Amanda Wilde (Host): Heart failure can often be managed with devices that allow us to live longer, healthier lives. Learn about living with implantable heart failure devices with cardiologist Dr. Asghar Fakhri. Dr. Fakhri is Associate Chair of Cardiology at UM Baltimore Washington Medical Center.

Welcome to the Live Greater Podcast, information for a healthier you from the University of Maryland Medical System. I'm Amanda Wilde. Dr. Fakhri, thank you so much for being here and sharing your expertise.

Asghar Fakhri, MD: Good afternoon, Amanda. And thank you for having me on. It's an honor, and I'm glad to have this conversation today.

Host: Good, because I have lots of questions. Starting with, can you give a brief explanation of what it means to be diagnosed with heart failure?

Asghar Fakhri, MD: Yeah. So, heart failure sounds quite scary when you're hearing the words for the first time as a patient. But the good news is in 2025, there are a lot of treatments that we can use to help heart failure patients live a normal healthy and productive life with the treatments that we have available.

What the diagnosis means is that the heart muscle has a malfunction, whether because it's weak or because it's stiff, and that weakness or stiffness of the heart muscle can cause fluid to build up in the body, particularly in the lungs, in the abdomen, and in the lower extremities, the legs. And those areas when they accumulate fluid can affect the function of those parts of the body.

So in the lungs, the fluid buildup can be perceived as shortness of breath or difficulty breathing. In the abdomen, it can cause a distension of the abdomen and affect your appetite and ability to eat. In the legs, if enough fluid accumulates, then it can make it difficult to walk. And all of these things can have a big impact on quality of life and cause patients to end up having to go to the hospital to get the fluid removed, whether by medication or by procedures. And also, the other challenging part of heart failure is if it is not treated, it can lead to further worsening of other organs in the body and even, in severe cases, death.

The good news is if we address heart failure early with the right treatments, including medications and sometimes devices, that you can restore people's health, you can prevent the fluid from accumulating, and you can prolong life.

Host: We want to get deeper into those devices. But first of all, how do doctors decide when a patient needs an implantable device instead of or in addition to medication?

Asghar Fakhri, MD: The implantable device is decided primarily based on a test that we use called echocardiogram, which is an ultrasound of the heart, and also, the EKG or ECG, which is an electrical reading of the heart. These two things can guide about us to decide which devices are appropriate for which patient.

The devices do not replace medications. Ninety to ninety-five percent of the benefit for treatment in heart failure is achieved with medications. And that last 5-10% extra step is achieved with the devices. But the medications are still critical to treating somebody with heart failure and helping them live a healthy and long life.

Host: So when do you decide to use an implantable device?

Asghar Fakhri, MD: So, the implantable devices that we typically use for heart failure are permanent devices, and sometimes heart failure can be a temporary condition. We use a measurement on the echocardiogram called the ejection fraction, which is the pumping strength of the heart muscle. We also look on the EKG or the ECG for a pattern called a left bundle branch block pattern. So, the ejection fraction and the bundle branch block pattern help us decide if a device is necessary, and what type of device is appropriate.

Host: Some patients worry that having a device implanted means their condition is very severe. Is that true or do these devices actually help prevent worsening heart failure?

Asghar Fakhri, MD: So, I think two separate questions. I think the first question: was does the fact that somebody who is getting one of these devices have a severe condition? The answer to that is, unfortunately, yes, it is a severe condition. We generally do not implant these devices for milder conditions. However, the devices can result in improvement of the patient's condition, or at least stabilize the condition and slow down the condition so it doesn't deteriorate as quickly.

Host: So, let's talk about the different devices. Many of us have heard of pacemakers and defibrillators, but may not know the difference. Can you explain what each device does and how they help heart failure patients?

Asghar Fakhri, MD: Yes. So, defibrillators are very similar in the way they work compared to the automatic external defibrillators. So when we walk through the airport or through a baseball stadium, you've probably seen on the wall, there's these devices in glass cabinets called AEDs, automatic external defibrillators. So with an external defibrillator, if somebody's heart stops, the paramedics or somebody trained in CPR can apply patches to the chest and revive a heart that has stopped beating by shocking it back to rhythm.

