February 28, 2025 • 35 mins
This week we review a recent review paper on newest innovations and literature on pacing in pediatric patients and learn a bit about such diverse pediatric pacing topics as:
The above are amongst the potpourri of pacing topics that we review with noted congenital electrophysiologist, Dr. Charles Berul of Children's National Hospital in Washington, DC in a co-branded episode with the SADS Foundation. For more information on SADS, please go to their website: SADS.ORG.
- Use of the Medtronic Micra device in an off-label manner for epicardial pacing in small infants
- Novel, less invasive approaches to placing epicardial leads in small children
- The role of leadless pacing in the pediatric or CHD patient
- Conduction system pacing in 2025 in the congenital patient
The above are amongst the potpourri of pacing topics that we review with noted congenital electrophysiologist, Dr. Charles Berul of Children's National Hospital in Washington, DC in a co-branded episode with the SADS Foundation. For more information on SADS, please go to their website: SADS.ORG.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:16):
Welcome to Pdheart Pediatric Cardiology Today. My name is doctor
Robert Cass and I'm the host of this podcast. I
am Professor of Pediatrics at the Icon School of Medicine
at Mount Sinai here in New York City. Thank you
for joining me for this three hundred and thirty first
episode of Pdheart. I hope everybody enjoyed last week's episode
with doctor Laura mrce Rosa, in which we took a
step back into time three years ago to talk about
(00:38):
using CMR to create better font hands. For those of
you interested in single ventricles and the foun tan operation,
I'd certainly recommend you take to listen to doctor Mercerosa
in episode two hundred and twenty seven, which we replayed
last week. As I say most weeks, if you'd like
to get in touch with me, my email is easy
to remember. It's Pdheart at gmail dot com. This week
(00:59):
is a special episode which we're co branding with the
Sudden a Rhythmia Death Syndrome Organization or Foundation, sometimes referred
to as SADS. For those of you interested in this
very important work that they're doing, please go to the
website SADS dot org.
Speaker 2 (01:14):
Today.
Speaker 1 (01:14):
The topic is electrophysiology. As would be expected with this
co branded episode. The title of the work we'll be
reviewing is Emerging Pacemaker Technology for Small Children. The first
author of this work is Charles Barrull and the senior
author Rohan comthekar and the authors come to us from
the Division of Cardiology at Children's National Hospital in Washington, DC,
(01:35):
as well as Nationwide Children's Hospital in Columbus, Ohio. When
we're done reviewing this paper, doctor Charles Barrull has graciously
agreed to speak with us about the emergence of new
technologies for pacing a very exciting episode. Indeed, therefore I'll
go straight into the description of this very brief article
and then a conversation with noted electrophysiologist Charles Barrull. This
(01:57):
week's brief work is a review from the journal Heart
Rhythm and was suggested to us by SADS dot org
and begins with the general comment that pacemakers and ICDs
and even leads are designed largely for adults, and the
authors state what is the reality for all pediatric electrophysiologists,
namely that we are all tasked with adapting adult sized
technologies into pediatric generally smaller patients. The authors then review
(02:22):
some of the major advances and what we have learned
and roughly the last year or two. They begin first
with the leadless pacemaker and review that this new leadless
device has been shown to reduce infection risk and avoids
venus seclusion commonly seen in those who get trans venus systems.
They remark that there's a paucity of data in children
(02:42):
and review this fact coupled with concerns about using them
in smaller children, as well as uncertainty regarding ability to
remove them in the future and battery longevity, which are
all factors that have largely caused US in pediatric EP
to enter gingerly into their use. The authors do, however,
reference a recent multi center work in which there were
sixty three patients receiving a micrometronic leadless single chamber pacemaker,
(03:07):
and they review that the average age of patients in
this work was fifteen years, and eight of the patients
were less than eight years and weighed less than thirty kilos.
The majority of these devices were implanted from the femoral
vein and rarely the internal jugular vein was used in
that small series, but again the largest thus far reported
in children, the complication rate was sixteen percent, with two
(03:29):
notable complications being one patient who had a rise acutely
in the capture threshold, which required retrieval of the device
and replacement, and a smaller nineteen kilo patient who developed
cardiac tampaat requiring drainage. And so I think, if I
were to summarize what the authors state on this topic
of leadless devices, there are some smaller reports of their
use with reasonable outcomes, but it still remains to be
(03:51):
seen at this moment in time what their precise role
will be in our field. The authors then move on
to epicardial pacing and review how at the present time
epicardial pacing remains the standard approach in small children who
need pacemakers. They reference a recent large retrospective review with
over eleven hundred neonates lessener equal to thirty one days
of age with third degree heart block who did not
(04:13):
have congenital heart disease surgery other than for isolated pacemaker implantation,
with fifty percent having it performed during their initial newborn presentation,
and twenty eight percent or three hundred and twenty six
patients having concominant congenital heart surgery with pacemaker insertion. Amongst
those who had congenital heart surgery and a pacemaker, I
found it surprising to read that inhospital mortality was as
(04:36):
high as thirty six percent, but for those with structurally
normal hearts, the mortality rate was lower at eight point
four percent. The authors then move on to neonatal pacemaker
generators and they review how even smaller pacemakers that are
presently commercially available are largely too large for premature infants.
For this reason, the authors review their own prior work
(04:56):
on a novel pediatric pacemaker. In their recent publication on
five premature newborns who underwent epicardial pacemaker implantations with this
smaller generator, they explained that the device is actually a
metronic micra leadless device, in which the ties of the
device are encased in a polymer header, which allows it
to actually be attached to a standard epicardial pacemaker lead.
(05:18):
The authors explain that with this technique, the size of
the micro device that is adapted is less than half
the size of the smallest currently available pacemaker, and they
review the major findings of their prior report with one
hundred percent acute success and with stable pacer parameters at
six to nine months follow up, and an expected longevity
of between one point eight and four point five years,
(05:39):
which the authors explain is lower than typically expected with
this device due to the need for faster heart rates
in this patient group and higher thresholds as well. They
also mention a disadvantage of this approach, which is the
inability to provide dual chamber pacing, but they explain that
this was not a clinically important issue, as chronotropic incompetence
was the major problem. The authors then move on to
(06:00):
a topic that is especially interesting to them, that of
percutaneous epicardial pacing, which you may recall as a topic
reviewed nearly seven years ago on this podcast with doctor
Brad Clark and doctor Yannive Barcone in episode number twenty
six of PDHART. The author's reference a more recent work
that they published on using a minimally invasive approach that
is percutaneous to implant epicardial pacing leads under direct visualization
(06:24):
in immature animals, and they review how the entire procedure
is performed via a four milimeter needlestick with a trocar
that provides entry and excellent lighting of the interthoracic space,
and then a specialized camera in the specially designed needle
allows for direct visualization of entry to the paracardial space,
and the authors use modified Seldinger technique to get in there,
(06:46):
allowing for implantation of a side biting helical epicardial lead
to the heart. They review how it was technically successful
in six infant piglets and suggests that this may allow
for less invasive pacemaker insertions in infants in the futureture.
The last topic of this brief report is that of
conduction system pacing and congel heart disease, and they begin
(07:06):
reviewing that diysynchrony from pacing can cause or contribute to
dysfunction and propose that conduction system pacing might avoid this,
particularly in small children who need lifelong pacing. They reference
a study by doctor Jeremy Moore and colleagues on conduction
system pacing in mostly adult congenital patients with a mean
age in that study of thirty seven years, showing that
(07:28):
in a small group it achieved in narrowed cures duration
versus more conventional cardiac resynchronization therapy and was comparable in
regards to improving LV function.
