Abstract 14753: A Novel Quadripolar Lead with a Narrow-Spaced Bipole Allows for Effective LV Pacing While Avoiding Phrenic Nerve Stimulation - Attain Performa LV Lead Study Primary Results

Introduction: The Medtronic Attain Performa™ Model 4298 Quadripolar left ventricular (LV) Lead has 4 electrodes, provides 16 different polarities & includes a short bipole (1.3 mm between 2nd & 3rd electrodes). A prospective clinical study was conducted to investigate the safety and effectiveness of this new lead in 20 countries worldwide. Methods: Cardiac resynchronization therapy defibrillator (CRT-D) patients were enrolled & implanted with the Model 4298 LV lead & a Quad CRT-D device. All implanted subjects(SUB) were followed at 1, 3, 6 and every 6 months (M) post-implant. Pacing capture thresholds (PCTs) were measured manually or with automated testing methods. Adverse events (AEs) were reported upon occurrence & reviewed by an independent committee. Events requiring invasive intervention or resulting loss of CRT were considered to be complications. Results: Of 499 SUB (68 + 11 yr, 71% male) who underwent an LV lead implant attempt, 487 (97.6%) had an LV lead implanted, Most (73%) had NYHA Class III or IV symptoms, average LV ejection fraction was 25 ± 7%, QRS duration was 155 ± 24ms & most (71%) had LBBB. There were 20 LV lead related complications in 19 SUB over 6M (LV lead related complication free survival rate = 96%). Phrenic nerve stimulation (PNS) occurred in 31 SUB (6.3%) & resolved with no treatment (N=1) or noninvasive reprogramming (N=29). The average PCT at 6M was 1.1 + 0.7 V at the programmed vector and 93.9% of SUB had a PCT≤ 2.5V. The vast majority (97.7%) of SUB had > 1 additional selectable pacing vector with a PCT ≤ 4V and no PNS. Non-standard pacing polarities (i.e., vectors other than LV1 [LV tip] to right ventricular coil [RVC], LV2 to RVC & LV1 to LV2) were utilized in 56% of SUB. LV1 was not used in the final vector in 46% of SUB. The LV1 to RVC was utilized in 19%, LV1 to LV2 in 18% & the short bipole (LV2 to LV3) in 12%. Conclusions: This large multicenter study demonstrated that implantation of the Model 4298 LV quadripolar lead is associated with a low complication rate and no unanticipated complications. PNS can be readily resolved with reprogramming & that PCT values are low & stable over time. Moreover, At least 1 back-up LV pacing vector was available in the vast majority of SUB. Non-standard vectors, including the short bipole (LV2-LV3) were used in 56% of subjects.

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Quadripolar Left Ventricular Lead in a Patient with CRT-D does Not Overcome Phrenic Nerve Stimulation

Clinical Medicine Insights Cardiology ◽

10.4137/cmc.s6759 ◽

2011 ◽

Vol 5 ◽

pp. CMC.S6759 ◽

Cited By ~ 3

Author(s):

Mariana S. Parahuleva ◽

Ritvan Chasan ◽

Nedim Soydan ◽

Yasser Abdallah ◽

Christiane Neuhof ◽

...

Keyword(s):

Nerve Stimulation ◽

Phrenic Nerve ◽

Biventricular Pacing ◽

Left Ventricular ◽

Left Ventricular Lead ◽

Cardiac Resynchronization ◽

Phrenic Nerve Stimulation ◽

Ventricular Lead ◽

Potential Alternative ◽

Physical Adjustment

Effective cardiac resynchronization therapy (CRT) requires an accurate atrio-biventricular pacing system. The innovative Quartet lead is a quadripolar, over-the-wire left ventricular lead with four electrodes and has recently been designed to provide more options and greater control in pacing vector selection. A lead with multiple pacing electrodes is a potential alternative to physical adjustment of the lead and may help to overcome high thresholds and phrenic nerve stimulation (PNS).

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Clinical efficacy of left ventricular pacing vector programmability in cardiac resynchronization therapy defibrillator patients for management of phrenic nerve stimulation and/or elevated left ventricular pacing thresholds: insights from the Efface Phrenic Stim study

EP Europace ◽

10.1093/europace/eur412 ◽

2012 ◽

Vol 14 (6) ◽

pp. 826-832 ◽

Cited By ~ 22

Author(s):

N. Klein ◽

M. Klein ◽

H. Weglage ◽

O. Przibille ◽

S. Fischer ◽

...

