Podcast Transcript

Introduction: Life is about the moments that make your heart tick, and we’re here to keep it ticking strong. I’m Dr. Barry Bertolet, and this is We're All Heart, where we dive into the latest cardiac care with the experts who live it every day.

From breakthrough procedures to the most cutting-edge treatments, we're putting heart health front and center. 

We're All Heart is brought to you by North Mississippi Health Services in partnership with Cardiology Associates of North Mississippi. Let's get to it. 

Dr. Barry Bertolet: I'm Dr. Barry Bertolet, and we are pleased today to have my colleague, Dr. Karthik Prasad with us today. He's an electrophysiologist and I'll let him explain what that means. Dr. Prasad, thank you for being here. 

Dr. Karthik Prasad: Thank you for having me. Welcome viewers. I'm part of the heart cardiology team at North Mississippi Medical Center. In addition to cardiology, I do something called cardiac electrophysiology. This involves specializing in the heart's electrical system. So we treat slow heart rates, abnormal heart rates, fast heart rates, and there are various different kinds of therapies we have. 

Today we're gonna talk about one such treatment called pacemaker.

Dr. Bertolet: And Dr. Prasad, tell me a little bit of background where you trained. And how did you become a specialist in cardiac pacing?

Dr. Prasad: Certainly. Takes a lot of graduations, I guess. So, medical school was back home in India. I spent about six years there. And then all my post-graduation, I've spent six years — three of those years were general medicine training at St. Louis University in Missouri. And then spent three additional years with general cardiology training, and then spent an additional year in what I do right now — cardiac electrophysiology at the University of Florida.

And  this has been my first job since then. I've been here at North Mississippi for eight years. And we're very proud of our program here. I think in the eight years that I've been, we've grown much more than what we were before.
Our plan is to keep growing further. 

Dr. Bertolet: And just for everybody. And then this is our running joke that we always say is that — I'm an interventional cardiologist, so I'm a plumber. He's an electrician. 

Dr. Prasad: That's the best analogy. 

Dr. Bertolet: The way to think about it is that  you know, the heart is like a house and there's toilets that gets clogged up — I’m that guy, and he makes sure the lights work. And so that, sort of what an electrician is or electrophysiologist. 

So Dr. Prasad, tell us what a pacemaker is. Why do we even need these? What is that? (Continued)
 

Dr. Prasad: Pacemakers - most people might be familiar. They've been around for a while now,  50, 60 years if not longer, but just as you can imagine, your iPhones evolved. Even pacemakers have evolved. And at the end of the day, a pacemaker comes down to two parts. There's a computer inside it and there's a battery. So that's what a pacemaker is.

And everything is a different iteration of that. Just as you can imagine. Technology has evolved. Pacemaker softwares have evolved.

Battery technology has evolved, but at the heart of it, it's a computer or processor with a battery inside, and they get attached to what we call leads.
In other words, we call it wires that go into the heart. And there are ways to secure these leads into the heart.

We usually involve making a cut underneath your collarbone. We get into the blood vessel through that. We put these wires into the heart and they get connected to a pacemaker. 

Dr. Bertolet: So I know that there's a lot of different kinds of cardiologists, but what type of cardiologist should be putting in pacemakers, or at least in the United States, what type of cardiologist puts in this  pacemaker device?

Dr. Prasad: Since most reasons for putting in pacemakers are heart electrical system disturbances. So someone who deals with heart electrical system — an electrician or electrophysiologist, should be primarily involved in treating these diseases. And we go through, like I mentioned, a specific training to learn how to put pacemakers. And it's not just putting in the pacemaker. There's also the management part of it when people have problems with further heart rhythm issues or pacemaker problems. 

So the whole training for us - cardiac electrophysiology - is centered primarily around this. So at least in our practice area here, if someone needs a pacemaker or abnormal heart rhythm, they get referred to us — cardiac electrophysiologist. And our focus is mainly to treat the heart's electrical system.

Dr. Bertolet: And for the folks that are listening today, who would need a pacemaker? What are some of the signs and symptoms that somebody might have that would be a clue that they need a pacemaker?