Speaker 3 (07:37):
Well.
Speaker 1 (07:37):
As I mentioned at the outset, this was a brief
summary of recent literature on pediatric pacing, and I'm sure
that many in the audience listening have had their own
experience with some of the technologies that I've described. Certainly,
the work of doctor Barul in doing percutaneous epicardyal pacing
is quite exciting and it's something we'll want to discuss
with him. I was surprised to hear the high mortality
(07:59):
rate in congenl heart patients undergoing congenital heart surgery and
a pacemaker, and wonder if Charlie has any thoughts on this.
I'm also interested to learn of doctor Burule's thoughts on
who in the present era deserves conduction system pacing and
if he thinks that the days of r V apical
septle pacing are about to end. Having such a world
renowned expert on pacing on this podcast this week is
(08:21):
a wonderful treat, and so in the interest of getting
to speak directly with our weekly expert, I think I'll
stop and move straight onto our conversation with this week's
first author, doctor Charles Barrull, joining us Now to discuss
this week's review article is doctor Charles Barrull. Charles Barull
is the emeritus Chief of Cardiology at Children's National Hospital.
Prior to going to Children's National Hospital in two thousand
(08:42):
and nine, doctor Barull was the director of the Pacemaker
Program at Children's Hospital Boston Harvard Medical School. Doctor Barull
is Professor of Pediatrics at George Washington University School of Medicine,
where he is the Van Meter Company's Professor of Cardiology.
Doctor Barull is a fellow the Heart Rhythm Society, American
Academy of Pediatrics and ark In College of Cardiology, Society
for Pediatric Research, and the American part Association Council on
(09:05):
cardiovascer Disease in the Young. He is the author of
more than one hundred and fifty publications in pediatric cardiology
and is a well known invited speaker nationally and internationally,
and an acknowledged expert and leader in our field of
pediatric electrophysiology. It is aslike to welcome my friend Charlie
to the podcast. Welcome Charlie to PDHART.
Speaker 3 (09:25):
I'm here now with doctor Charlie Barrul from Children's National
Hospital in Washington, DC. Charlie, thank you very much for
joining us this week on PD Heart.
Speaker 2 (09:32):
Thanks Rob for having met.
Speaker 3 (09:35):
Great pleasure for those in the audience. Doctor Burle was
kind enough to give us time right smack in the
middle of his afternoon, so we're very appreciative. You know,
Charlie very much enjoyed your brief summary of sort of
the latest and greatest in pacing for children and congenital
hard patients. One of the things that you reviewed was
you referenced a large scale retrospective study from a year
(09:56):
or two ago with over eleven hundred neon a who
got pacema makers and mentioned that in hospital mortality was
actually thirty six percent in the series amongst those who
had congenital heart surgery and also got a pacemaker. And
I'm wondering why you think that mortality was so high
in that group. Was it related to pacing or other factors,
(10:17):
And wondering those pacing or the need for it can
confirm additional risk on top of me and antal heart surgery,
or you think maybe it's just more a marker.
Speaker 4 (10:26):
Of people who have more complex heart disease.
Speaker 5 (10:28):
Yeah, thanks Rob, I think the first before I answered
the question I want to before I forget, want to
recognize doctor Rohan Taker, who is the author with me
on that article from Nationwide Children's Yes, and did a
lot of the work on that regarding that particle the
first reference. It's actually the second reference. I think you
mentioned that. I agree with you. I think that there's
(10:50):
a lot of confounding variables. That was a article pediatric
help I think with the PHIS stands for there was
a PHIS Illustrative database, you know, yeah, reviewing basing twenty
first century data, since most of the articles on natal
heart block are back in the twentieth century, and we
(11:14):
based a lot of our guidelines on that sort of old,
older clinical history, and so what they attempted to do
was get more current data. And then you looked at
the FIZZ database past twenty years and yeah, was surprisingly
high mortality in hospital mortality. And I think you're absolutely right,
(11:37):
and a lot of it was confounding. So many of
those babies were with munatal complete heart block, were premature
or had complex can general heart disease, so they didn't
necessarily die from the heart block, but certainly was a
major risk factor regardless of whether they got a pacemaker
or not.
Speaker 3 (11:57):
Yeah, you know, well facts. That was very helpful and
very clear. Charlie. I was wondering if you could speak
to the audience about the use, very exciting use of
the Metronic Micra leadless device with adjustments to allow for
attachment to a bipolar standard at Picardia lead. You've written
about the very early experience with it, and I was wondering,
(12:19):
what do we now know one or two years after
your initial description of this approach, and is this device
with this modification commercially available and how long do you
think this device is expected to work before there's battery
depletion if you assume somebody has a relatively reasonable capture threshold.
Have there been problems encountered with the use of it
(12:40):
in follow up that maybe weren't in the initial reports?
Speaker 2 (12:43):
Okay, a few questions there.
Speaker 5 (12:45):
So the first our first series was the first five
patients implanted, and that's now those patients are now two
or three years old and doing most of them doing well.
Speaker 4 (12:58):
Yes.
Speaker 5 (12:59):
Since then, there's been a multi center study presented by
doctor Hawk, one of my prior fellows, recent fellows, presented
at HRS this May, and that paper is actually coming
out next week. In next week in circulation EP with
(13:19):
from twelve US centers twelve of the fifteen centers in
the US, and that had implanted the device by last year.
Again the data was presented, so I can talk about
the presentation.
Speaker 2 (13:32):
I can't yet talked about the details.
Speaker 5 (13:34):
In the publications that's there embargoed until then. Yes, but yeah,
so roughly twenty nine kids in that study and follow
up up to two years since in Planet and includes
those first five that we published a couple of years ago.
Speaker 2 (13:52):
And you know, the.
Speaker 5 (13:54):
Battery estimated longevity is right on track with the estimates,
So I think that the battery is going to last
at least three years in these devices. Not quite as
good as a standard leadless pacemaker that's put in transvenously,
you know, just like any other epicardial, you know, device
(14:16):
with the lead.
Speaker 2 (14:17):
The thresholds are going.
Speaker 5 (14:18):
To be a little bit higher with what we've seen
with standard micro or vier pacemakers going right to the
rbendo cardium. So but even still and plus neonates, you know,
lower ratements are going to be a lot higher than
older kids and adults. So if you're pacing them, you know,
VBI at one hundred or one hundred and twenty one GEM.
(14:41):
He's going to be a lot shorter than VBI sixty.
But I think if you get three years out of it,
that's great because then they are big enough for a
standard sized generator when they need a generator replacement.
Speaker 4 (14:54):
Yeah, yeah, oh very interesting. That's great.
Speaker 3 (14:58):
And Charlie, right now in the United States, can somebody
call up Metronic and ask for one of these sort
of modified micros.
Speaker 5 (15:07):
Yeah, I didn't answer this the last part of your question.
You're right, it's not commercially available. So they're being placed
on emergency use authorizations, one of one of the FDA
mechanisms in the US. Other countries have different authorization mechanisms
in the US and emergency use or EUA authorization. So
(15:31):
you have to get IRB approval at least notification from
the I r V. You need to get a second
person to corroborate that the recommendation that the baby us
this device, and you have to get parental consent for
basically an unapproved device, and those three things, then Metronic
(15:55):
rule should should ship you the device.
Speaker 2 (16:00):
It's there.
Speaker 5 (16:02):
It's an individual, single patient basis, and sometimes in a
few days turnaround time.
Speaker 3 (16:09):
I see, so not quite ready for prime time yet,
but that sounds like it's on its way, hopefully, I hope.