The implantable defibrillators is essentially the same function but on the inside of the body. So, we implant a miniaturized version of an AED. Inside of the person's body. And the battery is smaller, the wires that deliver the electricity travel through the veins in the chest and into the right-sided chambers of the heart. And the device listens for abnormal heart rhythms, dangerous heart rhythms, that can cause the heart to stop. It is listening 24 hours a day, seven days a week, 365 days a year. And if it detects one of those, it will shock the heart to bring it back to rhythm and allow that person to have a chance to call for medical attention and come to the hospital and get treatment. It does not make the heart stronger necessarily just by putting in a defibrillator. It is a form of protection in case the heart suddenly stops. So, it prevents something that we call sudden cardiac death.

Now, all defibrillators have the ability to also serve as pacemakers. Pacemakers treat slow heart rates, which can also be dangerous. So, every defibrillator is also a pacemaker. But pacemakers are not a treatment for heart failure. There are treatment for slow heart rate, and some patients with heart failure can develop slow heart rate and they might need pacemaker treatment, and their defibrillator can do that if it's necessary. However, patients with weak heart, if they require pacemaker treatment all of the time, a standard pacemaker is not enough for those patients. And the reason for that is the electricity in our heart naturally moves in a certain direction, and a standard pacemaker doesn't deliver electricity in the natural direction. So, patients with congestive heart failure, they need a specialized type of pacemaker. And this type of pacemaker is called a cardiac resynchronization therapy device or CRT. So, this is a specialized type of pacemaker in patients who have a low ejection fraction and also have something called a left bundle branch block on their EKG, or if they have low ejection fraction and require pacemaker treatment all of the time. Those are the two situations where a CRT device will become necessary. And CRT is a specialized pacemaker only for patients with congestive heart failure and, only in certain situations, it can be combined with a defibrillator. Some people have combined devices, CRT defibrillator or CRT-D devices. So, some patients require plain defibrillators, some heart failure patients require CRT defibrillators, two different type of devices.

Host: All the devices we're talking about are implantable and permanent. What changes, if any, should patients expect in their daily lives living with these implantable devices?

Asghar Fakhri, MD: So, overall, the devices are designed to minimize disruption to patients' lives. They're small. Many of them are compatible with most standard activities that people do. However, there may be some activity restrictions. A lot of patients ask me, "Is it safe to go near a microwave?" And the answer to that is, yes, it's perfectly safe to go near a microwave. Patients ask, "Can they go through a metal detector safely at the airport?" You can, but it's going to set the metal detector off as far as the alarm. But it's not harmful to go through a metal detector. So, we usually provide patients with an identification card if they do have to travel through a metal detector, they can present the identification card, which will allow them to move through the security safely.

Alternatively, there are also concerns that people have about certain professions. So, welding can be a problem if somebody who's a professional welder. Sometimes there's electrostatic interference with professionals who weld. So, we do ask about that. We do recommend not doing that, not participating in that profession once a defibrillator is in place. Sometimes hunting with a rifle can be an issue, particularly if there's kickback from the rifle, and depending on which side the person is using the rifle. So, we'll plan for that and put the device on the opposite side, so that they can continue their hobby. Some activities such as basketball where somebody's reaching over their head frequently. And particularly in our younger patients who sometimes need a defibrillator, that can be problematic on certain occasions. Because if you imagine a paperclip and you bend it back and forth enough times, a paperclip can break. And similarly, there's a wire or multiple wires in a defibrillator. And these wires, with frequent movement, they can become dislodged or develop lead problems with the defibrillator. So, we do counsel on certain activities like that that involve frequent reaching over the head that it may need to be limited. Just standard reaching over the head every now and then to get something from a cabinet or something of that nature, that's not a problem. It's more the repetitive professions and activities if you're doing them constantly on a regular basis that pose a bigger problem. .