Dr. Prasad: Absolutely. Common symptoms are like I said, the heart of pacemaker is to treat slow heart rates, slow heart rhythms. And most people will have some form of symptoms when their heart rate gets too slow or too little. And common symptoms are, could be as simple as just getting fatigued or tired. I walk up my driveway last six months I could do it, but in the last few months I can't. I get more tired. That could be a sign of slow heart rate. When your heart rate gets low, your blood pressure gets low.

So most people experience this in the form of dizziness, lightheadedness, and in worst form, if your heart rate gets really slow and blood pressure drops, people can even pass out. So these are mostly the common situations that slow heart rate presence that leads to referral to a cardiologist or cardiac electrophysiologist. And there on, we try to find out if the slow heart rate is indeed what's causing the problems. And if so, a pacemaker is a very effective treatment in the situation. 

Dr. Bertolet: So, you mentioned the slow heart rate being one of the primary reasons why a person gets a pacemaker. What are some of the medical conditions that may cause a slow heart rate, so if the folks listening or watching have one of these conditions, they know that they may be at risk of a low heart rate.

Dr. Prasad: Just like everything in medicine, we say you get old things break apart and the heart, we have an electrical system in the heart  not exactly wires inside, but the whole heart is a big muscle. And certain areas of the heart muscle are specialized to do the job of electrical conduction. And as we age, just like our joints can wear down, even the heart's electrical system wears down.

We call it degenerative disease. All in simple words, as you get old, your higher chance of your heart getting slower. Other things can be actual medical conditions. Like I said, the whole heart is a muscle. And if someone were to have a heart attack and this heart attack affects the blood flow to their heart's electrical system, that can cause slowing of the heart rate.

There are certain infections. Folks who live around woods —  a specific kind of tick can cause something called Lyme's disease. It’s rather rare. But often we might encounter a relatively younger, healthier person coming in with slow heart rate. An advanced form of this tick bite or Lyme's disease can cause slow heart rate.

Generally if you get bad infections in the body that spreads to the blood, affects the heart, endocarditis we call it, that can cause heart infections and  slow heart rate. 

There are certain procedure-related problems. If you were to have open heart surgery, valve replacement, other procedures that can cause slow heart rate, that can all be treated with pacemakers.

Of course there are certain medications. Sometimes  we have to use certain medications to treat certain conditions where we believe the benefit of the medication truly exists. But one of the side effects might be slow heart rate. When possible, of course we try to eliminate this medication, but if you really need that benefit from the medication, then it might have to be treated with the pacemaker as  well. 

Dr. Bertolet: So if somebody had heart disease, just say whatever they had, coronary artery disease, had a stent, had a heart attack in the past, would that person be more at risk for bradycardia in the future than maybe somebody who had not had a heart problem?

Dr. Prasad: Yeah, I guess generally if you have heart disease  like Dr. Bertolet mentioned —  blockages in the heart arteries and stuff not necessarily electrical system, but it implies there is some overall heart disease existent. And yes, an individual like that will probably be at a higher risk of having to get a pacemaker as against an exactly same aged individual who doesn't have heart disease. 

So yeah if you already have established heart disease, you're probably more susceptible to have problems related to electrical system of the heart. 

Dr. Bertolet: Certainly. And when we're talking about pacemakers, is this sort of like one size fits all? Are there different kinds of pacemakers that you can choose from to treat people? 

Dr. Prasad: Well, It's  2025. I guess nobody even buys ready-made shirts anymore. Everything's custom designed. So I think that's been the general switch in all of medicine tailored approach customized to individual patient scenarios. So yeah, we do have different pacemakers that have their own niche and where at the end of the day we want to treat the slow heart rate and all different pacemakers will do it. But there are certain niches. 

The traditional pacemaker that I described earlier where you make a cut underneath your collarbone and put wires in the heart. We call them transvenous pacemaker, meaning we go through the vein. This is an example here. This is what we call a pacemaker lead or wire.

It's about 50-60 centimeters long. And at the end of it, there's a screw with which we attach to the pacemaker and they get connected to the pacemakers itself. 

Here, this would be an example of a traditional pacemaker.

And over the last about 10 years now it's evolved. We have what we call leadless pacemaker, where the whole pacemaker is about the size of a capsule. This is really a multivitamin capsule. There are different iterations of that. And they can, for the most part do the same job as these pacemakers with the long leads and battery. 

Now not every pacemaker is meant for everyone, like Dr. Bertolet said, but in the right situation, these pacemakers can do a lot of work that these pacemakers do. And inside this little pacemaker, there's a battery life of about eight to 10 years long.