So yeah, now try I'm going to ask you the
question of the ones that I've prepared that I think
is going to be the most interesting to you. You know,
your team have talked a fair bit and published on
novel mechanism of placing leads via a percutaneous approach in babies.
Speaker 4 (16:31):
This is really earth shadowingly exciting.
Speaker 3 (16:34):
I'm wondering, could you review with us how this is done,
what sort of pacemaker lead you're using, and you know,
where are you in this work? I mean, have you
actually done this in a human yet? In the paper
you reference some animal studies, and you know, maybe you
can just sort of give us some bare bones general
(16:55):
generalities about this.
Speaker 4 (16:56):
It's really exciting.
Speaker 5 (16:57):
Sure, it's been you know, this, this has been We've
been working on this for about it just a little
over ten years, I guess, twelve years now, from when
we first started doing.
Speaker 2 (17:07):
This and published the first piglet work.
Speaker 5 (17:10):
And there's been a lot of iterations of this device,
making it smaller and less invasive, pretty much straw sized now,
a little port that goes in the subzyphoid region, and
through that port you can place both a camera and
a lead so that you can have direct visualization of
(17:30):
where you're placing the pacing or defibrillator lead on the
apocardial surface. So far, it is still only in animals
and a few different animal models, a variety of sizes
from two kilograms up to adult size, with good short
and intermediate term results. The biggest challenge is not the port,
(17:51):
it's as you allude to, the lead, and so we've
used several different commercially available leads which aren't perfect for
this route of implantation. And then we have some non
commercially available leads that one of the manufacturers has collaborating
with us, and you know, their engineering expertise is invaluable
(18:15):
to work on this with us and trying to design
a lead that is ideal to deliver through the poort
well pretty close. I actually had a baby two weeks
ago that I was trying to get emergency use of this,
but I could not get the unlabeled lead for the
(18:37):
manufacturer to let us use that. Yet we have we
could use our port FDAs to prove to the use
of our port and individual meunates who this This baby
had dominal issues that would have really made her not
ideal for an epic cardial pacemaker in a large pocket.
(18:58):
But anyway, I couldn't sway the company to elect use
this lead, and so I wasn't quite ready yet to
do it. But I'm hoping soon. I don't have a
timeline that each each year I say hopefully this year,
and I'm still optimistic and say.
Speaker 2 (19:13):
Hopefully this year.
Speaker 3 (19:14):
I see, well, very exciting and I'm sure you guys
will report it. For those in the audience, you may
remember that I think six years ago we spoke with
Brad Clark about some of the initial experiments done with Charlie,
and I'd recommend some of you take a listen to
that episode, which.
Speaker 4 (19:29):
I referenced earlier in this podcast.
Speaker 2 (19:31):
This week, Well, it's been fun.
Speaker 5 (19:33):
Brad and Rohan and I continue to collaborate together at
three different institutions, and we come together and do some
of this work and meet, you know, once every other
week by Zoom.
Speaker 2 (19:45):
To push this forward.
Speaker 3 (19:46):
That's wonderful. Thank you for all your efforts in that regard. Well,
I'm taking advantage of having one of the most experienced
electrophysiologists in the world here, so I'm going to ask
him some more general questions about pacing since we have
the latest and greatest leader right here. So you know, Charlie,
you're very experienced pediatric and congenital electro physiologist.
Speaker 4 (20:09):
Okay, well, then I.
Speaker 3 (20:11):
Guess I'm also in that category. But you know, in
the present era, who amongst our pediatric or even adult
congenital patients would you think are you would consider as
a good candidate for leadless devices, which you do mention
in the article. It seems like they're popping up increasingly.
But I'm wondering, like, what do we know about them
long term and congenital hard patients. Do you have any
(20:34):
concerns about ultimate ability to remove and replace them? And
are there newer technologies that might even preclude the need
to extract these devices? I remember reading about auto recharging
of these devices. I'm wondering, what's your stance on this
right now?
Speaker 2 (20:53):
Yeah, you hit the nail on the head.
Speaker 5 (20:54):
I think that the biggest issue is not the technical
challenge of gain and in. It's going to be the
challenge of what to do when they need to come
out or do they need to come out? I think
in terms of putting them in and what's the best indication.
I think intermittent heart block is a great indication for it.
I think that they may not be ideal for patients
(21:17):
with you know, congenital complete heart block or post operative
complete heart block where they're past one hundred percent of
the time.
Speaker 2 (21:25):
There are aby sequential ones.
Speaker 5 (21:28):
The abbot one of year, you can put a leadless
pacemaker in the hrim and in the ventricol and they
talk to each other and the future ones will have
more of that cross communication.
Speaker 2 (21:42):
Right now, the metronic one, the micro av.
Speaker 5 (21:47):
Uses not electrical use of mechanical signal to sense atrial closure.
And it's good but not perfect. And you know, I
think we aim to get about you know, sixty seventy
AB synchrony in that model, and I think in personal
experiences less say it's you know, I'm happy if I
(22:09):
can get half of the beats are eb synchronous with
pretty challenging, non intuitive program.
Speaker 2 (22:17):
For electric physiologists.
Speaker 5 (22:18):
So I think there's definitely a learning curve for programming
those devices. In terms of removal or abandonment, animal studies
have shown you can put up to you can leave
up to five devices in an adult size right ventrible.
I don't know if that's a good.
Speaker 2 (22:36):
Idea, but they do get indootherelialized and you know, fully encapsulated.
Speaker 5 (22:40):
But I'm not sure i'd be that comfortable having five
abandoned bullet size leadless pacemakers and my right ventricle the
Avere model as a little port to be able to
connect to at a docking station for removal. I haven't
(23:00):
personally removed any of these devices. I don't have any
personal experience, but I'm quite interested in the work that's
being published. Looking at you know, right now about two
years after implant extracting these devices with some challenges and
complete end or falization of the devices, so they're not
(23:22):
going to be easy to take out. And as you
know and seen in your experience a hints our patients,
young adults and children have a much more vigorous by
product process. So just even general transvenious lead extraction is
harder in a twenty year old than in a sixty
year old, and so I would imagine the same to
(23:44):
be true with leadless spacemakers.
Speaker 3 (23:47):
Yeah, yeah, yeah, I mean I don't do extractions. Of course,
many know that Charlie is quite expert at doing pediatric extractions.
But I can tell you that in my entire career,
if I want to get my adult colleagues us, all
I have to do is tell them that I have
a twenty year old who has a fifteen year lead
in there, and I can see the most aggressive and
(24:09):
brave extractor get a little nervous right before my eyes
and ask me you're sure it needs.
Speaker 2 (24:16):
To come out so exactly.
Speaker 4 (24:18):
So, yeah, I am worried.
Speaker 3 (24:19):
About these devices similarly, but I guess the time will
tell if maybe.
Speaker 5 (24:25):
Hopefully they'll be more design specific tools for extraction of
leadless pacemakers. I'm sure some of these companies will come
up with creative ways for removal of the devices, but
they're not there yet.
Speaker 3 (24:39):
And some of you may be aware of the so
called oh No device by Matt Gillespie and Chop and
he's been hawking that device but has a number of
very interesting case reports of removal of all sorts of
things in the heart with that, So who knows, maybe
that'll be.
Speaker 4 (24:55):
Part of the armamentarium.