Other patients also ask, "Can I safely get MRI scans after these devices are implanted?" And the good news there, in 2025, the vast majority of devices are compatible or what we call conditional and can get MRI scans. It does require a certain level of expertise at the center doing the MRI in terms of getting the device adjusted to the correct settings before an MRI is performed. We do offer that setting here at Baltimore Washington Medical Center. And other hospitals in the area also offer it.

One of the exciting programs that we were able to develop here is we also now have a program that allows for scanning of devices that are not traditionally labeled as MRI-compatible or conditional, you can still safely do MRIs in these patients with the appropriate supervision. There was a large study at Johns Hopkins that documented that it is safe to do MRIs in patients, even with non-conditional or legacy older devices, but it does require a little bit more expertise, which we do offer here at BWMC. But MRIs are safe in these devices, essentially all cardiac devices such as pacemakers, defibrillators.

Host: You mentioned how these devices support heart rhythm and rate normalizing things. What safety features are built into these devices to protect patients if something goes wrong?

Asghar Fakhri, MD: Yeah. So like I said, the devices are watching the heart rhythm 24 hours a day. They are programmed to look for dangerous fast heartbeats and dangerous slow heartbeats and react to both of those, particularly defibrillators. Pacemakers cannot react to fast heartbeats in terms of treating those, but defibrillators can treat both fast and slow heartbeats.

So for a fast heartbeat, the defibrillator will try to suppress it by pacing at a slightly faster heart rate than the rhythm, and then get it to quiet down. And if that doesn't work, it will shock the heart back into normal rhythm. It is very similar to, again, an external defibrillator or sometimes some of our patients have had a procedure called a cardioversion. So, a defibrillator essentially can do a very similar job as far as putting the fast heartbeat back to a normal heartbeat by overdrive pacing or shocking the heart back into normal rhythm. The slow heartbeats are simply treated by increasing it when the pacemaker option kicks in. So, that's how it's programmed to deal with either of those situations.

Now, newer technology with modern devices has more advanced features for, heart failure beyond just treating fast and slow heartbeats. So, patients with congestive heart failure who have one of those CRT devices that synchronizes the movement of electricity through both sides of the heart. And the benefit of that is it can actually cause the muscle to become stronger over time. Now, unfortunately, the CRT devices only work for a small group of patients with weak heart muscle who have very specific patterns on their EKG. But the patients that do meet those criteria for CRT devices, they can have a significant improvement in their heart muscle function and also have an improvement in the ability of the body to get rid of fluid buildup to the extent that some of them even can reduce the amount of medications that they depend on once these devices are placed.

The other advantage with some of these newer devices is they can detect fluid buildup before the patient even knows it's building up. So many of the devices have technology to measure fluid within the chest, and they can alert the doctor at the cardiologist's office, or even the physicians at the hospital that fluid is accumulating. And the medications may need to be adjusted to remove the fluid faster before the patient gets into a crisis or ends up in the hospital. And that is one of the advantage of these newer devices that have that technology. Patients can actually transmit readings from home to their cardiologist using a little portable monitoring device that they keep on their nightstand. And anytime they're concerned, they want to send a reading to their cardiologist. They can do that. In addition, the devices actually check themselves every night by going through a cycle of device parameter evaluations every night. And if there's a problem, it will transmit a reading to the cardiologist's office. So, the technology has improved tremendously. And the real time communication with doctors and hospitals makes it possible for us to intervene and help patients before things get out of hand.

Host: So, you are always seeing advances and more complexities in these technologies as they evolve.

Asghar Fakhri, MD: Yeah. I think the technology, even cardiologists are having sometimes difficulty keeping up with the pace of development advancing so rapidly. There are newer devices always coming on the market. And that's one of the good things about this profession is you're always learning.

Host: Well, beyond pacemakers and defibrillators, what new technologies are on the horizon right now?

Asghar Fakhri, MD: Yeah. So, there are some newer devices being evaluated. There is a specialized type of pacemaker called cardiac contractility modulation or CCM. It's still in the very early stages in clinical trials, but this is a pacemaker that provides improvement of heart failure symptoms in patients who are not eligible for those CRT devices. This is an option for the other sort of 80-90% of heart failure patients with low ejection fraction who don't qualify for a CRT device. And that's a new technology that's on the horizon that we're hoping can mature in the next few years. And once it does, that we have additional tools to offer our patients.