So there are different situations for different pacemaker. Traditional pacemakers used to be what we call a two wire, one in the top chamber, one in the bottom chamber. 

Besides the situations we talked about with slow heart rate there are other situations where we call heart failure. You have a weak heart function because the two bottom chambers of the heart can't beat together.

And pacemakers are used in that situation where we can try to help the two bottom chambers beat synchronously and that's an additional form of pacemaker.

Dr. Bertolet: So that would be if somebody had a bundle branch block?

Dr. Prasad: Absolutely right. We've known this for a long time like you talked about the electrical system, in addition to just being slow heart rate, think of the heart like we have two bottom chambers, right side and left side. And if I were to stand in the center of the room and if I have no barriers and I talk in the center, everyone across the room hears, we call that paddle activation. From one point I can activate the entire heart.

Everything beats together, which is how we want it in a normal fashion. Bundle branch block. Think of it as I'm standing in the center of the room, but I've got a wall on one side and now I'm gonna talk on this side. The sound will still get around, but it's gonna be a delay coming across and in the heart we call this activation in series where one chamber activates then the other chamber.
So this itself results in the two bottom chambers beating out of synchrony. And that can cause weakening of heart function or we call it heart failure. 

And we have pacemakers in these situations where we can put pacemaker wires to the right and left bottom and we can time them to synchronize them to beat together, which can help improve the heart function, improve their breathing and symptoms. We call that a bi-ventricular pacemaker, or in other words we call it a three-wire — there’s one for each of the bottom chamber wires.

Dr. Bertolet: A lot of times I've described this to my patients is if this is the right and the left ventricle and as they beat, this is the way God intended our heart to beat. And then when you get that electrical problem, that bundle branch block, then all of a sudden your heart does this and then it doesn't beat well. And so if you reorder the electrical flow to the heart with the pacemaker, he just talked about, you make it do like this again. And if you do that, we can see patient's heart pump function improve.

So I've personally seen somebody go from the twenties all the way to, to normal. 

Dr. Prasad: Yeah. 50-60%. Yeah. It can completely normalize their heart function and they go on to have a normal life there. 

Dr. Bertolet: And I was going to go back, you were pointing to these pacemakers. And so you were talking about this lead attached to these pacemakers through a cut in the shoulder.

Dr. Prasad: Correct. 

Dr. Bertolet: But how do these leads get put in? Do you swallow them or do they go in some other way because they're about the size of a capsule? How does that go in? 

Dr. Prasad: That's a great question. Yeah, like I said, in a very specific situation. We call these leadless pacemaker because there's not this long lead attached. And the end of the pacemaker itself is designed to hook into the heart muscle. So instead of the traditional cut underneath the shoulder, we go through a puncture in the blood vessels in the groin crease area. And we do a needle puncture in there, put a long tube and it goes through that tube into the heart.

So when individuals get this, when they're done with the procedure, there is no scar, there is no sign of how the pacemaker got in. And most people, almost all of them, they don't even realize they have a pacemaker because they can't feel it inside the heart, yet the pacemaker does what it's supposed to do. So yeah, it's a very great advancement.

We believe the field is gonna move entirely in this direction or the next 5, 10, 15 years where the traditional pacemakers with wires and stuff might get lower and lower and everything might go in the direction of this leadless pacemaker.

Dr. Bertolet: Yeah. And how long have you been putting in leadless pacemakers or how long have they been available and how long have we been doing that here at North Mississippi?

Dr. Prasad: When we did our first leadless pacemaker, we were the first in north Mississippi to do it. This was I think 2018 when we did our first leadless pacemaker. And, they've come a long way.

There are different iterations of it. We could usually put only in the bottom chamber of the heart. Now there's another version from another manufacturer where you can put it both in the top and the bottom chamber of the heart. And we were the first ones in north Mississippi again to do this here in net Tupelo here. So the batteries on these things will last eight to 10 years.

And like I said, most patients who get it don't even have any feeling that they have a pacemaker 'cause there is no incision or scar tissue on the outside there. 

Dr. Bertolet: And you mentioned that pacemakers could be used as not just a treatment for slow heart rate, but also heart failure. Yeah. Are there other ways that we use these pacemakers? 