Speaker 3 (24:57):
Well, Charlie, I really can't thank you enough for spending
time with us. I'm going to wrap this up with
one last question. You know, in your review you mentioned
the work of Jeremy Moore in conduction system pacing in
mostly ADHD adults with some impressive initial results. What do
we know about this in kids and why might this
(25:19):
approach be problematic in kids? I mean with left bundle
branch pacing. I often wonder is it concern that you know,
when you stick the lead in so deeply to get
the left bundle that it may be impossible to extract
it one day?
Speaker 4 (25:33):
And you know, I'll ask.
Speaker 3 (25:35):
I'll finish with a provocative question, which is do you
think anyone in twenty twenty five should have a so
called standard transvenous rv apical septal ventricular lead placement?
Speaker 2 (25:46):
Yeah? Great question, rob Well.
Speaker 5 (25:49):
First kudos to that group, to doctor Moore and his
co authors from centers around the world.
Speaker 2 (25:55):
For their early.
Speaker 5 (25:57):
Data sixty five cases in Kanja heart disease, pretty and
some were you know, tetrology and.
Speaker 2 (26:05):
D SC patients, but you know, they had pretty good results.
Speaker 5 (26:09):
I think that you know, conduction system pacing technically left
bundle area at least is technically a little easier than
trying to do his bundle pacing where the thresholds hadn't
been great, and there were some concerns about threshold rises
and his lodgment. And as you know, I mean an
agree conventional CRT patient is not a layup. In general,
(26:34):
heart disease sometimes hard to find the CES.
Speaker 2 (26:36):
It's often in an abnormal place and in corrected transposition.
For example, Doctor Morris written several papers on doing that.
But to get to the left bundle branch area is
more consistent. It's not always perfect. You know, you can
get narrow, narrow ish paste fuel restorations. It may not be.
Speaker 5 (27:01):
They might not be super narrow like you can sometimes
get when you get an ideal branch.
Speaker 2 (27:06):
In the CS and true vibeing tricular pacing.
Speaker 5 (27:10):
But it's pretty good and I do think it's better
than apical right particular apical pacing. So for patients that
are hundred percent paced, my practice has changed over the
past two years to new implants or getting left bundle
branch pacing if there are one hundred percent paced, if not,
(27:31):
if they're if they're mostly a past or only me
me paced, not as compulsive about getting to the left bundle.
Speaker 3 (27:39):
I see, I see well, I think, and do you
have any concerns as an extractor Charlie of those rare
times when someone gets infected and you have to pull
out the system. Is there any literature on difficulty in
pulling out?
Speaker 4 (27:53):
I mean, for those in the.
Speaker 3 (27:55):
Audience, in order to paste the left bundle, you have
to really push the lead aggressively into the septums so
that you can capture the left bundle a little bit
more than we would with a typical standard for tricular
pacing lead. Is that has that been proven to be
difficult or not so much?
Speaker 5 (28:13):
I'm not aware of it yet, but I think it's
too soon to know. I think, you know, to take
out an infected lead that's been in nine months is
going to be easy, relatively, and so we have transvenous
iced leads that have been in twenty.
Speaker 2 (28:28):
Years that are much harder to take out.
Speaker 5 (28:31):
And so I think in twenty years, when we're trying
to take out these left bundle area pacing leads, that
maybe there may be some surprises that we find, you know,
maybe we're going to.
Speaker 2 (28:42):
Take some conduction tissue with us when we pull the
leads out. I don't have any experience with long term
chronic in twelve leads.
Speaker 3 (28:52):
I guess I guess if it works, it's worth that.
It's worth the risk in order to you know, avoid
all of the downsides rather of not pacing the left
bundle and not having maybes.
Speaker 5 (29:05):
You know, I think so as you said, I think
with an infection is going to be the need to
take them out, and hopefully that won't be long term.
Speaker 2 (29:13):
You know, that will be very eau.
Speaker 5 (29:15):
The momentless leads that are most people are using for
left bundle area pacing quite reliable and have a good history.
Speaker 2 (29:24):
Of guests of not failing.
Speaker 5 (29:27):
So you're right, infection is going to be your mucation
and hopefully those won't be so bad.
Speaker 4 (29:32):
I see.
Speaker 3 (29:32):
Well, I guess all very exciting innovations, and I think
the book hasn't been written on almost everything we've discussed today,
but that's why it's so exciting and interesting to discuss it. Well, Charlie,
I really can't thank you enough for those in the audience. Again,
Charlie was nice enough to give us time, and I
just want to on the podcast thank Charlie for always
(29:53):
being such a supportive colleague throughout my entire career. It's
always been a great honor to call you friends. And
I'm really appreciative for all that you've meant to me
in my career, and of course today I'm very appreciative
for you coming on the podcast, and also want to
fact the SADZ Foundation, who are nice enough to recommend
you as an outstanding guest.
Speaker 4 (30:12):
And I'm sure that lots and lots of people are
going to listen this week.
Speaker 2 (30:15):
Well, thanks so much. Who was going to say the
same thing.
Speaker 5 (30:17):
And I shout out to the SADS Foundation and you
Rob for decades of friendship and being good college.
Speaker 4 (30:24):
Thank you well.
Speaker 3 (30:25):
As I'm app to say when the guest is good,
there really is not a whole lot more to add.
Doctor Barul is one of the true leaders in our
fields of pediatric electrophysiology, particularly in pacing, and he has
made so many important contributions that have saved the lives
of so many. As he is an uncommonly clear speaker
and had so much to share with us today, I
think there's really not much more to add other than
(30:47):
to once more thank him and SADS and particularly Marsha
Baker who's the program director for the SADS Foundation and
Alis Laura, who is president and CEO of SADZ. And
I would again suggest that you go go to their
wonderful organization website, sads dot org for a wealth of
resources for families, patients, and providers of children with conditions
(31:07):
that are associated with sudden death. I am quite certain
that you'll find your time there on this free website
to be time well spent.
Speaker 1 (31:14):
To conclude this three hundred and thirty first episode of
Pete Hart Pediatric Cardiology, Today, in a co branded episode
with sads dot org, we hear one of the most
extraordinary of opera stars who was born in February of
nineteen twenty, Miss Eileen Farrell. Farrell was one of the
great operatic dramatic sopranos of the twentieth century who was
known for a beautiful and particularly gigantic voice. I recall
(31:38):
reading once that when she recorded opera duets with the
great American tenor Richard Tucker, she had to be placed
a few feet behind mister Tucker in the studio because
her voice was so profoundly overpowering. What made Miss Farrell
a true anomaly, though, was that she was also a
gifted singer of popular song and recorded a series of
albums of popular songs that are lauded. Didn't recorded history
(32:01):
at least as much as her wonderful operatic output. Today
we hear the non operatic side of miss Farrell in
the nineteen sixties live performance of Gershwin's Not for Me.
Thank you for joining me for this three hundred and
thirty first episode, Thanks to the Satz Foundation for suggesting
our wonderful guest, Doctor Barule, and thanks once again to
doctor Barule. I hope I'll have a good week ahead.
Speaker 2 (32:25):
Riding song.
Speaker 3 (32:28):
Of love but not for me, A lucky stars of the.
Speaker 2 (32:43):
But not for me.
Speaker 3 (32:47):
We're love to leave the way.
Speaker 5 (32:53):
I've found a cloud love great.
Speaker 3 (33:00):
Any Russian play could.
Speaker 5 (33:05):
Guarantee I was a fool.
Speaker 3 (33:14):
To fall and get that way.
Speaker 5 (33:21):
High elass and also lack a day all can dismiss.
Speaker 2 (33:39):
The memory of.
Speaker 5 (33:43):
His kids.
Speaker 3 (33:47):
I guess he's.
Speaker 5 (33:50):
Not for.
