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: Hi there, I'm Dr. Barry Bertolet and welcome back to another edition of We're All Heart. This is a podcast about cardiovascular disease and the therapy of that. And this is going to be all about you. 

Today, we're excited to have a guest. This is my partner, Dr. Michael Boler. He's an interventional cardiologist. Welcome, Michael.

Dr. Michael Boler: Thank you for having me.

Dr. Bertolet: Tell me a little bit about where you trained at, your education and what got you where you're at now.

Dr. Boler: Yeah, so I'm originally from Greenwood, Mississippi, so down in the Delta, not too far from here, about two hours. Trained in internal medicine and cardiology at University of Mississippi Medical Center in Jackson.

After there ended up coming here. It's my first job out of training and have been here for about six years now, so have enjoyed Tupelo and the northeast Mississippi area. It's been good for myself, but most importantly my family really enjoyed it up here. I've been welcomed with open arms and haven’t looked back since. 

Dr. Bertolet: And when you were in college, you played a sport. What was that?

Dr. Boler: Yeah, I was on the basketball team. Playing is a loose definition, but I got some quality time, four years at Mississippi State playing small forward and some shooting guard. But, you know, got my time when I got it.

Played hard when I was in there and really enjoyed it. Got to see, see a lot of places, do a lot of cool things, meet a lot of neat people.

Really enjoyed my time at Mississippi State.

Dr. Bertolet: So when we're in the cath lab and it's me standing next to him, it, it, it's sort of funny looking. So, yeah, just sort of. So today we're talking about percutaneous coronary intervention. 

So that's a big word, but a lot of people have probably heard of getting a balloon, getting a stent.

And so really I wanted you to sort of talk about what is your definition of this PCI that we recommend to so many people?

Dr. Boler: Well, just from the definition in and of itself. So percutaneous just means through the skin. So we do all of our work through just a small hole in the skin into the femoral artery or the radial artery, most commonly. Anyway, the coronary part of it just means the heart artery part of it. Coronary, just because it's the only artery in the body that's on top of the muscle it supplies. So it's like a crown, a coronary.

And then intervention. So you're fixing something. So as opposed to surgical intervention, where you’re actually having to cut open the chest, expose the body. This is all done through the small hole.

Much less risky as far as recovery goes, and usually a good result for most patients when it's indicated.

(Continued)
 

Dr. Bertolet: And so just to reiterate, so you said radial artery. So that would be in your wrist.

So you could do a needle stick in the wrist, go up, fix a blockage in my heart artery, pull everything back out, and then what happens to my wrist?

Dr. Boler: So, you know, as the saying goes, all roads lead to home. So no matter where you stick, if you trace the artery backwards, you're going to end up at the heart.

And so, you know, obviously once you have done that, you know, in surgery, they suture things back together, they tie bones back together.

But in the wrist, when you're just accessing the artery itself, you can either put a wristband on that has a small balloon that you inflate to a - not to the point where it's completely occluding the artery, but just enough to where the blood flow is stopped and the vessel can heal on its own.

Dr. Bertolet: Now, you talked about fixing a heart artery. What if somebody's had previous bypass? Is that fixable? If there was a blockage that developed in a bypass that was put in several years ago?

Dr. Boler: Some of those interventions do tend to be a little more risky, but yeah. So once you've had bypass surgery, that doesn't mean that that's all you have. And once that goes down, you're done.

Thankfully, that with the devices we have and the medications we have during an intervention, you can successfully and safely fix a bypass graft when needed.
So it's a nice option to have for folks that don't want to have another open heart surgery or maybe not a good candidate for another open heart surgery. Once you've had one, your risk goes up with each subsequent one. And sometimes it's indicated, but sometimes the better way to fix it is with a percutaneous intervention.

Dr. Bertolet: And I see that we got several examples, and I know not all these are designed for the heart, but sort of gives people an idea about what a stent really is.

I think a good way to describe it, a lot of people, like a Chinese finger pull sometimes, is that it is a weave of metal that then can expand a blocked blood vessel open.

And then I think you got an example of a coronary coverage stent there.

Dr. Boler: This is, you know, it's hard to imagine exactly how big your coronary arteries are, but if you can see here closely, you know, most coronary arteries hover anywhere from 2 to 5 millimeters in diameter. So this is an example of a stent. And I usually explain to my patients that it's kind of like a chicken wire scaffold.