Dr. Prasad: Yeah, It's, it's almost like it's come a full circle. Over the last five to eight years now it has made our whole pacemaker field a lot more exciting and intellectually challenging for us. 

Going back 20-30 years ago when we learned how to put pacemakers. These wires, we used to just put it in one of the two bottom chambers of the heart.

Like Dr. Bertolet showed the right side and the left side. We used to traditionally go and put it in the right bottom chamber with the main goal trying to get the heart rate back to normal. Now we learned that instead of putting it just anywhere, we try to tap into an individual's own electrical system.

So, a suitable analogy is to use what the surgeons do for bypass surgery.
If your main artery is blocked, they go and plug – or if you’re in traffic. If your main highway is blocked, you wanna build a side road where you can get back onto the highway, you can go through the side roads and get to where you want, but it's not the same as driving on the highway. So you want to get back to the highway. So the surgeons do it now where they put another bypass and they bypass this blockage and go below. So we do the same thing. We've learned to do the same thing with pacemakers.

If your electrical system is blocked in a certain segment, there are ways to identify to put the pacemaker wire just beyond that blockage to still use the normal electrical system. So that synchrony that you mentioned, we want the two bottom chambers to beat together. And it's very elegant —  once again has shown to improve heart failure in a lot of people who get it.

And  it’s even become the standard of care now. And we were among the first in north Mississippi here to do it. We've been doing it for about three and a half to four years. We have been part of big clinical trials with this as well. And it's become the new standard of care, what we call conduction system pacing.

If your electrical system is broken somewhere, we try to put the pacemaker just beyond the broken area to still use your normal electrical system.

Dr. Bertolet: And is there a problem if you just put a pacemaker in the old way, so to speak? 

Dr. Prasad: Yeah, I guess it was one of those things where if you, if you don't ask what's wrong, then you're not going to find it.

We often get caught in that status quo kind of thing. So this was one of those things where pacemakers were doing just fine for 20-30 years, why change?

And when we started asking questions as what can be done better, we learned about 20 to 30% individuals who used to get the traditional pacemakers can go on to develop heart failure. Purely, once again comes to the fact where, like you said, the way God meant you wanted the two chambers to beat together. Now we stimulate one then the other. So about 20%, one in five chance, that your heart function might get weak. 

So now doing this technique where we tap into the electrical system, that rate instead of one in four is probably like one in 20, one in 30, so much lower. So that's become the new way for doing pacemakers.

Dr. Bertolet: So I guess to restate, what I heard you say is that the traditional pacemaker in some people could cause heart failure.

Dr. Prasad: Heart failure, while you're trying to treat the slow heart rate. Yes, it fixes that, but you might be creating another problem. So the whole idea of what we call conduction system pacing is still treat the problem of slow heart rate without causing additional problems.

Dr. Bertolet: So for folks listening, one of the axioms of medicine is that we first do no harm. Do no harm. And so unfortunately it sounds like we learned…

Dr. Prasad: We learned over 20-30 years with more and more research. I think that's why research is important to ask the right questions. And this was one of those things. And now that we started doing this, it makes a complete no brainer.

Why haven't we been doing this for the last 30 years? But now that we learned about it, it's become the new standard of care.

Dr. Bertolet: Now we talked about heart failure. So what about AFib? Does a pacemaker treat AFib? 

Dr. Prasad: Yeah, we get this asked a lot. There are a lot of patients with AFib who also get pacemakers. Pacemakers like I said, it's to treat slow heart rate. A pacemaker in itself, can't fix your AFib, cannot treat AFib. We use it in a very special situation where most people with AFib and irregular heart rhythm, they tend to have rapid heart beating palpitations, like their heart is running away, beating fast.

Some of them in addition to that, will have episodes where they go from being too fast to too slow. A pacemaker can be used in that situation where when they get slow, the pacemaker fills the gaps and it gives us room to use medications to treat the rapid beating or palpitations. So in essence, pacemaker can't treat AFib, but it might be part of your treatment for AFib in addition to other steps involved. 

Dr. Bertolet: Okay. 

Dr. Prasad: And all pacemakers also act as heart monitors. So yes, even if you have AFib and if you have a pacemaker, there are tons of diagnostic information we get in terms of how much AFib you're having, which might help tailor your treatment better. 

