volume centers

• Techniques to stabilize the autograft and prevent dilation (deep LVOT implant, Dacron grafts, wrapping with native root)

• Post-op strategies including strict blood pressure control for favorable remodeling

• Durability data: 85–90% freedom from reintervention at 10 years

• Managing failures: surgical re-repair, TAVR options, and future dedicated devices

• Patient selection: under 50, women, and those with small aortic roots

• The role of root enlargement and replacement in lifetime management

• Minimally invasive approaches: mini-thoracotomy vs sternotomy

• TAVR-first vs surgery-first strategies in younger patients

• Why the valve clinic model and shared decision-making matter in 2025

This is a must-watch for surgeons, interventional cardiologists, and valve clinic teams navigating lifetime aortic valve management.

Chapters:

00:00 – Intro & guest background

01:00 – Why the Ross procedure is resurging

02:15 – Stabilizing the autograft: surgical techniques

04:00 – Blood pressure control & early remodeling

05:20 – Jacketed Ross and long-term durability

06:30 – Failure rates and freedom from reintervention

07:15 – Options for failing autografts & future TAVR devices

10:30 – Homografts vs autografts: differences in calcification

12:00 – Ross volumes, outcomes, and national trends

13:30 – Patient selection: under 50, women, and small roots

14:15 – Root enlargement and replacement strategies

20:00 – CT planning and AI modeling for AVR

21:15 – Minimally invasive AVR: mini-thoracotomy vs sternotomy

22:15 – TAVR first vs Ross first in younger patients

23:30 – Challenges with TAVR explant vs SAVR explant

26:00 – Techniques for safe TAVR explant

27:00 – TAV-in-TAV as a lifetime strategy

28:30 – Coronary protection & unicorn procedure

31:30 – Valve clinics & shared decision-making

33:15 – The debate over single-operator TAVR

35:00 – Closing thoughts & takeaways

#RossProcedure #AorticValve #CardiacSurgery #ValveSurgery #StructuralHeart #TAVR #LifetimeManagement #ValveClinic #InterventionalCardiology #MurmurMD