Influence of pacing configurations, body mass index, and position of coronary sinus lead on frequency of phrenic nerve stimulation and pacing thresholds under cardiac resynchronization therapy

Seifert, Martin; Schau, Thomas; Moeller, Viviane; Neuß, Michael; Meyhoefer, J.; Butter, Christian

doi:10.1093/europace/euq119

Cited by 58 publications

(59 citation statements)

References 20 publications

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“…However, only onethird of patients had the Ring3 RV coil configuration available when tested. 9 In contrast to our findings, Burri et al 8 reported that Ring3 RV coil configuration had a higher LV voltage threshold at 0.4 -0.5 ms when compared with Tip3 RV coil and Tip3 Ring configurations, without a difference between Tip3 RV coil and Tip3 Ring configurations. However, this study had 2 limitations: (1) Ring3 RV coil was programmed only 3% of the time, and (2) testing was not performed for these 3 configurations in each patient.…”

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confidence: 99%

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Disparity in Left Ventricular Stimulation Among Different Pacing Configurations in Cardiac Resynchronization Therapy

Huízar

Kaszala

Koneru

et al. 2012

Circ: Arrhythmia and Electrophysiology

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Background-Cardiac resynchronization therapy (CRT) demands high energy utilization due to continuous biventricular pacing. Current technology allows 6 pacing configurations for a bipolar left ventricular (LV) lead. Understanding the energy requirements for each configuration will allow optimization of pacing output. Methods and Results-Pacing impedance, LV voltage threshold at 1.5 ms (rheobase) and 0.4 ms and chronaxie were obtained in 6 LV configurations in 49 consecutive patients undergoing CRT implantation or replacement. Strengthduration curves were derived using the Lapicque formula. Pacing impedances and voltage thresholds at 1.5 and 0.4 ms, calculated minimum threshold energy at chronaxie, current drain, energy thresholds at 0.4 ms, and strength-duration curves were statistically different between LV configurations (PϽ0.05). The lowest threshold energy requirements were found in Tip3right ventricular (RV) coil and Tip3 Can configuration. Energy strength-duration curves involving the ring as the cathode (Ring3 RV, Ring3 Can, and Ring3 Tip) had the highest LV thresholds. The pacing configuration with the lowest energy threshold correlated 89% of the time with the lowest voltage threshold at 0.4 ms. The probability to reach LV thresholds Ͻ1.5 V at 0.4 ms was increased from 51% with 2 LV configurations to 67% with 6 LV configurations. Conclusions-Pacing impedance, LV thresholds, minimum threshold energy at chronaxie, current drain, voltage, and energy strength-duration curves were statistically different between LV pacing configurations. LV pacing configuration with the lowest voltage threshold does not always reflects the lowest energy threshold, particularly in the presence of a low impedance configuration. The availability of 6 LV configurations increases the probability of optimizing LV pacing output. (Circ Arrhythm Electrophysiol. 2012;5:140-146.)Key Words: cardiac resynchronization therapy Ⅲ biventricular pacing Ⅲ pacing thresholds Ⅲ strength-duration curve C ardiac resynchronization therapy (CRT) has been developed as an adjunctive therapy in patients with congestive heart failure and left bundle-branch block. This therapy requires effective, safe, and permanent biventricular pacing to obtain clinical benefit and anatomic remodeling. 1 With implantation of a bipolar lead in the coronary sinus, current technology allows electronic programming of 6 different left ventricular (LV) pacing configurations or vectors. Frequently, LV pacing thresholds show a wide variation among LV pacing configurations in the same patient. To our knowledge, no prior studies have investigated the difference in LV thresholds and strength-duration curves between LV pacing configurations in the same patient. The main objective of this study was to determine and understand the difference of LV pacing thresholds and strength-duration curves among different LV pacing configurations, which in turn might provide insights to optimize LV pacing output and battery longevity. Clinical Perspective on p 146 MethodsThis prospective study inc...