Dr. Bertolet: Now, I bet you get this question a ton. What about a microwave? What about a cell phone? And can I get an MRI? 

Dr. Prasad: So this — the microwaves are amazing because I think the last time somebody with the pacemaker could not use a microwave was probably 30 or 40 years ago, but somehow that's the most common word on the street. In fact, I had an older gentleman  who had symptoms of heart failure for pacemaker. For the longest time he had turned down a pacemaker. And when eventually we got to it as to why the guy had lost his wife, he couldn't cook to save his life, he relied on frozen meals. So he was completely under the impression if he were to get a pacemaker, he could not eat anymore because he could not use a microwave. 

So this is amazing. Like I said, I think the last time something like this was probably 30 or 40 years ago, but somehow microwave has stood the test of time. 

So for practical purposes, yes, you can completely and safely use a microwave with a pacemaker. Cell phones — absolutely no trouble. The electrical frequency that these electronic devices create does not interfere with the pacemaker. 

Most power tools around the house you can safely use. Really the only concerning things that we alert people to be safe is if you're working with high voltage power lines like electricians working on power grids and stuff.

Or if you're really involved in arc welding, arc welding has a frequency that might somewhat mimic to certain electrical rhythms that the heart creates.
So arc welding and working with high voltage power cords are probably some areas where you need some caution, but all of the electrical devices do not interfere with pacemakers. 

Dr. Bertolet: So you heard it here first folks. Microwave is good. So the, the other thing, what about MRI scans?

So MRI has become, you know, a common diagnostic tool, but all the time people say, well, you got a pacemaker, you can't have an MRI. Is that true or false?

Dr. Prasad: It used to be false. Now it's all true, at least for the last 10-12 years.

Now, every manufacturer who creates pacemaker devices and these leads or this leadless pacemaker, they're all made to be MRI safe.

Meaning you can have an MRI safely without any side effect to it. As you viewers might know, MRIs create an electromagnetic field and we're talking about electronic devices. So that was the concern in the past. But most devices, at least the ones that are manufactured in the last 10 to 15 years are completely MRI safe, meaning you can safely have an MRI without any ill effects to you, or if you have a pacemaker. 

Some of the older devices  there was questions whether you can do it or not. And across the country now, this is over numerous clinical trials and guidelines. It is possible to perform MRI on pacemakers that were not officially labeled to have an MRI in the past. There are ways to do it. It require some monitoring on the behalf of the physicians and our device representatives. But yes, we can safely do MRIs in a lot of pacemakers.

If it's a brand new pacemaker in the last 10 years, absolutely no trouble, you can do it. Even older pacemakers with some monitoring can be safely done.

Dr. Bertolet: Now I, here's another one that I hear a lot. If I go, if I'm flying somewhere and I got to go through airport security, can I get through the microwave scanner with this?

Or do I have to go get frisked and patted down in the back corner?

Dr. Prasad: Most of these airport screening things are metal detectors at the end of the day. And pacemakers are metal, and this is a metal casing here. And so when you go through a metal detector, yes, it's going to alert. Just like if you wear a belt with a buckle, it's going to go off on your metal detector. So, the same thing, even the pacemaker's going to go off. 

So every individual who gets a pacemaker gets a card with the brand of the pacemaker, what kind of pacemaker it is and stuff. And we encourage everyone to carry this in their wallet.

So that at least shows you what kind of device you have. Most of the time when you go through this, if it alerts the metal detector, you might have to have a quick pat down, at least in the area where the device is, and having that card might save the trouble, but going through the metal detector or the scanner will not damage your pacemaker, will not affect the function of your pacemaker.

So it's not going to hurt you. Like I said, it will beep when you go through a metal detector.

Dr. Bertolet: That's a great question. That's just what I was going to ask you. Are there things that if I had a pacemaker is there anything that I could get involved in that would hurt the pacemaker? Like if, let's say if I'm out hunting. 

Dr. Prasad: In fact yeah, we get this hunting question a lot. I mentioned left collar bone, that's where we put most people, assuming most individuals are right-handed folks, and we put it on the left side. But I've I've been practicing here for eight years now, so I've come to learn, before I ask right or left-handed, I say, where do you hold your gun?

So as long as your gun doesn't directly rest on your pacemaker, it's completely safe to shoot from that side.

