If the cardiologists who fix blockages in the heart or coronary arteries are the “plumbers,” then Dr. Steven Bailin is the cardiac “electrician.”

Bailin, a cardiologist with Iowa Heart Center, has pioneered an alternative technique for attaching pacemaker leads to the heart muscle that he claims provides more efficient functioning of the heart.

Once each month, Bailin offers a class in that technique, known as septal pacing, which has attracted cardiologists from around the country who have considered the alternative procedure. In septal pacing, the pacemaker leads are implanted in a more centralized part of the heart muscle than in the standard procedure.

Normal heart contractions begin as an electrical impulse in the right atrium of the heart. That impulse comes from an area of the atrium called the sinoatrial or sinus node, which is the heart’s “natural pacemaker.” Many patients, particularly older adults, may experience a slowed heart rhythm that requires treatment. In some cases, the patient may experience an irregular rhythm resulting from abnormal electrical impulses in the heart.

Overseas interest

That’s where heart specialists like Bailin come in, to determine whether medication, a pacemaker or an implanted defibrillator would be the best treatment option. An expert in electrophysiology – the study of the body’s electrical systems – Bailin uses special diagnostic equipment to determine the paths of electrical impulses that trigger each heartbeat.

Once that path has been determined, he can prescribe treatment to alleviate a racing heartbeat or correct other irregular heart rhythms. Treatments include medications, ablation therapy (destroying the affected area in the heart) and the implantation of pacemakers and defibrillators.

The septal pacing technique, which has been approved for treatment in the United States for the past five years, was recently approved for use by heart surgeons in Japan. That led a delegation of Japanese surgeons to travel to Des Moines to observe the procedure.

Bailin now uses septal pacing for all of the pacemakers he implants in his patients, and he has become an evangelist for the technique among his fellow cardiologists.

“I think there is a fair amount of evidence to suggest that where we normally (place the leads) isn’t such a good idea,” he said. “There is a believable amount of evidence that doing this in the (heart) atrium makes a fair amount of difference.”

When Bailin initially introduced the technique in medical abstracts, there were concerns about how the leads would respond in the different area. “People didn’t know if there was different tissue, or a possibility of screwing into the heart or the aorta,” he said. “But it turns out there really isn’t any difference between the pacing characteristics. And in terms of removal, it’s about the same.”

Akira Koshimo, a representative from Medtronic Inc., said this was the first time he had brought a delegation of surgeons to Des Moines from Japan. The Twin Cities-based medical electronics manufacturer has developed a specialized catheter surgeons can use to guide the tiny leads into the heart muscle.

About 120 patients were enrolled in the original trials of the technique, which Bailin conducted with two other cardiologists, one in Minnesota and another in Davenport. Because the technique is no longer experimental but an accepted standard of care, the placement of the leads is no longer part of the discussion with patients, Bailin said.

“We just talk about the general possibilities of complications related to implantation, without going into details about where one paces,” he said. “Sometimes it’s a problem when you get in there because the site where you wanted to pace doesn’t work. Then you have to look at alternatives.”

Treating heart failure

“Originally, the focus was on maintaining normal rhythm, but as this (specialty) evolved, we’re doing more with treating heart failure,” Bailin said. “With that, we do what’s called bi-ventricular pacing – pacing on both the left and right sides. The problem that you can have is determining the timing. … You want it to be able to pace symmetrically.

“So there has been a lot of interest in using septal pacing in particular for people with heart failure, because you now have greater flexibility in terms of timing,” he said. “We have a couple of patients where we have actually moved the lead in order to improve the outcome. It allows the atrium to contract the way it’s supposed to.”

The types of patients who need Bailin’s services have changed somewhat in the past 10 years.

“The patient population we were seeing back then were mostly (diagnosed with) intermittent atrial fibrillation,” he said. “There, the choices were basically medicine, or you could knock out the conduction system and put a pacemaker in to control their symptoms. But over the last five to 10 years, there’s been more emphasis on trying to do curative therapy on atrial fibrillation by itself.”

Most of his patients are older people who are being treated for slow heart rates, “but I follow a fair number of patients that are younger who have congenital problems in their heart,” he said. “They may have defibrillators because they have a genetic predisposition for sudden death. And with that, we can also makes choices about where we pace” through the placement of the leads.

Bailin said he believes the technique is slowly catching on. “I think in the end, over time, more doctors are going to be doing a better job of pacing physiologically so that you’re not really distorting the natural way things are supposed to be,” he said.

“When I started my fellowship in 1990, we were happy if (a pacemaker) could sense and it could pace. Now, we’re concerned about where we can pace most effectively in the heart. That’s become sort of the new frontier in pacing.”