Cardiac resynchronization therapy: a comparison among left ventricular bipolar, quadripolar and active fixation leads

Abstract

We evaluated the performance of 3 different left ventricular leads (LV) for resynchronization therapy: bipolar (BL), quadripolar (QL) and active fixation leads (AFL). We enrolled 290 consecutive CRTD candidates implanted with BL (n = 136) or QL (n = 97) or AFL (n = 57). Over a minimum 10 months follow-up, we assessed: (a) composite technical endpoint (TE) (phrenic nerve stimulation at 8 V@0.4 ms, safety margin between myocardial and phrenic threshold <2V, LV dislodgement and failure to achieve the target pacing site), (b) composite clinical endpoint (CE) (death, hospitalization for heart failure, heart transplantation, lead extraction for infection), (c) reverse remodeling (RR) (reduction of end systolic volume >15%). Baseline characteristics of the 3 groups were similar. At follow-up the incidence of TE was 36.3%, 14.3% and 19.9% in BL, AFL and QL, respectively (p < 0.01). Moreover, the incidence of RR was 56%, 64% and 68% in BL, AFL and QL respectively (p = 0.02). There were no significant differences in CE (p = 0.380). On a multivariable analysis, “non-BL leads” was the single predictor of an improved clinical outcome. QL and AFL are superior to conventional BL by enhancing pacing of the target site: AFL through prevention of lead dislodgement while QL through improved management of phrenic nerve stimulation.

Six months clinical outcome comparison between quadripolar and bipolar left ventricular leads in cardiac resynchronization therapy: A prospective, non-randomized, single-centre observational study

“…As quadripolar lead offers multi-vector pacing, the tip of lead can be wedged in more distally while other electrodes are placed at optimum pacing sites providing better stability and more vectors for effective biventricular pacing [ 30 ]. PNS was managed with reprogramming in both the groups (83.3% in Quad vs 75% in BiP) consistent with previous studies [ 29 , [31] , [32] , [33] ]. Electronic repositioning due to multiple poles in the quadripolar lead is an easy answer to high thresholds and PNS in the Quad group.…”

“…In a study done by Ziacchi et al. (2018) [ 29 ], quadripolar lead was associated with fewer PNS (8% vs 17% in BiP; p 0.014) and LV lead dislodgement (5%vs 15% BiP; p 0.005) which was also observed in this study where the rates of dislodgement was (3.23% in Quad vs 12.9% in BiP; p 0.045). These findings can be attributed to the design of quadripolar LV lead as it is more flexible and available in preformed curves providing the upper hand to the operator for selection as per the anatomy of coronary sinus tributaries.…”

Long-term single-centre large volume experience with transseptal endocardial left ventricular lead implantation

“…reported a CS lead dislodgement rate of 1%, using passive fixation CS leads, however, the exact lead types were not reported. In a more recent study, Ziacchi et al 25 . reported an overall 9% dislodgement rate with various LV lead types (bipolar, quadripolar, and active fixation leads), with a 4.8% rate for LV lead dislodgement required a re-operation.…”

Effective nonapical left ventricular pacing with quadripolar leads for cardiac resynchronization therapy

“…In CRT implantations, the use of quadripolar LV leads have become the first-line strategy, since their use is associated with a lower total mortality, cardiac mortality, and HF hospitalization [13]. LV quadripolar leads enable a better reverse remodeling compared to conventional bipolar leads, due to a decreased dislodgement rate from the targeted stimulation site [14]. Multiple pacing options let the electrophysiologist to handle issues represented by PNS and high PCT, as well as enhancing the likelihood of successfully pacing non-apical LV segments.…”