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Keeping the Beat: How Pacemakers Protect the Heart’s Rhythm · Meaningful Medicine with Novant Health

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  Melanie Cole, MS (Host): Welcome to Meaningful Medicine, a Novant
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  Health podcast, bringing you access to leading doctors who answer
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  questions they wish you would ask.
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  From routine care to rare conditions, our physicians offer tips to navigate medical
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  decisions and build a healthier future.
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  I'm Melanie Cole.
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  And today, we're learning about the heart and specifically
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  pacemakers with my guest, Dr.
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  George Waits.
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  He's a cardiologist with Novant Health.
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  Dr.
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  Waits, thank you so much for joining us today.
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  Please start by telling us a little bit about what a
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  pacemaker is and how it works.
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  What's it doing in the heart?
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  George Waits, MD: Well, Melanie, thank you for having me on.
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  It's a pleasure to be with you, and I'm more than happy to discuss
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  pacemaker therapy, which is a big part of what we offer in the
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  Cardiovascular Institute here at Novant.
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  So, a pacemaker is a device that we offer to particular patients primarily
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  with problems with a slow heart rate, and the symptoms that come with that.
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  We can address those problems in many cases by implanting a pacemaker,
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  which is a device that is implanted to guarantee that a heart rate does
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  not fall below a level that we set.
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  And in many cases, I'm pleased to share that we're able to address patients'
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  symptoms and give them the heart rate that they need to do what they need to do.
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  Melanie Cole, MS: Thank you for that.
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  So, what kinds of heart rhythm conditions typically lead to you to recommend
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  a pacemaker in the first place?
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  So, you mentioned that they help keep the pace of the heart so
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  that it doesn't get too low.
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  Tell us a little bit about some of these disorders.
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  George Waits, MD: Absolutely.
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  So, I would say that a large population of people that we treat
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  suffer from some type of electrical rhythm disorder of their heart.
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  And what I'm talking about is either the impulse that forms the heartbeat is
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  failing to initiate, and we call that sick sinus syndrome, the inability to
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  generate an adequate heart rate to supply the body's needs, or if their heart rate
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  is initiating properly, sometimes there's a failure of that heart rhythm to conduct
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  along the conduction system of the heart.
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  Commonly, we refer to a condition called heart block, or sometimes it's
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  a complete heart block, or sometimes it's a high-grade heart block, but some
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  failure of conduction between the top chambers of the heart, the atria, and
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  the bottom chambers, the ventricles.
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  So, whether the heart doesn't start well or whether it fails to conduct
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  well, those are the most common reasons why patients might feel symptoms, you
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  know, fatigue, low energy levels, in some cases,you know, even passing out.
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  You know, some more alarming symptoms can be due to these disorders.
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  And, in many cases, we identify, we implant the pacemaker, and we're able
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  to treat these common conditions.
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  Melanie Cole, MS: Thank you for telling us also about some of those symptoms, because
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  that's an important thing for patients to really know and be able to recognize.
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  Are there different types of pacemakers?
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  George Waits, MD: Absolutely.
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  Yes, there are different types of pacemakers, and we try to tailor the
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  choice of pacemakers towards what that specific patient is needing.
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  The very, you know, initial models, you know, going back to the late
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  '50s when the first pacemakers were implanted were based on what is called
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  a transvenous or lead-based system.
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  And that is that we use wires that are connected and wires that run through
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  the course of the body's veins, usually from the shoulder into the heart.
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  And depending on the particular application, that patient may require
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  one, two, or in some cases even three wires to appropriately restore
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  the proper conduction of the heart.
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  And that system, again, that goes back to the '50s, is still frequently used today.
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  I would still consider it to be, in most cases, the standard
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  of care for most patients.
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  But technology has advanced.
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  And with innovation, there are other types of pacemakers as well.
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  We are now positioning those leads in different places that are able to
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  pace the heart in a way that is more physiologic, that is we're able to pace
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  the body's own wiring directly rather than just pacing the excitable muscle.
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  And in certain cases, there are pacemakers that require no leads
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  whatsoever, which I can go into further.
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  So in certain cases, the leadless pacemakers are
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  chosen in certain scenarios.
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  Melanie Cole, MS: Well then, let's expand on that a little bit, Dr.