It's crimped down onto a balloon. You expand the balloon and the scaffold itself has little holes in it. So in case you do need to cover another vessel with it, that vessel can still stay open.

A lot of times the stents we have nowadays have medication on them to help them from closing back down, helping the vessel heal without compromising blood flow down the vessel itself and give you a better long term result.

Dr. Bertolet: So I understand that you brought a stent with us to deploy. I'll let you show.

Dr. Boler: So if you have to imagine this is all done through the wrist artery, through the wrist, all the way back to the heart. So you insert a wire down through the heart artery itself. So you cross the blockage with a very small wire. It's 0.14 millimeters in diameter.

Dr. Bertolet: So it's the width of a human hair.

Dr. Boler: Yes, it is very small. And you thread it down the vessel and then over that wire, acting like a monorail, you deliver a stent or a balloon. And so as you can imagine, this as you have the access through the artery, over that wire, you insert this balloon or stent and it's like a monorail. So it rides over that wire and across the blockage where you see it. 

And then, so once you see the stent, this is just something you take out beforehand, but the stent itself. And I think this is just going to be a balloon.

Looks like it's just a balloon, doesn't have any stent on there. But anyways, the same concept, but the stent would be crimped down onto this balloon right here.

And then you have what's called an end deflator. So this actually is something that will blow up the balloon from outside the body.

So I'll get you to hold that there and we can blow up the stent here. So the end deflator, lock it into place, you start going up to pressure and as you can see, and hopefully this will work, the balloon will start expanding.

There we go.

It is a stent. Yeah. So it's got a little covered stent there.

And so once you get to a nominal pressure, which usually is somewhere in the 10 to 12 atmosphere range, the stent is now expanded. And so when you want to deploy the stent where it is, you actually let the balloon back down.

So the balloon will come back down, sometimes fast, sometimes slowly, but then you slide the balloon back off and the stent stays in place, touching the vessel walls. This here is a covered stent. I know I mentioned it was kind of open celled. This is a covered stent. These are used for just more emergent needs. But nonetheless, that's exactly what a stent does for the as far as the mechanism of action there.

Dr. Bertolet: And what if somebody needs a stent but they have heart failure, they got a bad heart muscle.

Doctors have told them before they're too sick for anything. Nothing can help them. Is that true or is there things that we can do to help them?

Dr. Boler: Well, it's true that in the sense that sometimes your heart is too sick for things, but thankfully there are ways to get around that now that now these procedures are more high risk. But if someone has a really sick heart or a bad cardiac output or too much vole on board, meaning too much fluid on board, their heart can't mobilize through the body.

Anytime you want to fix something in the heart arteries themselves, as someone once told me, you're only going to make things worse before you make things better. So while you're in the process of making things worse, if someone has a bad heart, you don't want to have that. They don't have any reserve, I guess is to say, and so they don't have the ability to recover when you're trying to fix things. 

And so what we can do in order to mitigate the problems that can be associated with that is use what's called a mechanical circulatory support or MCS. And there's different devices out there. The one that we use most commonly in people that really have sick hearts is called an Impella, and it's basically an Archimedes screw. So it siphons blood out of the left ventricle and into the aorta. And so you have to imagine this is placed across your aortic valve, which your aortic valve is what separates your ventricle, which is your pumping chamber, to your aorta, which is the main vessel that delivers blood to your body.

And so if your heart's not working very well, it has a tough time getting blood from out of the left ventricle and into the body. But the Impella here, you place this across that aortic valve. So this chamber right here, if you can see, this is where blood goes in from the left ventricle. There's a pump, a centrifugal pump, or not really centrifuge, it's actually an Archimedes screw. So it basically rotates and siphons blood out of the left ventricle and displaces it into the aorta. And so while you're intervening on the heart and you're requiring more recovery time from the heart, this is actually fully supporting your heart and your cardiac output while you're intervening in the arteries themselves.

So this is a really good way to support someone who is very sick. And like I said, these procedures tend to be a very high risk procedure. And so this gives us a way that we can keep them safely supported while intervening.

And then once the procedure, this is not a permanent device. Once the procedure is over, if they need it for 24 to 48 hours, that'd be the ideal time that we could leave it in.