There are also other technologies on the horizon that affect the hormonal systems that control heart failure and so forth. And a lot of developments are occurring. It's, again, like I said, difficult to keep up sometimes, but there's a lot of hope for patients in the future.

Host: For patients and caregivers who feel nervous about these devices, what advice or reassurance can you share?

Asghar Fakhri, MD: I think it's right for patients to feel nervous, because it is an invasive procedure. You should never, as a patient, agree to an invasive procedure without understanding risks and benefits. Everything has risks and benefits. These devices do have risks, because it is a minor surgery to get it implanted. Again, a minor surgery, but still a surgery. Ninety-nine percent of the time the surgery will go just fine and the patient will do well with the device. But that rare risk of complications is there. We do discuss those risks with patients before we do any kind of procedures to inform them. I do advise more caution in elderly patients, patients who have more medical illnesses such as kidney failure and dialysis. Those patients have higher risk of getting these devices implanted such as device infections and bleeding and so forth. And it may not be appropriate to get these devices in certain situations.

Similarly, towards the end of life, we have patients who have other medical illnesses that we've treated their heart, but maybe they go on to develop other illnesses such as cancer and so forth. And towards the end of life, we have to adjust the settings on their device, because they're enrolling in hospice. And the shocks from the device in somebody who is facing an end-of-life moment, those can be painful and we don't want patients to suffer pain at those moments in life. So, it can be very difficult already as it is for patients and family.

So, I'm not saying that these devices don't have complications and challenges, but the vast majority, 99% of patients, greater than 99% of patients, will have tremendous benefits. And the benefits vastly outweigh the risks and complications. But I'd never try to minimize complications or risks. And if a patient is not comfortable, we don't force anybody to undergo any procedure that they're not comfortable with. We are here to work with the patient and meet the patient where they are. And remember, the medications are 90-95% of the benefit for treating heart failure. The devices are sort of a cherry on top. But I'm happy if you're able to work with me on medications, there's so much we can do with that still. So, I don't say just because you're not comfortable getting the device, that there's no hope. There's plenty of hope and there's a lot to do with medications.

Host: Well, that's a tremendously high success rate for both medications and these implantable devices.

Asghar Fakhri, MD: Absolutely. Absolutely. I think that's the take-home here is congestive heart failure sounds scary because you hear the word failure, but you can often turn it into success with a lot of these treatments.

Host: Dr. Fakhri, as we wrap up, based on the discussion we've just had, do you have any final thoughts or takeaways you'd like to share?

Asghar Fakhri, MD: I think that there's a lot of hope in 2025 for patients with this illness. And I think hope is something that it was harder to offer 40 years ago. We just didn't have the treatments and the technologies to make as big of an impact as we can now. None of these are miracle cures, okay? What we're hoping to do is give people good quality of life and, to some degree, extend quantity of life as best as we can, and we can achieve those things. Can we have people live forever? No. I wish, but that's not possible. But improving quality of life is the number one goal. And there's a lot we can do to achieve that. So, I tell patients, "Don't give up hope if you hear the word heart failure. There's a lot we can do."

Host: And as you've mentioned, there's a lot of technological developments yet on the horizon happening so fast, it's hard to even keep up with. So, that's encouraging as well.

Asghar Fakhri, MD: Absolutely.

Host: Well, Doctor, thank you so much for all of this up-to-date information and the clarity you've provided on implantable heart failure devices and the exciting technological developments you've mentioned that give patients even more options and hope.

Asghar Fakhri, MD: Glad to share what I could with you. And please feel free to reach out if you have any other questions.

Host: Thank you, Dr. Asghar Fakhri is Associate Chair of Cardiology at UM Baltimore Washington Medical Center, and a cardiologist at UM Baltimore Washington Heart Associates. Find more shows just like this one at umms.org/podcast and on YouTube. Thank you for listening to Live Greater, a Health and Wellness podcast, brought to you by the University of Maryland Medical System. We look forward to you joining us again, and please share this on your social media.