Speaker 4 (34:04):
M.
Speaker 5 (34:22):
I lost.
Speaker 4 (34:30):
And get that way.
Speaker 5 (34:35):
High home a laps.
Speaker 2 (34:39):
And also.
Speaker 5 (34:41):
Lacker day all can disny.
Speaker 2 (34:56):
The memory on.
Speaker 4 (35:00):
His king.
Speaker 3 (35:06):
I guess.
Speaker 4 (35:09):
He's not me.
Welcome to Pdheart Pediatric Cardiology Today. My name is doctor
Robert Cass and I'm the host of this podcast. I
am Professor of Pediatrics at the Icon School of Medicine
at Mount Sinai here in New York City. Thank you
for joining me for this three hundred and thirty first
episode of Pdheart. I hope everybody enjoyed last week's episode
with doctor Laura mrce Rosa, in which we took a
step back into time three years ago to talk about
(00:38):
using CMR to create better font hands. For those of
you interested in single ventricles and the foun tan operation,
I'd certainly recommend you take to listen to doctor Mercerosa
in episode two hundred and twenty seven, which we replayed
last week. As I say most weeks, if you'd like
to get in touch with me, my email is easy
to remember. It's Pdheart at gmail dot com. This week
(00:59):
is a special episode which we're co branding with the
Sudden a Rhythmia Death Syndrome Organization or Foundation, sometimes referred
to as SADS. For those of you interested in this
very important work that they're doing, please go to the
website SADS dot org.
Speaker 2 (01:14):
Today.
Speaker 1 (01:14):
The topic is electrophysiology. As would be expected with this
co branded episode. The title of the work we'll be
reviewing is Emerging Pacemaker Technology for Small Children. The first
author of this work is Charles Barrull and the senior
author Rohan comthekar and the authors come to us from
the Division of Cardiology at Children's National Hospital in Washington, DC,
(01:35):
as well as Nationwide Children's Hospital in Columbus, Ohio. When
we're done reviewing this paper, doctor Charles Barrull has graciously
agreed to speak with us about the emergence of new
technologies for pacing a very exciting episode. Indeed, therefore I'll
go straight into the description of this very brief article
and then a conversation with noted electrophysiologist Charles Barrull. This
(01:57):
week's brief work is a review from the journal Heart
Rhythm and was suggested to us by SADS dot org
and begins with the general comment that pacemakers and ICDs
and even leads are designed largely for adults, and the
authors state what is the reality for all pediatric electrophysiologists,
namely that we are all tasked with adapting adult sized
technologies into pediatric generally smaller patients. The authors then review
(02:22):
some of the major advances and what we have learned
and roughly the last year or two. They begin first
with the leadless pacemaker and review that this new leadless
device has been shown to reduce infection risk and avoids
venus seclusion commonly seen in those who get trans venus systems.
They remark that there's a paucity of data in children
(02:42):
and review this fact coupled with concerns about using them
in smaller children, as well as uncertainty regarding ability to
remove them in the future and battery longevity, which are
all factors that have largely caused US in pediatric EP
to enter gingerly into their use. The authors do, however,
reference a recent multi center work in which there were
sixty three patients receiving a micrometronic leadless single chamber pacemaker,
(03:07):
and they review that the average age of patients in
this work was fifteen years, and eight of the patients
were less than eight years and weighed less than thirty kilos.
The majority of these devices were implanted from the femoral
vein and rarely the internal jugular vein was used in
that small series, but again the largest thus far reported
in children, the complication rate was sixteen percent, with two
(03:29):
notable complications being one patient who had a rise acutely
in the capture threshold, which required retrieval of the device
and replacement, and a smaller nineteen kilo patient who developed
cardiac tampaat requiring drainage. And so I think, if I
were to summarize what the authors state on this topic
of leadless devices, there are some smaller reports of their
use with reasonable outcomes, but it still remains to be
(03:51):
seen at this moment in time what their precise role
will be in our field. The authors then move on
to epicardial pacing and review how at the present time
epicardial pacing remains the standard approach in small children who
need pacemakers. They reference a recent large retrospective review with
over eleven hundred neonates lessener equal to thirty one days
of age with third degree heart block who did not
(04:13):
have congenital heart disease surgery other than for isolated pacemaker implantation,
with fifty percent having it performed during their initial newborn presentation,
and twenty eight percent or three hundred and twenty six
patients having concominant congenital heart surgery with pacemaker insertion. Amongst
those who had congenital heart surgery and a pacemaker, I
found it surprising to read that inhospital mortality was as
(04:36):
high as thirty six percent, but for those with structurally
normal hearts, the mortality rate was lower at eight point
four percent. The authors then move on to neonatal pacemaker
generators and they review how even smaller pacemakers that are
presently commercially available are largely too large for premature infants.
For this reason, the authors review their own prior work
(04:56):
on a novel pediatric pacemaker. In their recent publication on
five premature newborns who underwent epicardial pacemaker implantations with this
smaller generator, they explained that the device is actually a
metronic micra leadless device, in which the ties of the
device are encased in a polymer header, which allows it
to actually be attached to a standard epicardial pacemaker lead.
(05:18):
The authors explain that with this technique, the size of
the micro device that is adapted is less than half
the size of the smallest currently available pacemaker, and they
review the major findings of their prior report with one
hundred percent acute success and with stable pacer parameters at
six to nine months follow up, and an expected longevity
of between one point eight and four point five years,
(05:39):
which the authors explain is lower than typically expected with
this device due to the need for faster heart rates
in this patient group and higher thresholds as well. They
also mention a disadvantage of this approach, which is the
inability to provide dual chamber pacing, but they explain that
this was not a clinically important issue, as chronotropic incompetence
was the major problem. The authors then move on to
(06:00):
a topic that is especially interesting to them, that of
percutaneous epicardial pacing, which you may recall as a topic
reviewed nearly seven years ago on this podcast with doctor
Brad Clark and doctor Yannive Barcone in episode number twenty
six of PDHART. The author's reference a more recent work
that they published on using a minimally invasive approach that
is percutaneous to implant epicardial pacing leads under direct visualization
(06:24):
in immature animals, and they review how the entire procedure
is performed via a four milimeter needlestick with a trocar
that provides entry and excellent lighting of the interthoracic space,
and then a specialized camera in the specially designed needle
allows for direct visualization of entry to the paracardial space,
and the authors use modified Seldinger technique to get in there,
(06:46):
allowing for implantation of a side biting helical epicardial lead
to the heart. They review how it was technically successful
in six infant piglets and suggests that this may allow
for less invasive pacemaker insertions in infants in the futureture.
The last topic of this brief report is that of
conduction system pacing and congel heart disease, and they begin
(07:06):
reviewing that diysynchrony from pacing can cause or contribute to
dysfunction and propose that conduction system pacing might avoid this,
particularly in small children who need lifelong pacing. They reference
a study by doctor Jeremy Moore and colleagues on conduction
system pacing in mostly adult congenital patients with a mean
age in that study of thirty seven years, showing that
(07:28):
in a small group it achieved in narrowed cures duration
versus more conventional cardiac resynchronization therapy and was comparable in
regards to improving LV function.
Speaker 3 (07:37):
Well.
Speaker 1 (07:37):
As I mentioned at the outset, this was a brief
summary of recent literature on pediatric pacing, and I'm sure
that many in the audience listening have had their own
experience with some of the technologies that I've described. Certainly,
the work of doctor Barul in doing percutaneous epicardyal pacing
is quite exciting and it's something we'll want to discuss
with him. I was surprised to hear the high mortality
(07:59):
rate in congenl heart patients undergoing congenital heart surgery and
a pacemaker, and wonder if Charlie has any thoughts on this.