We usually try to wean down. You can actually adjust how much flow this device is outputting. And so you kind of wean down slowly to see if their heart's going to recover or not. If it's not, then you leave it in for one or two days and then slowly start the weaning process with other medications on board to try to try to help the cardiac output improve.

But it's a very good option for those that are too sick for surgery or even potentially too sick for just a standard intervention percutaneously.

Dr. Bertolet: So this is like a tiny artificial heart in a way?

Dr. Boler: Yeah, I mean, it's essentially - artificial hearts have known to be just devices that can displace blood from inside the heart out to the body. And so that's essentially what this device is doing. It's displacing that blood from inside the heart itself and getting it out to help your body perfuse.

Dr. Bertolet: So I looked and I read that North Mississippi does about 1,500 percutaneous interventions a year. Does that sound about right?

Dr. Boler: That's the number that I was told. I didn't know myself until I asked, but yeah, that's about right. 

Dr. Bertolet: So that's quite a few. 

And are these procedures, do they require patients to come into the hospital to stay in the hospital or is this an outpatient procedure or how are most of these percutaneous interventions done?

Dr. Boler: Most are done as an outpatient. I mean, it all depends on why you're coming in.

You know, any intervention that you do in the cardiac world is designed to do two things. It's designed to make you feel better or live longer. Now, if you're in from just strictly speaking, a blood flow standpoint to the heart, arteries, stents or interventions can help you live longer if you're having a heart attack. Now, those are the ones that are in the hospital usually going to require at least 24 to 48 hours of stay.

Those are the ones that tend to be more sick because they're coming in acutely. But the people that don't feel well, the people that want to feel better, and it's related to a lack of blood flow, those are the ones that come in as an outpatient. So you can come in as an outpatient. You get your procedure if you're intervened upon. Usually you can go home the same day. So it can be done within a same day visit where you don't have to spend the night in the hospital.

So it's like I said, you know, for folks that don't feel well and it's related to coronary artery disease or heart artery blockages, these are great ways that we can help people feel better in a pretty quick manner. Usually there's a pretty quick recovery from these two. You know, with surgery, you're having to stay in the hospital for recovery purposes. But I mean, the recovery here is very minimal.

Dr. Bertolet: So I got three different scenarios.

What if you have a lot of calcium, hard concrete in your blood vessel? What if you've had a previous stent and it's re narrowed? And then what if a blockage is at a branch point where you got two blood vessels coming off the same point?
Do you have therapy to fix that?

Dr. Boler: We do, we do. There's options for all of those. So to start from the first one, calcium buildup tends to be one of the bigger issues related to percutaneous intervention. When you put a stent in, you want it to be fully expanded. Stents do their best when they are. You know, every stent we have has a different size, a different length. You want to make sure that when you're deploying a stent, you don't want to have it under inflated. You don't want it to have it malpositioned or not touching the wall like it should. 

And one of the biggest obstacles to that is just calcium. I mean, as that artery hardens over time, it becomes like a boulder and you have to get it out of the way in order for it to, to expand.

Options have progressed over the years as far as, especially as far as risk go. It used to be that we had to shave it or kind of like burr it with a, with a device to shave down the plaque and that could, that leads to its own unique complications or problems. It's a good device when it works well. And it can work well.

There's other devices out there now, such as what's called an intravascular lithotripsy, which is, or a shock wave balloon, or a balloon that delivers an ultrasonic pulse. And what it does, it fractures the calcium. So instead of a boulder, you've now broken up that boulder into small fragments. And so when you deploy the stent like we showed earlier, it can fully expand and kind of that calcium is not like a rock that's pushing on one focal area. It kind of distributes itself out so the stent can expand.

So between shaving plaque down, fracturing the calcium in and of itself, we can get the stent fully expanded to get the patient the best long term outcome.

The second option or the second scenario that you just presented there was the branch point.

So with the branch point, there are different ways to focus on how to fix that. There's different techniques that are available.

A lot of it depends on the size of the vessel that you're trying to intervene on. These tend to do better in bigger vessels. But the way these stents work, they can be, they're malleable. So if you need to, you can crimp it down, open it back. So if you could imagine here, I guess if you had to stick a branch point, you gotta think of it like a tree branch. So. And these are just a squared off end, essentially. So if the tree branch is coming off at an angle and you try to put a stent right at the beginning of that branch point, it's gonna hang out into the main trunk.