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  Waits.
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  What are the advantages of a leadless pacemaker for patients compared
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  with those older wired systems?
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  Tell us a little bit about patient selection and what are the advantages?
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  George Waits, MD: Leadless pacemakers certainly raised our interest and
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  excitement when early models have been available for some time now,
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  probably close to 10, 15 years now.
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  But just, you know, recently, we've been implanting, in some cases,
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  two-chamber pacemaking systems.
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  That is two separate components where we take pacemakers that are
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  smaller than a AAA battery, but that themselves have battery lives
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  sometimes approaching 10 years.
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  Occasionally, we will use even two components so that to restore
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  or maintain communication between more than one chamber of the heart.
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  And so, I consider that type of therapy for patients who require a pacemaker,
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  but have particular reason, where they might benefit from a leadless system.
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  So, I think of patients, one example would be
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  patients who require dialysis because of advanced kidney disease.
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  In those patients, we really want, as best we can, to spare their vasculature.
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  And so, putting in a wire in those patients sometimes can lead to,
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  you know, adverse effects on that vein that they would otherwise
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  benefit from using for dialysis.
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  Other patients would be those who have a high risk of infection.
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  So, it's often, you know, the case if you've had an infection before.
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  Any infection that is serious enough to affect the bloodstream can involve those
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  wires that are in the heart or even the pulse generator, which is implanted, you
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  know, beneath the skin near the shoulder.
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  If those areas get infected, that can create a serious clinical scenario.
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  So, I know that if patients, you know, have had infection or are at high risk of
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  having that, then that can be a reason to reach for the leadless pacemaker first.
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  And it's important to say too that we don't offer that to everyone.
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  And the reason I say that goes back to what I referred to before, is
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  that it all goes to where exactly the impulse of the pacing is happening.
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  And under the current leadless pacing design, those leadless pacemakers
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  are pacing the heart muscle.
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  And so, the way that the heart is activated is not quite as physiologic
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  as when we're able to pace.
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  There are specialized conduction fibers in the heart.
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  And if we're able to pace those directly, we often see more of a benefit.
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  And I would describe that as a current limitation of the current
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  leadless pacemaker systems.
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  There are efforts underway to allow them to pace deeper into the
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  specialized fibers of the heart.
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  And I think when that becomes feasible, then yes, I think that very well could
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  shift our focus towards maybe implanting those more as a first-line therapy.
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  But as it stands now, I reserve that for patients with specific interests
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  in avoiding, you know, those lead and what we describe as pocket-related
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  complications of the standard model.
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  But that's how I would characterize it.
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  Melanie Cole, MS: Well, Dr.
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  Waits, while you're telling us about the ideal candidate for
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  these leadless pacemakers and the patients that might still require the
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  traditional kind, are we looking at the age of the patient or the BMI?
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  Are there other factors that you take into consideration?
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  George Waits, MD: I do.
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  We always want to account for demographics and medical
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  history to make the best choice.
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  You know, when it comes to age, I would say that, with the very elderly, you
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  know, I do give a little more thought to leadless pacing in certain context.
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  And to explain that, I would say that we need to just give a little further
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  background, which is that, again, when I make that distinction between
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  pacing heart muscle versus pacing the conduction system, the reason we
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  know that that's important is that what we've learned in the decades of
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  the old standard of just pacing the heart muscle alone in no particular
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  location, there were a subset of patients who would develop heart failure.
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  Now, it might take many years, but there is a described phenomena where certain
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  patients may develop heart failure just by the way that their hearts are being paced.
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  And of course, that's not the intention of the therapy.
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  And it doesn't happen often, but it's enough that many of us
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  are now changing our approach to trying to pace the conduction
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  system fibers as much as we can.
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  And so, for that reason, I'd say because that phenomena is long-term,
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  if I, you know, am under the care of someone who's very elderly and,
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  you know, they're concerned about maybe they've got some bleeding risk or
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  infection risk, that they've developed, I do think a lead-less pacemaker,
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  you know, after a full discussion, if that's something that they're interested
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  in doing, I do think that that's a reasonable thing to consider only
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  because many of those complications are not seen for many years afterwards.
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  So, it's an individual call.
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  But, you know, again, we take age and complexity to trying to find
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  the right device for everybody.