I'm also interested to learn of doctor Burule's thoughts on
who in the present era deserves conduction system pacing and
if he thinks that the days of r V apical
septle pacing are about to end. Having such a world
renowned expert on pacing on this podcast this week is
(08:21):
a wonderful treat, and so in the interest of getting
to speak directly with our weekly expert, I think I'll
stop and move straight onto our conversation with this week's
first author, doctor Charles Barrull, joining us Now to discuss
this week's review article is doctor Charles Barrull. Charles Barull
is the emeritus Chief of Cardiology at Children's National Hospital.
Prior to going to Children's National Hospital in two thousand
(08:42):
and nine, doctor Barull was the director of the Pacemaker
Program at Children's Hospital Boston Harvard Medical School. Doctor Barull
is Professor of Pediatrics at George Washington University School of Medicine,
where he is the Van Meter Company's Professor of Cardiology.
Doctor Barull is a fellow the Heart Rhythm Society, American
Academy of Pediatrics and ark In College of Cardiology, Society
for Pediatric Research, and the American part Association Council on
(09:05):
cardiovascer Disease in the Young. He is the author of
more than one hundred and fifty publications in pediatric cardiology
and is a well known invited speaker nationally and internationally,
and an acknowledged expert and leader in our field of
pediatric electrophysiology. It is aslike to welcome my friend Charlie
to the podcast. Welcome Charlie to PDHART.
Speaker 3 (09:25):
I'm here now with doctor Charlie Barrul from Children's National
Hospital in Washington, DC. Charlie, thank you very much for
joining us this week on PD Heart.
Speaker 2 (09:32):
Thanks Rob for having met.
Speaker 3 (09:35):
Great pleasure for those in the audience. Doctor Burle was
kind enough to give us time right smack in the
middle of his afternoon, so we're very appreciative. You know,
Charlie very much enjoyed your brief summary of sort of
the latest and greatest in pacing for children and congenital
hard patients. One of the things that you reviewed was
you referenced a large scale retrospective study from a year
(09:56):
or two ago with over eleven hundred neon a who
got pacema makers and mentioned that in hospital mortality was
actually thirty six percent in the series amongst those who
had congenital heart surgery and also got a pacemaker. And
I'm wondering why you think that mortality was so high
in that group. Was it related to pacing or other factors,
(10:17):
And wondering those pacing or the need for it can
confirm additional risk on top of me and antal heart surgery,
or you think maybe it's just more a marker.
Speaker 4 (10:26):
Of people who have more complex heart disease.
Speaker 5 (10:28):
Yeah, thanks Rob, I think the first before I answered
the question I want to before I forget, want to
recognize doctor Rohan Taker, who is the author with me
on that article from Nationwide Children's Yes, and did a
lot of the work on that regarding that particle the
first reference. It's actually the second reference. I think you
mentioned that. I agree with you. I think that there's
(10:50):
a lot of confounding variables. That was a article pediatric
help I think with the PHIS stands for there was
a PHIS Illustrative database, you know, yeah, reviewing basing twenty
first century data, since most of the articles on natal
heart block are back in the twentieth century, and we
(11:14):
based a lot of our guidelines on that sort of old,
older clinical history, and so what they attempted to do
was get more current data. And then you looked at
the FIZZ database past twenty years and yeah, was surprisingly
high mortality in hospital mortality. And I think you're absolutely right,
(11:37):
and a lot of it was confounding. So many of
those babies were with munatal complete heart block, were premature
or had complex can general heart disease, so they didn't
necessarily die from the heart block, but certainly was a
major risk factor regardless of whether they got a pacemaker
or not.
Speaker 3 (11:57):
Yeah, you know, well facts. That was very helpful and
very clear. Charlie. I was wondering if you could speak
to the audience about the use, very exciting use of
the Metronic Micra leadless device with adjustments to allow for
attachment to a bipolar standard at Picardia lead. You've written
about the very early experience with it, and I was wondering,
(12:19):
what do we now know one or two years after
your initial description of this approach, and is this device
with this modification commercially available and how long do you
think this device is expected to work before there's battery
depletion if you assume somebody has a relatively reasonable capture threshold.
Have there been problems encountered with the use of it
(12:40):
in follow up that maybe weren't in the initial reports?
Speaker 2 (12:43):
Okay, a few questions there.
Speaker 5 (12:45):
So the first our first series was the first five
patients implanted, and that's now those patients are now two
or three years old and doing most of them doing well.
Speaker 4 (12:58):
Yes.
Speaker 5 (12:59):
Since then, there's been a multi center study presented by
doctor Hawk, one of my prior fellows, recent fellows, presented
at HRS this May, and that paper is actually coming
out next week. In next week in circulation EP with
(13:19):
from twelve US centers twelve of the fifteen centers in
the US, and that had implanted the device by last year.
Again the data was presented, so I can talk about
the presentation.
Speaker 2 (13:32):
I can't yet talked about the details.
Speaker 5 (13:34):
In the publications that's there embargoed until then. Yes, but yeah,
so roughly twenty nine kids in that study and follow
up up to two years since in Planet and includes
those first five that we published a couple of years ago.
Speaker 2 (13:52):
And you know, the.
Speaker 5 (13:54):
Battery estimated longevity is right on track with the estimates,
So I think that the battery is going to last
at least three years in these devices. Not quite as
good as a standard leadless pacemaker that's put in transvenously,
you know, just like any other epicardial, you know, device
(14:16):
with the lead.
Speaker 2 (14:17):
The thresholds are going.
Speaker 5 (14:18):
To be a little bit higher with what we've seen
with standard micro or vier pacemakers going right to the
rbendo cardium. So but even still and plus neonates, you know,
lower ratements are going to be a lot higher than
older kids and adults. So if you're pacing them, you know,
VBI at one hundred or one hundred and twenty one GEM.
(14:41):
He's going to be a lot shorter than VBI sixty.
But I think if you get three years out of it,
that's great because then they are big enough for a
standard sized generator when they need a generator replacement.
Speaker 4 (14:54):
Yeah, yeah, oh very interesting. That's great.
Speaker 3 (14:58):
And Charlie, right now in the United States, can somebody
call up Metronic and ask for one of these sort
of modified micros.
Speaker 5 (15:07):
Yeah, I didn't answer this the last part of your question.
You're right, it's not commercially available. So they're being placed
on emergency use authorizations, one of one of the FDA
mechanisms in the US. Other countries have different authorization mechanisms
in the US and emergency use or EUA authorization. So
(15:31):
you have to get IRB approval at least notification from
the I r V. You need to get a second
person to corroborate that the recommendation that the baby us
this device, and you have to get parental consent for
basically an unapproved device, and those three things, then Metronic
(15:55):
rule should should ship you the device.
Speaker 2 (16:00):
It's there.
Speaker 5 (16:02):
It's an individual, single patient basis, and sometimes in a
few days turnaround time.
Speaker 3 (16:09):
I see, so not quite ready for prime time yet,
but that sounds like it's on its way, hopefully, I hope.
So yeah, now try I'm going to ask you the
question of the ones that I've prepared that I think
is going to be the most interesting to you. You know,
your team have talked a fair bit and published on
novel mechanism of placing leads via a percutaneous approach in babies.
Speaker 4 (16:31):
This is really earth shadowingly exciting.