But these stents do allow for, so if you needed to flatten down an angle to get it flush to the, to where it comes off, you can do that. But then you can also open it back up again to let the blood flow circulate back down and, and then put another stent to cover it if you need to, and then you can balloon it to have it. You basically reset a whole new branch point between the two.

Like I said, there's different techniques available for that, but it is an option for intervention to fix a branch point. And you have to remind me of the third thing again.

Dr. Bertolet: What if I've had a stent and it's now the stent's re-narrowed.

Dr. Boler: There we go. So, yeah, so one of the issues with stents, they're not a forever fix, they're a temporizing procedure and they tend to last for a long time. But the stents we have now have medication on them to reduce the likelihood or reduce the rate at which your tissue will grow into the stent. So your heart tissue will actually grow into the stent. And so that's where the stents, you know, when people say their stent's not working anymore, it's not because the stent quit, it's because that tissue has started to tighten up and get layer upon layer until it's starting to narrow that vessel again.

And so it used to be that we had to put another stent with another layer of medicine in there to give the vessel that medication to reduce that process. But now there are balloons available that you can treat the lesion itself without having to put an extra layer of stent in there. So if you need to another stent, it's not unreasonable to put two layers of stent in. You know, you don't want to keep putting layer upon layer. 

But, but now with the balloon available, you could leave one layer of stent in there, open it up with a balloon, but the balloon has medication on it to reduce that cellular turnover, to decrease the process of that tissue growth. And so you can get a better long term result without having to leave a second layer of stent in. So like I said, there's good options that are coming down the road. More technologies that are going to be available to us in the future as well. So a lot to look forward to.

Dr. Bertolet: Yeah. And so if a patient needs you, what is you, meaning your group of interventional cardiologists? What's the availability? Is it Monday through Friday, 8 to 4 or what's the availability there?

Dr. Boler: We're always open, so there's always someone on call. There's always someone available if needed, emergently in the middle of the night. If it's an emergency, then yes, someone is there available. But we're, you know, thankfully we're in a group where there's 14 of us, I believe.

And so we're all able to cover for each other and to help out the patients in need. And whether it's your patient or one of your partner's patients, there's always someone available if a need arises.

Dr. Bertolet: And if that need were to be an angioplasty and a stent, is there an interventional cardiologist that's available 24/7/365?

Dr. Boler: That's correct. There's someone available at the hospital that's for any emergent need, whatever time of day.

Dr. Bertolet: And how many interventional cardiologists does North Mississippi have?

Dr. Boler: I believe I have six, if I'm not mistaken. So there's always someone around and available.

Dr. Bertolet: And all are board certified in interventional cardiology. Not just cardiology. 

Dr. Boler: That is correct. That is a separate board exam that we all have to take and an additional year of training. Some places it's two, but most places it's just one extra year. But yes, an extra year of training, an extra board exam. And so. And all the ones at North Mississippi are board certified interventional cardiologists.

Dr. Bertolet: That's great. So that's wonderful. So the, one of the slogans that North Mississippi has is that you're our true north.

And so I'm going to ask you this final question, is that what is your true north? What has brought you to Tupelo? What drives you to get up at 2 o' clock in the morning to go in to treat a heart attack patient?

Dr. Boler: There's a - I guess that could be a long answer to that question, but the basics of it are Tupelo provided a lot of opportunities for myself and my family, for my wife and my kids to grow up in a somewhat smaller community that had a lot of opportunities.

And in me personally, in just my professional life, there was nothing here that was lacking that I needed or wanted. Everything that was here from a work standpoint was things that I was interested in doing, helping people.

Of course, that's the easy answer to this, is you want people to feel better. That's why people get into medicine and get through the process of medical school to begin with is you're wanting to do something to help people. And cardiology is one of those things that, you know, you just kind of find yourself or me personally, I just found myself gravitating towards. 

And as I got through cardiology, interventional cardiology started becoming something I became more interested in. And everything at North Mississippi that I came here to do, I've been able to do. And we've been able to help a lot of people. And I've been thankful for the opportunity and look forward to many more years to come.

Dr. Bertolet: Well, we thank you for being here. And so as we wrap up with this section here, I thank you for tuning in, and I invite you to come back the next time that we meet on We're All Heart. Thank you very much.