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  Melanie Cole, MS: And how long do these pacemakers really last?
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  What happens when the battery runs low?
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  George Waits, MD: Yeah.
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  So, it's great that the batteries last a lot longer than the initial models.
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  You know, the first pacemaker famously last for, I think, about six hours.
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  But nowadays, we're talking 10 years is a good average battery life.
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  And this is true for both the traditional, what I call, transvenous models with
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  the wire as well as the leadless pacemakers, really long battery lives.
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  And in the case of the traditional pacemaker, when that battery
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  starts to reach its end of its duration, we are monitoring that
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  patient, you know, throughout the time that they have the implant.
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  But certainly, as it approaches the end of the battery life, we are meeting with that
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  patient more frequently and monitoring through remote monitoring systems that
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  we have available, and that allows us to appropriately schedule a battery change.
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  And in many cases, the only thing we have to change is what we call the can
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  or the pulse generator, which is about a half an hour procedure, and patients
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  go home the same day, and their battery is good for another 10 years after that.
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  So, a very minimally complex scenario.
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  In the case of a leadless pacemaker, because they're so small, either we
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  can remove the old device and put in a new one or, in some cases, you know,
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  depending on expected longevity and those things, you know, we might even be able
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  to just implant an additional device, and leave the other one where it is.
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  So, again, it's an individualized approach.
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  But usually when it comes to restoring, you know, changing the battery,
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  it's not nearly as complex or as complex as the initial implant.
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  Melanie Cole, MS: Or as it used to be.
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  And I mean, really, the technology is amazing, and it's such an
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  exciting time in your field, Dr.
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  Waits.
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  So looking ahead, what emerging advances in cardiac device technology
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  are you most excited about?
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  I mean, with the advent of AI and even televisits to help you monitor
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  your patients, tell us a little bit about really what excites you
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  beyond today's leadless pacemakers.
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  George Waits, MD: You're right to say there is a lot of great
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  innovation that's happening.
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  I think the two most recent advances
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  that I'm most enthusiastic about is how, you know, everything that I've said
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  earlier about conduction system pacing and, you know, that has developed over the
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  last 10 to 15 years, but it's been focused on the way that we pace the ventricle.
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  And there's also a growing interest in applying that same
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  rationale towards pacing the top chambers of the heart, the atria.
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  So, you know, since earlier this year, I've adopted a new style of implanting,
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  doing conduction system pacing in the atrium through direct pacing of an
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  anatomic structure called Bachmann's bundle, which is, again, one of those
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  conduction system components in the atria.
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  And, you know, there's a lot of hope, not proof yet, but expectation that we may
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  be able to do a better job in pacing, perhaps preventing atrial fibrillation,
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  perhaps managing heart failure better.
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  Again, unproven claims.
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  But good physiologic reason to suspect that we may be able to do a better job for
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  our patients by pacing Bachmann's bundle.
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  The other advance is what I mentioned to you about leadless pacemaking's
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  limitation not currently being able to pace conduction system fibers.
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  There are efforts underway to change that where the leadless pacers can
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  pace deeper into the heart muscle tissue and restore normal conduction.
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  And I really think, you know, once we figure out the practicality of doing
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  that well, and if we can establish tje same reliability that we enjoy, you
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  know, with the transvenous systems, I really do think that could change the
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  field, and we could be putting in more leadless pacemakers, and people could
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  be having less of a drawback, you know, less soreness in the shoulder afterwards,
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  which is a common, you know, issue that people face in the existing models.
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  So, a lot of exciting changes there.
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  I love, you know, the idea of being able to help patients by
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  correcting their heart rhythm.
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  And so, these are just some of the things that, you know, on the horizon.
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  Melanie Cole, MS: Thank you so much, Dr.
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  Waits, for joining us today and really sharing your incredible expertise
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  and explaining it in a way that we can understand, because it's really
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  highly technical, but very exciting.
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  And thank you again for joining us.
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  And to find a physician, you can always visit novanthealth.org.
• 15:55
  And for more health and wellness information from our experts,
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  visit healthyheadlines.org.
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  I'm Melanie Cole.
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  And that concludes this episode of Meaningful Medicine, a podcast from
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  the specialists at Novant Health.