title: 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: OBJECTIVE
  Elevated left ventricular (LV) pacing thresholds or phrenic nerve stimulation (PNS) might be possible reasons for absence of continuous and effective biventricular stimulation. This study investigated the benefit and clinical efficacy of the ability to choose one out of three different LV pacing vectors for the management of suboptimal LV pacing thresholds and PNS.
  
  
  RESULTS
  This prospective, observational multicentre study enrolled 132 patients (Pts) implanted with a cardiac resynchronization therapy defibrillator, that offers three LV pacing vectors: (i) Bipolar; (ii) LVtip ↔ RVcoil; (iii) LVring ↔ RVcoil (RV = right ventricular). Left ventricular pacing thresholds and PNS thresholds were obtained in sitting and left lateral body position for all programmable LV pacing vectors at hospital discharge and follow up (FU). In 97%, a bipolar transvenous LV lead was successfully implanted. In 87% of Pts at least one acceptable pacing vector could be identified that provides good pacing threshold (≤ 2.5 V at 5 ms) and acceptable margin to PNS (≥ 2:1). This is an increase of 18% compared with conventional bipolar systems (74%) with two LV vectors and of 25% compared with unipolar systems (70%). The LVtip ↔ RVcoil vector provided the best LV pacing thresholds, but the highest rate of PNS.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Universitätsklinikum Leipzig AÖR, Medizinische Klinik I, Liebigstraße 20, 04103 Leipzig, Germany. norbert.klein@medizin.uni-leipzig.de
authors.forename: Norbert
authors.initials: N
authors.lastname: Klein
authors.forename: Maika
authors.initials: M
authors.lastname: Klein
authors.forename: Heinrich
authors.initials: H
authors.lastname: Weglage
authors.forename: Oliver
authors.initials: O
authors.lastname: Przibille
authors.forename: Sven
authors.initials: S
authors.lastname: Fischer
authors.forename: Hans-Joachim
authors.initials: HJ
authors.lastname: Trappe
authors.forename: Frank
authors.initials: F
authors.lastname: Birkenhauer
authors.forename: Dietrich
authors.initials: D
authors.lastname: Pfeiffer
mesh_terms: D000368:Aged; D058406:Cardiac Resynchronization Therapy / Q000009:adverse effects* / Q000379:methods*; D017147:Defibrillators, Implantable / Q000009:adverse effects*; D004567:Electrodes, Implanted / Q000009:adverse effects; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010791:Phrenic Nerve / Q000503:physiopathology*; D011446:Prospective Studies; D018487:Ventricular Dysfunction, Left / Q000503:physiopathology / Q000628:therapy*