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

Klein, N.; Klein, Maika; Weglage, Heinrich; Przibille, Oliver; Fischer, Sven; Trappe, Hans‐Joachim; Birkenhauer, Frank; Pfeiffer, Dietrich

doi:10.1093/europace/eur412

Cited by 23 publications

(14 citation statements)

References 26 publications

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“…This result is in the range of previously reported rates of PNS with bipolar leads, ranging from 1% [16] to 13% [17]. Therefore, bipolar leads remain a reliable and World Journal of Cardiovascular Diseases suitable alternative in patients whose anatomy prevents multiple electrode implantation.…”

Section: Discussionsupporting

confidence: 72%

Bipolar Leads for Prevention of Phrenic Nerve Stimulation: Results from the ORPHEE Observational Study

Benkemoun¹,

Pons²,

Kübler³

et al. 2017

WJCD

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Background: Up to one in three patients implanted with a cardiac resynchronization therapy-defibrillator (CRT-D) device experience phrenic nerve stimulation (PNS). Quadripolar leads are effective at reducing PNS, but compared to standard bipolar leads they have limitations related to maneuverability and high pacing thresholds. The ability of standard bipolar leads to overcome PNS is explored here. Methods: The French multicenter, observational study ORPHEE enrolled 90 CRT-D-eligible patients. Detection of PNS took place after satisfactory positioning of the LV bipolar lead (stable pacing threshold < 2.5 V). The aim of the primary analysis was to show that, at implant, three programmable pacing vectors (LV tip -LV ring, LV tip -RV ring and LV ring -RV coil) could prevent PNS from occurring in at least 90% of patients. Results: In 80 evaluable patients, PNS was reported in 12 patients (15%). Reprogramming overcame PNS in 10 patients: LV ring -RV coil in 8 patients; LV tip -LV ring in 1; and LV tip -RV ring in 1. As PNS was avoided in 78 of 80 patients (97.5%), the primary endpoint was significant (97.5% vs.90%, p = 0.01). Conclusion: During CRT-D implantation, PNS occurred in 15% of patients. In most (97.5%) implanted patients, PNS could be avoided by vector reprogramming using a bipolar LV lead. For patients whose coronary sinus anatomy precludes the implantation of multi-electrode leads, bipolar leads are a suitable, reliable alternative.

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Section: Discussionsupporting

confidence: 72%

Bipolar Leads for Prevention of Phrenic Nerve Stimulation: Results from the ORPHEE Observational Study

Benkemoun¹,

Pons²,

Kübler³

et al. 2017

WJCD

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“…Improvements in lead design and delivery tools led to a transvenous approach into a venous tributary of the coronary sinus, thus eliminating the morbidity and complexity inherent to epicardial LV lead implantation . However, these leads needed to be wedged into branch vessels for lead stability; as a result, electronic repositioning had limited success in eliminating PNS . Initial CRT clinical studies were all performed with unipolar or bipolar leads with these limitations .…”

Section: Discussionmentioning

confidence: 99%

Performance of Anatomically Designed Quadripolar Left Ventricular Leads: Results from the NAVIGATE X4 Clinical Trial

Mittal

Nair

Padanilam

et al. 2016

Cardiovasc electrophysiol

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“…It is estimated that up to 5% of all patients with CRT devices undergo repeat surgery for PNS, and at least 1–2% have their LV lead deactivated due to PNS . Electronic reprogramming has been an important tool to minimize PNS without compromising the efficacy of CRT . Ideally, a given LV pacing configuration should have a low LV threshold without PNS and/or large PN threshold–LV threshold difference to allow program pacing output at twice LV threshold (ideal 100% LV capture safety margin).…”

Section: Discussionmentioning

confidence: 99%

“…Two studies reported that Ring→RV coil and Tip→Ring had a significantly higher PN voltage threshold compared to Tip→RV coil . These studies included devices with only 3 available pacing configurations.…”

Section: Discussionmentioning

confidence: 99%

“…In the presence of a bipolar lead in the coronary sinus, electronic programming of 6 different left ventricular (LV) pacing configurations or vectors is possible. Prior studies comparing PNS in different pacing configurations have only reported voltage thresholds . However, LV thresholds comparing energy or delivered current, are more accurate than voltage for LV pacing due to significant impedance differences between LV pacing configurations .…”

Section: Introductionmentioning

confidence: 99%

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Comparison of Different Pacing Strategies to Minimize Phrenic Nerve Stimulation in Cardiac Resynchronization Therapy

Huízar

Kaszala

Koneru

et al. 2013

Cardiovasc electrophysiol

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Introduction Phrenic nerve (PN) stimulation (PNS) frequently limits cardiac resynchronization therapy (CRT). Yet, pacing strategies to minimize PNS have not been systematically compared. We propose to: 1) compare different pacing strategies to minimize PNS in CRT and 2) evaluate differences between PN and left ventricular (LV) capture thresholds among LV pacing configurations. Methods and Results PN and LV thresholds were obtained using 6 LV configurations in 28 patients with any PNS during CRT implantation or replacement. Incidence of PNS was compared in all LV configurations by programming pacing output to 1) One Volt above LV threshold, 2) triple pulse width (PW) at LV threshold, and 3) 1.5 times LV threshold for each patient. PN thresholds and PN strength-duration curves were statistically different between configurations (P<0.05). Ring→RVcoil and Ring→Can had the largest difference between PN and LV thresholds. Pacing output programmed to 1.5 times LV threshold, 1 Volt above LV threshold and triple PW at LV threshold had similar probability of PNS between LV configurations. However, 1 volt above LV threshold and triple PW at LV threshold frequently resulted in poor (<30%) LV capture safety margin (14–43% and 53–68%, respectively). Freedom from PNS (programmed output at twice LV threshold) was found in 88%, 84% and 52% with 6, 3, or 2 available LV configurations, respectively. Conclusion Multiple LV pacing configurations marginally increase the probability of avoiding PNS by electronic reprogramming. Pacing output programmed to 1.5 times LV threshold is an additional alternative to minimize PNS when electronic reprogramming options are limited.

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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

Abstract: The programmability of LV pacing vectors is a powerful feature to avoid PNS and obtain acceptable LV pacing thresholds. In order to retain reprogramming options for LV vectors during FU, LV pacing leads with at least two electrodes should be chosen whenever possible.

Cited by 23 publications

References 26 publications

Bipolar Leads for Prevention of Phrenic Nerve Stimulation: Results from the ORPHEE Observational Study

Bipolar Leads for Prevention of Phrenic Nerve Stimulation: Results from the ORPHEE Observational Study

Performance of Anatomically Designed Quadripolar Left Ventricular Leads: Results from the NAVIGATE X4 Clinical Trial

Comparison of Different Pacing Strategies to Minimize Phrenic Nerve Stimulation in Cardiac Resynchronization Therapy

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