Keyword(s):

Cardiac Resynchronization Therapy ◽

Clinical Efficacy ◽

Nerve Stimulation ◽

Phrenic Nerve ◽

Left Ventricular ◽

Cardiac Resynchronization ◽

Ventricular Pacing ◽

Resynchronization Therapy ◽

Phrenic Nerve Stimulation ◽

Left Ventricular Pacing

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Occurrence of phrenic nerve stimulation in cardiac resynchronization therapy patients: the role of left ventricular lead type and placement site

EP Europace ◽

10.1093/europace/eus237 ◽

2012 ◽

Vol 15 (1) ◽

pp. 77-82 ◽

Cited By ~ 36

Author(s):

M. Biffi ◽

D. V. Exner ◽

G. H. Crossley ◽

B. Ramza ◽

B. Coutu ◽

...

Keyword(s):

Cardiac Resynchronization Therapy ◽

Nerve Stimulation ◽

Phrenic Nerve ◽

Left Ventricular ◽

Left Ventricular Lead ◽

Cardiac Resynchronization ◽

Resynchronization Therapy ◽

Phrenic Nerve Stimulation ◽

Ventricular Lead

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Phrenic Nerve Stimulation in a Patient with a Dorsal Column Stimulator

Pain Management Case Reports ◽

10.36076/pmcr.2017/1/247 ◽

2017 ◽

pp. 247-249

Author(s):

Daniel D. DuBose

Keyword(s):

Nerve Stimulation ◽

Phrenic Nerve ◽

Dorsal Column ◽

Left Ventricular ◽

Cardiac Resynchronization ◽

Phrenic Nerve Stimulation ◽

Ventricular Lead ◽

Before And After ◽

Muscle Spasms ◽

Cardiac Resynchronization Therapy Device

We present a case of a 76-year-old female who developed recurrent left-sided muscle spasms resembling hiccups after permanent dorsal column stimulator (DCS) implantation. The patient had a cardiac resynchronization device with defibrillating capabilities (CRT-D) in place, which was interrogated before and after the permanent DCS placement with no interference reported. Due to the timing of the event with the placement of the DCS, it was presumed that the spasms were related to the DCS implantation, and removal of the DCS was considered. However, further evaluation by a cardiology consultant revealed that a lead from her CRT-D was most likely stimulating the phrenic nerve and causing diaphragmatic contractions. The patient was sent to the electrophysiology clinic where the voltage on her left ventricular lead was reduced, and her symptoms resolved completely. Due to the time, risks, and expense of implanting a DCS, it is imperative to consider all other possible causes of diaphragmatic contractions prior to removing a DCS system. Key words: Dorsal column stimulator, cardiac resynchronization therapy device, phrenic nerve stimulation, hiccups, muscle spasms, diaphragmatic contractions, interference

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Multisite, multipoint pacing

In a good rythm ◽

10.5604/01.3001.0010.3966 ◽

2017 ◽

Vol 2 (43) ◽

pp. 9-13

Author(s):

Przemysław Mitkowski

Keyword(s):

Nyha Class ◽

Standard Of Care ◽

Left Ventricular ◽

Cardiac Resynchronization ◽

Ventricular Pacing ◽

Reduced Ejection Fraction ◽

Clinical Benefits ◽

Qrs Duration ◽

Left Ventricular Pacing ◽

Rv Pacing

Cardiac resynchronization therapy in patients with heart failure, reduced ejection fraction and prolonged QRS duration has become standard of care. Unfortunately, despite improvements in delivery of this treatment still approximately 30% of patients are non-responders. Among causes of this phenomenon one can find an inability to deliver hemodynamically effective left ventricular pacing. There were proposed several solutions to solve the problem, including: multisite RV pacing, multisite LV pacing, multipoint LV pacing. Multisite RV pacing (two RV leads positioned in RV: apex and RVOT), although causes some hemodynamic improvement in LVEF or distance in 6MWT and reduction of LVESD or number of hospitalizations in comparison to no paced patients, but its efficacy is significantly worse than normal CRT. So it should not be considered as an alternative to CRT even to surgically placed LV lead. Multisite LV pacing (two leads iv cardiac veins) gives significant benefits over standard CRT, especially in patients with poor heart vein system, which preclude optimal LV lead placement. Clinical benefits of this mode of therapy were observed in non-responders to classical CRT, and were proved in: higher responder rates, improved EF, VO2, distance in 6MWT, reduction of NYHA class, LVESV, LVEDD and increase of dP/dt. Multipoint LV pacing (different pacing point located on the same LV lead) is encouraging way of CRT delivery and does not require any additional lead. Benefits of MP pacing over classical CRT were proved in numerous trails in acute tests by improvement in dP/dt, increase in maximal strain rate, shortening of total activation time, reduction in QRS duration and after mid- and long term follow-up in reduction of LVESV, increase in EF, reduction of asynchrony and higher percentage of responders. Multipoint left ventricular pacing should be a standard of CRT delivery in first implantations.