Speaker 3 (16:34):
I'm wondering, could you review with us how this is done,
what sort of pacemaker lead you're using, and you know,
where are you in this work? I mean, have you
actually done this in a human yet? In the paper
you reference some animal studies, and you know, maybe you
can just sort of give us some bare bones general
(16:55):
generalities about this.
Speaker 4 (16:56):
It's really exciting.
Speaker 5 (16:57):
Sure, it's been you know, this, this has been We've
been working on this for about it just a little
over ten years, I guess, twelve years now, from when
we first started doing.
Speaker 2 (17:07):
This and published the first piglet work.
Speaker 5 (17:10):
And there's been a lot of iterations of this device,
making it smaller and less invasive, pretty much straw sized now,
a little port that goes in the subzyphoid region, and
through that port you can place both a camera and
a lead so that you can have direct visualization of
(17:30):
where you're placing the pacing or defibrillator lead on the
apocardial surface. So far, it is still only in animals
and a few different animal models, a variety of sizes
from two kilograms up to adult size, with good short
and intermediate term results. The biggest challenge is not the port,
(17:51):
it's as you allude to, the lead, and so we've
used several different commercially available leads which aren't perfect for
this route of implantation. And then we have some non
commercially available leads that one of the manufacturers has collaborating
with us, and you know, their engineering expertise is invaluable
(18:15):
to work on this with us and trying to design
a lead that is ideal to deliver through the poort
well pretty close. I actually had a baby two weeks
ago that I was trying to get emergency use of this,
but I could not get the unlabeled lead for the
(18:37):
manufacturer to let us use that. Yet we have we
could use our port FDAs to prove to the use
of our port and individual meunates who this This baby
had dominal issues that would have really made her not
ideal for an epic cardial pacemaker in a large pocket.
(18:58):
But anyway, I couldn't sway the company to elect use
this lead, and so I wasn't quite ready yet to
do it. But I'm hoping soon. I don't have a
timeline that each each year I say hopefully this year,
and I'm still optimistic and say.
Speaker 2 (19:13):
Hopefully this year.
Speaker 3 (19:14):
I see, well, very exciting and I'm sure you guys
will report it. For those in the audience, you may
remember that I think six years ago we spoke with
Brad Clark about some of the initial experiments done with Charlie,
and I'd recommend some of you take a listen to
that episode, which.
Speaker 4 (19:29):
I referenced earlier in this podcast.
Speaker 2 (19:31):
This week, Well, it's been fun.
Speaker 5 (19:33):
Brad and Rohan and I continue to collaborate together at
three different institutions, and we come together and do some
of this work and meet, you know, once every other
week by Zoom.
Speaker 2 (19:45):
To push this forward.
Speaker 3 (19:46):
That's wonderful. Thank you for all your efforts in that regard. Well,
I'm taking advantage of having one of the most experienced
electrophysiologists in the world here, so I'm going to ask
him some more general questions about pacing since we have
the latest and greatest leader right here. So you know, Charlie,
you're very experienced pediatric and congenital electro physiologist.
Speaker 4 (20:09):
Okay, well, then I.
Speaker 3 (20:11):
Guess I'm also in that category. But you know, in
the present era, who amongst our pediatric or even adult
congenital patients would you think are you would consider as
a good candidate for leadless devices, which you do mention
in the article. It seems like they're popping up increasingly.
But I'm wondering, like, what do we know about them
long term and congenital hard patients. Do you have any
(20:34):
concerns about ultimate ability to remove and replace them? And
are there newer technologies that might even preclude the need
to extract these devices? I remember reading about auto recharging
of these devices. I'm wondering, what's your stance on this
right now?
Speaker 2 (20:53):
Yeah, you hit the nail on the head.
Speaker 5 (20:54):
I think that the biggest issue is not the technical
challenge of gain and in. It's going to be the
challenge of what to do when they need to come
out or do they need to come out? I think
in terms of putting them in and what's the best indication.
I think intermittent heart block is a great indication for it.
I think that they may not be ideal for patients
(21:17):
with you know, congenital complete heart block or post operative
complete heart block where they're past one hundred percent of
the time.
Speaker 2 (21:25):
There are aby sequential ones.
Speaker 5 (21:28):
The abbot one of year, you can put a leadless
pacemaker in the hrim and in the ventricol and they
talk to each other and the future ones will have
more of that cross communication.
Speaker 2 (21:42):
Right now, the metronic one, the micro av.
Speaker 5 (21:47):
Uses not electrical use of mechanical signal to sense atrial closure.
And it's good but not perfect. And you know, I
think we aim to get about you know, sixty seventy
AB synchrony in that model, and I think in personal
experiences less say it's you know, I'm happy if I
(22:09):
can get half of the beats are eb synchronous with
pretty challenging, non intuitive program.
Speaker 2 (22:17):
For electric physiologists.
Speaker 5 (22:18):
So I think there's definitely a learning curve for programming
those devices. In terms of removal or abandonment, animal studies
have shown you can put up to you can leave
up to five devices in an adult size right ventrible.
I don't know if that's a good.
Speaker 2 (22:36):
Idea, but they do get indootherelialized and you know, fully encapsulated.
Speaker 5 (22:40):
But I'm not sure i'd be that comfortable having five
abandoned bullet size leadless pacemakers and my right ventricle the
Avere model as a little port to be able to
connect to at a docking station for removal. I haven't
(23:00):
personally removed any of these devices. I don't have any
personal experience, but I'm quite interested in the work that's
being published. Looking at you know, right now about two
years after implant extracting these devices with some challenges and
complete end or falization of the devices, so they're not
(23:22):
going to be easy to take out. And as you
know and seen in your experience a hints our patients,
young adults and children have a much more vigorous by
product process. So just even general transvenious lead extraction is
harder in a twenty year old than in a sixty
year old, and so I would imagine the same to
(23:44):
be true with leadless spacemakers.
Speaker 3 (23:47):
Yeah, yeah, yeah, I mean I don't do extractions. Of course,
many know that Charlie is quite expert at doing pediatric extractions.
But I can tell you that in my entire career,
if I want to get my adult colleagues us, all
I have to do is tell them that I have
a twenty year old who has a fifteen year lead
in there, and I can see the most aggressive and
(24:09):
brave extractor get a little nervous right before my eyes
and ask me you're sure it needs.
Speaker 2 (24:16):
To come out so exactly.
Speaker 4 (24:18):
So, yeah, I am worried.
Speaker 3 (24:19):
About these devices similarly, but I guess the time will
tell if maybe.
Speaker 5 (24:25):
Hopefully they'll be more design specific tools for extraction of
leadless pacemakers. I'm sure some of these companies will come
up with creative ways for removal of the devices, but
they're not there yet.
Speaker 3 (24:39):
And some of you may be aware of the so
called oh No device by Matt Gillespie and Chop and
he's been hawking that device but has a number of
very interesting case reports of removal of all sorts of
things in the heart with that, So who knows, maybe
that'll be.
Speaker 4 (24:55):
Part of the armamentarium.
Speaker 3 (24:57):
Well, Charlie, I really can't thank you enough for spending
time with us. I'm going to wrap this up with
one last question. You know, in your review you mentioned
the work of Jeremy Moore in conduction system pacing in
mostly ADHD adults with some impressive initial results. What do
we know about this in kids and why might this
(25:19):
approach be problematic in kids? I mean with left bundle
branch pacing. I often wonder is it concern that you know,
when you stick the lead in so deeply to get
the left bundle that it may be impossible to extract
it one day?
Speaker 4 (25:33):
And you know, I'll ask.
Speaker 3 (25:35):
I'll finish with a provocative question, which is do you
think anyone in twenty twenty five should have a so
called standard transvenous rv apical septal ventricular lead placement?