Most people say they wedge it in the shoulder on your fascia here, so the gun itself is not directly resting on the pacemaker, but you can't hurt it with that.

And talking about hurting it, unless, I mean a physical altercation, somebody punches you there. I think if it hurts your pacemaker, probably it's hurt something more in the process. I don't think just getting punched on the chest can damage your pacemaker. I wouldn't advise people to try it, but I don't think those are common ways to damage a pacemaker.

Dr. Bertolet: Now, we've talked about a lot of, I guess, thought that goes behind how to pick a pacemaker, what type to pick which access to pick. But when I put a pacemaker in, is it not an emergency? 

Dr. Prasad: Yes and no. Like I described the situations, if it's more of a, I'm a little tired, don't have energy, lightheadedness, usually these things lead to outpatient evaluation and then a pacemaker — not necessarily emergent. But if it's the latter situation where the heart rate really drops and an individual is passing out, we call that syncope where you pass out from an extremely slow heart rate that is an absolute emergency. We had one yesterday. But yeah, these are emergency situations where a pacemaker has to be done very urgently.

And as you can imagine, this is a surgical procedure, and we have a backup option called temporary pacemaker in certain individuals where we go through the blood vessel in the leg or in the in the neck or the leg.

And we put a wire into the heart as a temporary situation only until we can put a permanent pacemaker. But yeah, there are emergent situations when it has to be done then to fix the heart rate immediately.

Dr. Bertolet: And what would be the percentage of those you think?

Dr. Prasad: I would say less than 10% emergency. Less than 5%. Emergent where that is the absolute critical step to save an individual's life. 

Dr. Bertolet: Yeah. So I got one last question. So this came up. So I got a  son who's talking to me. His mother is elderly, she is  now in a nursing home.

And his question was, is the pacemaker going to keep her alive longer than what she would live naturally? 

Dr. Prasad: Yeah, it's a very real situation. This comes up periodically or either that, or individuals in the ICU terminal care where family wishes, to let that individual pass easily. And pacemakers are not going to prolong an individual's life. 

If the pacemaker was put in because somebody had lightheadedness, dizziness. And yes, we can turn off the pacemaker, it's not going to expedite their passing, but in the process it's going to bring back the same symptoms they were suffering before. So if the idea is you're trying to do palliative care or hospice where you're trying to make it easy on the individual passing, it might not be the best thing to turn it off.

Because you're trying to comfort them. The question is whether the pacemaker is keeping my mama alive as she's trying to go?

It's not possible. And even if an individual is dying from other situations where the rest of your organs are shutting down, even the heart, if it starts shutting down, a pacemaker cannot stimulate a heart that is dying. So even though we see it in the hospital where it looks like the pacemaker is trying to stimulate, but if your body is dying because of other situations, then a pacemaker alone cannot keep you alive. So we don't usually turn off pacemakers. 

There's another device called defibrillator that is a different discussion, but when it comes to pacemakers, a pacemaker itself cannot prolong an individual's death if there are other conditions that are causing an individuals to pass away.

So to your question, I guess in that situation, the answer would be no, it's not prolonging his mom's life there. 

Dr. Bertolet: So I've been asking everybody following along the, the slogan developed by NMHS about your true north. So I'm going to ask you, what is your true north, what are you looking to achieve by moving and living in Tupelo and your practice here? 

Dr. Prasad: Yeah, it's a little bit of an evolving north, I guess compared to where I started in 2017 versus now. So I believe at least in our division electrophysiology, we made significant progress. We've been able to stay very relevant and up to date in the north Mississippi area, not just north Mississippi, perhaps in the state among the first ones to do a lot of different things.

We're excited about the training program we are starting. Our hope is to start training cardiac electrophysiologists like me in the training program here, at least in the next five years. That would be one such goal. Other goals would be research. We do a good bit of research, and I think the goal of research is —  most of this research happens in big cities, big academic institutions, and our patients here do not have access to all of these things. So by participating in research, we can bring all these advanced technologies to our patients right here. So I think that helps us stay relevant and provide our patients here the best care.

Dr. Bertolet: Well, thank you Dr. Prasad. And if you want to stay relevant and up to date, join us on our next podcast. 

So this is We’re All Heart. Thank you for joining and we will see you next time.

We’re All Heart is brought to you by North Mississippi Health Services in partnership with Cardiology Associates of North Mississippi.