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confidence: 99%

“…8,9 Similar to our findings, a study comparing these 3 configurations in 96 patients reported that Tip3 RV coil had a significantly lower voltage threshold at 1 ms when compared with Tip3 Ring configuration. However, only onethird of patients had the Ring3 RV coil configuration available when tested.…”

Section: Prior Studies Comparing LV Pacing Configurationssupporting

confidence: 88%

Disparity in Left Ventricular Stimulation Among Different Pacing Configurations in Cardiac Resynchronization Therapy

Huízar

Kaszala

Koneru

et al. 2012

Circ: Arrhythmia and Electrophysiology

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“…PNS needs to be managed at the same pacing sites that are deemed optimal for CRT. 6,7,9,11 When PNS is detected at implantation, several approaches are used: moving the lead to a different position in the vein, programming the LV cathode to a different electrode in devices featuring this technology, or lowering the LV output to avoid PNS when the other options have failed. 6,11,14 LV lead repositioning to another vein is the last resort and is possible only when other coronary veins are suitable for LV lead placement.…”

Section: Discussionmentioning

confidence: 99%

“…[3][4][5] Phrenic nerve stimulation (PNS) is a major complication that may result in withdrawal of CRT. PNS is observed in 33% to 37% of patients, [6][7][8] and although it is actively addressed in different ways during implantation, 6 it may be difficult to overcome in the long-term management of CRT patients. [9][10][11] Indeed, ≈15% of patients need to be reevaluated after hospital discharge because of PNS occurrence at follow-up, [9][10][11] and ≈6.6% eventually report PNS symptoms at long-term followup, despite multiple attempts to avoid PNS.…”

mentioning

confidence: 99%

Effect of Bipolar Electrode Spacing on Phrenic Nerve Stimulation and Left Ventricular Pacing Thresholds

Biffi

Foerster²,

Eastman³

et al. 2012

Circ: Arrhythmia and Electrophysiology

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Background-Phrenic nerve stimulation (PNS) is a common complication of cardiac resynchronization therapy when left ventricular (LV) pacing occurs via a coronary vein. The purpose of this study was to evaluate the effects of bipolar electrode spacing on PNS and LV pacing thresholds. Methods and Results-Electrophysiology catheters with standard (2 mm-5 mm-2 mm) or modified (1 mm-5 mm-1 mm) interelectrode spacing was, respectively, inserted in a posterior/lateral cardiac vein in a randomized order in 6 anesthetized dogs via jugular access. The phrenic nerve was dissected via a left minithoracotomy and repositioned over the vein as close as possible to one of the electrodes. The presence of PNS was verified (ie, PNS threshold <2 V at 0.5 ms in unipolar configuration). Bipolar pacing was delivered using the electrode closest to the phrenic nerve as the cathode, and multiple bipolar electrode spacing configurations were tested. During bipolar pacing, PNS threshold increased as bipolar electrode spacing was reduced (P<0.05), whereas LV pacing thresholds did not change significantly (P>0.05). Compared with a standard bipolar electrode spacing of 20 mm for LV leads, 1 and 2 mm bipolar electrode spacing resulted in a PNS threshold increase of 5.5±2.2 V (P=0.003) and 2.8±1.7 V (P<0.001), respectively. Similarly, PNS threshold increased by 6.5±3.7 V with 1 mm and by 3.8±1.9 V with 2 mm bipolar pacing (both P<0.001), compared with unipolar pacing. Conclusions-This study suggests that reducing LV bipolar electrode spacing from the standard 20 mm to 1 or 2 mm may significantly increase the PNS threshold without compromising LV pacing thresholds. (Circ Arrhythm Electrophysiol. 2012;5:815-820.)

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“…[6][7][8] An important limiting factor in the implementation of successful CRT are often the variations and limitations of the anatomy of the coronary veins and the position of the cardiac veins relative to the phrenic nerve. 5,[9][10][11][12][13][14] Lead movement after implantation and phrenic nerve stimulation (PNS) due to patient posture are challenges that we face. In fact, a 12% rate of CRT failure postoperatively related to either loss of LV capture or PNS has been reported.…”

Section: Introductionmentioning

confidence: 99%

Performance of a novel left ventricular lead with short bipolar spacing for cardiac resynchronization therapy: Primary results of the Attain Performa Quadripolar Left Ventricular Lead Study

et al. 2015

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Influence of pacing configurations, body mass index, and position of coronary sinus lead on frequency of phrenic nerve stimulation and pacing thresholds under cardiac resynchronization therapy

Abstract: Flexible LV pacing configurations are a useful feature of CRT systems for preventing PNS. The optimal LV pacing configuration should be determined on the basis of individual patient testing.

Cited by 58 publications

References 20 publications

Disparity in Left Ventricular Stimulation Among Different Pacing Configurations in Cardiac Resynchronization Therapy

Disparity in Left Ventricular Stimulation Among Different Pacing Configurations in Cardiac Resynchronization Therapy

Effect of Bipolar Electrode Spacing on Phrenic Nerve Stimulation and Left Ventricular Pacing Thresholds

Performance of a novel left ventricular lead with short bipolar spacing for cardiac resynchronization therapy: Primary results of the Attain Performa Quadripolar Left Ventricular Lead Study

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