Speaker 2 (25:46):
Yeah? Great question, rob Well.
Speaker 5 (25:49):
First kudos to that group, to doctor Moore and his
co authors from centers around the world.
Speaker 2 (25:55):
For their early.
Speaker 5 (25:57):
Data sixty five cases in Kanja heart disease, pretty and
some were you know, tetrology and.
Speaker 2 (26:05):
D SC patients, but you know, they had pretty good results.
Speaker 5 (26:09):
I think that you know, conduction system pacing technically left
bundle area at least is technically a little easier than
trying to do his bundle pacing where the thresholds hadn't
been great, and there were some concerns about threshold rises
and his lodgment. And as you know, I mean an
agree conventional CRT patient is not a layup. In general,
(26:34):
heart disease sometimes hard to find the CES.
Speaker 2 (26:36):
It's often in an abnormal place and in corrected transposition.
For example, Doctor Morris written several papers on doing that.
But to get to the left bundle branch area is
more consistent. It's not always perfect. You know, you can
get narrow, narrow ish paste fuel restorations. It may not be.
Speaker 5 (27:01):
They might not be super narrow like you can sometimes
get when you get an ideal branch.
Speaker 2 (27:06):
In the CS and true vibeing tricular pacing.
Speaker 5 (27:10):
But it's pretty good and I do think it's better
than apical right particular apical pacing. So for patients that
are hundred percent paced, my practice has changed over the
past two years to new implants or getting left bundle
branch pacing if there are one hundred percent paced, if not,
(27:31):
if they're if they're mostly a past or only me
me paced, not as compulsive about getting to the left bundle.
Speaker 3 (27:39):
I see, I see well, I think, and do you
have any concerns as an extractor Charlie of those rare
times when someone gets infected and you have to pull
out the system. Is there any literature on difficulty in
pulling out?
Speaker 4 (27:53):
I mean, for those in the.
Speaker 3 (27:55):
Audience, in order to paste the left bundle, you have
to really push the lead aggressively into the septums so
that you can capture the left bundle a little bit
more than we would with a typical standard for tricular
pacing lead. Is that has that been proven to be
difficult or not so much?
Speaker 5 (28:13):
I'm not aware of it yet, but I think it's
too soon to know. I think, you know, to take
out an infected lead that's been in nine months is
going to be easy, relatively, and so we have transvenous
iced leads that have been in twenty.
Speaker 2 (28:28):
Years that are much harder to take out.
Speaker 5 (28:31):
And so I think in twenty years, when we're trying
to take out these left bundle area pacing leads, that
maybe there may be some surprises that we find, you know,
maybe we're going to.
Speaker 2 (28:42):
Take some conduction tissue with us when we pull the
leads out. I don't have any experience with long term
chronic in twelve leads.
Speaker 3 (28:52):
I guess I guess if it works, it's worth that.
It's worth the risk in order to you know, avoid
all of the downsides rather of not pacing the left
bundle and not having maybes.
Speaker 5 (29:05):
You know, I think so as you said, I think
with an infection is going to be the need to
take them out, and hopefully that won't be long term.
Speaker 2 (29:13):
You know, that will be very eau.
Speaker 5 (29:15):
The momentless leads that are most people are using for
left bundle area pacing quite reliable and have a good history.
Speaker 2 (29:24):
Of guests of not failing.
Speaker 5 (29:27):
So you're right, infection is going to be your mucation
and hopefully those won't be so bad.
Speaker 4 (29:32):
I see.
Speaker 3 (29:32):
Well, I guess all very exciting innovations, and I think
the book hasn't been written on almost everything we've discussed today,
but that's why it's so exciting and interesting to discuss it. Well, Charlie,
I really can't thank you enough for those in the audience. Again,
Charlie was nice enough to give us time, and I
just want to on the podcast thank Charlie for always
(29:53):
being such a supportive colleague throughout my entire career. It's
always been a great honor to call you friends. And
I'm really appreciative for all that you've meant to me
in my career, and of course today I'm very appreciative
for you coming on the podcast, and also want to
fact the SADZ Foundation, who are nice enough to recommend
you as an outstanding guest.
Speaker 4 (30:12):
And I'm sure that lots and lots of people are
going to listen this week.
Speaker 2 (30:15):
Well, thanks so much. Who was going to say the
same thing.
Speaker 5 (30:17):
And I shout out to the SADS Foundation and you
Rob for decades of friendship and being good college.
Speaker 4 (30:24):
Thank you well.
Speaker 3 (30:25):
As I'm app to say when the guest is good,
there really is not a whole lot more to add.
Doctor Barul is one of the true leaders in our
fields of pediatric electrophysiology, particularly in pacing, and he has
made so many important contributions that have saved the lives
of so many. As he is an uncommonly clear speaker
and had so much to share with us today, I
think there's really not much more to add other than
(30:47):
to once more thank him and SADS and particularly Marsha
Baker who's the program director for the SADS Foundation and
Alis Laura, who is president and CEO of SADZ. And
I would again suggest that you go go to their
wonderful organization website, sads dot org for a wealth of
resources for families, patients, and providers of children with conditions
(31:07):
that are associated with sudden death. I am quite certain
that you'll find your time there on this free website
to be time well spent.
Speaker 1 (31:14):
To conclude this three hundred and thirty first episode of
Pete Hart Pediatric Cardiology, Today, in a co branded episode
with sads dot org, we hear one of the most
extraordinary of opera stars who was born in February of
nineteen twenty, Miss Eileen Farrell. Farrell was one of the
great operatic dramatic sopranos of the twentieth century who was
known for a beautiful and particularly gigantic voice. I recall
(31:38):
reading once that when she recorded opera duets with the
great American tenor Richard Tucker, she had to be placed
a few feet behind mister Tucker in the studio because
her voice was so profoundly overpowering. What made Miss Farrell
a true anomaly, though, was that she was also a
gifted singer of popular song and recorded a series of
albums of popular songs that are lauded. Didn't recorded history
(32:01):
at least as much as her wonderful operatic output. Today
we hear the non operatic side of miss Farrell in
the nineteen sixties live performance of Gershwin's Not for Me.
Thank you for joining me for this three hundred and
thirty first episode, Thanks to the Satz Foundation for suggesting
our wonderful guest, Doctor Barule, and thanks once again to
doctor Barule. I hope I'll have a good week ahead.
Speaker 2 (32:25):
Riding song.
Speaker 3 (32:28):
Of love but not for me, A lucky stars of the.
Speaker 2 (32:43):
But not for me.
Speaker 3 (32:47):
We're love to leave the way.
Speaker 5 (32:53):
I've found a cloud love great.
Speaker 3 (33:00):
Any Russian play could.
Speaker 5 (33:05):
Guarantee I was a fool.
Speaker 3 (33:14):
To fall and get that way.
Speaker 5 (33:21):
High elass and also lack a day all can dismiss.
Speaker 2 (33:39):
The memory of.
Speaker 5 (33:43):
His kids.
Speaker 3 (33:47):
I guess he's.
Speaker 5 (33:50):
Not for.
Speaker 4 (34:04):
M.
Speaker 5 (34:22):
I lost.
Speaker 4 (34:30):
And get that way.
Speaker 5 (34:35):
High home a laps.
Speaker 2 (34:39):
And also.
Speaker 5 (34:41):
Lacker day all can disny.
Speaker 2 (34:56):
The memory on.
Speaker 4 (35:00):
His king.
Speaker 3 (35:06):
I guess.
Speaker 4 (35:09):
He's not me.
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