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45Improving the optimization of cardiac resynchronization therapy: Does multipoint left ventricular pacing shorten the paced-QRS duration compared to the fusion-optimized intervals method?

EP Europace ◽

10.1093/europace/euaa162.032 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

R San Antonio ◽

M Pujol-Lopez ◽

R Jimenez-Arjona ◽

A Doltra ◽

F Alarcon ◽

...

Keyword(s):

Cardiac Resynchronization Therapy ◽

Biventricular Pacing ◽

Left Ventricular ◽

Cardiac Resynchronization ◽

Reverse Remodeling ◽

Prospective Clinical Study ◽

Battery Life ◽

Resynchronization Therapy ◽

Qrs Duration ◽

Phrenic Stimulation

Abstract Funding Acknowledgements Cardiac Pacing Scholarship from the Spanish Society of Cardiology (SEC) Background Electrocardiogram-based optimization of cardiac resynchronization therapy (CRT) using the fusion-optimized intervals (FOI) method has demonstrated to improve both acute hemodynamic response and left ventricle (LV) reverse remodeling compared to nominal programming of CRT. FOI optimizes the atrioventricular (AV) and ventriculo-ventricular (VV) intervals to achieve the shortest paced-QRS duration. The recent development of multipoint pacing (MPP) enables the activation of the LV from 2 locations, also shortening the QRS duration compared to conventional biventricular pacing. Purpose To determine if MPP reduces the paced-QRS duration compared to FOI optimization. Methods This prospective clinical study included 25 consecutive patients who successfully received a CRT with MPP pacing capability. All patients were in sinus rhythm and had an PR interval below 250 ms. The QRS duration was measured with a 12-lead digital electrocardiography (screen speed of 200 mm/s) at baseline and using 3 different configurations: MPP, FOI and a combined FOI-MPP strategy. In MPP, the intervals were (based on previous studies): 1) AV 130 ms, 2) Right ventricular (RV)-LV2 (Δ1) 5 ms, and 3) LV1-LV2 (Δ2) 5 ms. In FOI, AV and VV intervals were optimized to achieve fusion between intrinsic conduction and biventricular pacing. In FOI-MPP, the Δ2 was set at 5 ms, while AV and Δ1 intervals were optimized using the FOI method. The CRT device was programmed with the configuration that achieved a greater paced-QRS shortening. After 45 days, battery life was estimated. Results Mean age was 65 ± 10 years, 20 were men (80%) and baseline QRS duration was 177 ± 17 ms. The FOI method bested nominal MPP (QRS shortened by 58 ± 16 ms vs 43 ± 16 ms, respectively, p = 0.002). Adding MPP to the narrowest QRS by FOI did not result in further shortening (FOI: 58 ± 16 ms vs FOI-MPP: 59 ± 13 ms, p = 0.81). The final configuration was FOI method alone in most cases (n = 16, 64%) and FOI-MPP in all others (n = 9, 36%; figure). In total, 10 out of 25 patients (40%) were not candidates to MPP due to: 1) pacing thresholds exceeding 3.5 V/0.4 ms at the distal or proximal electrode (8, 32%), and 2) phrenic stimulation (2, 8%). Estimated battery longevity was longer in patients receiving FOI as compared to MPP (8.3 ± 2.1 years vs. 6.2 ± 2.2 years, p = 0.04). Conclusion In CRT, the FOI method is not improved by coupling with MPP. Up to 40% of patients are not candidates for MPP due to high thresholds or phrenic stimulation. The use of MPP in unselected patients would result in a decrease of battery longevity, without any additional benefit over FOI. Abstract Figure.

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