In April 2017, Matthew Goldstein, MD, a cardiac electrophysiologist at Paoli Hospital and Lankenau Heart Institute, part of Main Line Health, joined a very exclusive club. He became one of only a handful of cardiac electrophysiologists in the country to insert a pacemaker using an advanced technique that substantially enhances the heart’s ability to perform. This novel approach, known as His-bundle pacing, involves a more advantageous placement of the pacemaker’s wiring to better mimic the electrical connection in a healthy heart.
“Over time, the electrical connection between the upper and lower chambers of the heart can become broken,” explains Dr. Goldstein. “To fix the broken connection, we place a pacemaker in the chest to monitor electricity in the upper chamber and in turn, send electrical pulses to the lower chamber that prompt the heart to beat at a normal rate.”
For the past 50 years, pacemaker technology has remained much the same. Until now. His-bundle pacing promises to be a game-changer.
With traditional pacemaker insertion, one wire is placed in the upper chamber of the heart, and a second wire is placed into muscle at the bottom of the lower chamber. It’s a safe and effective approach, but the electrical connection is slower and less coordinated than that of a normal heart, resulting in reduced heart function. In some cases, the traditional approach eventually causes heart failure, requiring the insertion of a different kind of pacemaker to correct this.
The His-bundle pacing technique involves a different type of wire placed with much greater precision, considerably improving the electrical connection between the upper and lower chambers.
“We are now able to place the pacemaker wire directly into what is known as the bundle of His,” says Dr. Goldstein. “The bundle of His is the electrical superhighway of the heart. We use mapping to identify exactly where the electrical connection is broken, and then insert the wire back into the His bundle just beyond the break. So, we’re quickly bypassing the broken area and coming right back onto the superhighway.”
Says Dr. Goldstein, “Think of it this way. You’re traveling from Philadelphia to Miami. Do you take all back roads? No, you take 95−the fastest and most direct route−to get there. You get on 95 and stay on it. Before His-bundle pacing, we were going on back roads the entire way. With this new technology, when there is a bad accident, you get off the highway at that point and get back on right after. So you’re skipping the accident, but you’re still primarily using the highway for your entire trip.”
Ed Mehalick was the first of Dr. Goldstein’s patients to benefit from His-bundle pacing. Mehalick first came under Dr. Goldstein’s care two years ago when he was diagnosed with a heart arrhythmia. When his atrial flutter progressed to atrial fibrillation and he needed a pacemaker, Mehalick says he did not think twice when Dr. Goldstein suggested using the new insertion technique.
“Dr. Goldstein is a very knowledgeable individual and he explained the option well,” says Mehalick, a former engineer and one-time paramedic. “I’m a firm believer in technology and new advancements in healthcare, and the His-bundle seemed to me to be a much more natural site to place the wire. It made perfect sense.”
The new insertion technique increases the pacemaker procedure from 45 minutes to about two hours, allowing time for the cardiac electrophysiologist to map the heart and identify the exact location of the break. Mehalick stayed overnight at Paoli Hospital for monitoring and was released the next day.
“I immediately noticed that my heartbeat was regular,” recalls Mehalick. “For the first time in quite a while, I didn’t feel anything, which was a good thing. Before, I could feel the palpations. I had very little pain after the procedure−just a little soreness at the incision. It was a tremendous experience.”
“When you do an EKG after using the His-bundle pacing technique, it looks so normal that you often cannot tell the patient even has a pacemaker,” say Dr. Goldstein, who has since performed the technique in additional patients. The approach is applicable to 75 percent of patients requiring a pacemaker.
“While we’ve been aware of the benefits of His-bundle pacing for some time now, it was just this past April that the FDA approved its compatibility with MRIs,” says Dr. Goldstein. “Before, patients with His-bundle pacing were unable to have MRIs. Now that this obstacle has been removed from the equation, there are no drawbacks.”
These days, Ed and his wife Marilyn serve as the “daycare center” for their two grandchildren, ages two and four. And Ed works part-time doing taxes, even though he considers himself retired. He continues to see Dr. Goldstein for follow-up visits. “My pacemaker is working beautifully,” he reports.
As the tools involved continue to improve and more physicians are trained in this technique, His-bundle pacing is expected to become the new standard for pacemaker insertion. For now, Dr. Goldstein remains a member of an elite club of cardiac electrophysiologists who can offer this advanced procedure. Says Dr. Goldstein, “The future is here.”