title: Effectiveness and Reliability of Selected Site Pacing for Avoidance of Phrenic Nerve Stimulation in CRT Patients with Quadripolar LV Leads: The EffaceQ Study.
abstract: BACKGROUND
  Cardiac resynchronization therapy (CRT) relies on sufficient left ventricular (LV) pacing with safety margin to phrenic nerve stimulation (PNS). Previous studies introduced LV vector reprogramming in bipolar coronary sinus leads to optimize LV pacing and avoid PNS. We investigated the efficacy and reliability of quadripolar leads in CRT.
  
  
  METHODS
  The EffaceQ study enrolled 344 patients with de novo CRT implantation with a quadripolar LV lead in an observational, prospective multicenter study. The study was powered to demonstrate that in at least 90% of patients with an implanted quadripolar LV lead, a viable LV pacing configuration (LVPC) is available (primary end point: LV pacing threshold ≤2.5 V/0.5 ms, sufficient PNS margin).
  
  
  RESULTS
  Quadripolar leads were successfully implanted in 96% of patients. A total of 278 of 299 (93.0%) patients with complete data met the criteria for viable LVPC. With the use of traditional LVPCs, a viable LVPC would have been available (268 of 299 patients; P = 0.002) in significantly fewer patients (89.6%). In any LVPC, PNS was inducible in 65.0% of patients and 22.6% of patients reported PNS during ambulatory 3-month follow-up. LVPC reprogramming was performed in 49.8% of patients. PNS inducibility decreased from distal to proximal electrodes, whereas LV pacing thresholds increased from distal to proximal. At prehospital discharge, 5.9 ± 2.8 viable LVPCs were observed, stable during follow-up. The quadripolar electrode offered significantly more LVPC for LV optimization and PNS avoidance.
  
  
  CONCLUSIONS
  Quadripolar LV leads yield high numbers of patients with viable LVPCs and alternatives for noninvasive repositioning of LV pacing.
authors.affiliation: Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany.
authors.forename: Hanno
authors.initials: H
authors.lastname: Oswald
authors.affiliation: Heart Center, University of Freiburg, Germany.
authors.forename: Stefan
authors.initials: S
authors.lastname: Asbach
authors.affiliation: Münster University Hospital, Münster, Germany.
authors.forename: Julia
authors.initials: J
authors.lastname: Köbe
authors.affiliation: Marienhospital Osnabrück, Osnabrück, Germany.
authors.forename: Heinrich
authors.initials: H
authors.lastname: Weglage
authors.affiliation: Krankenhaus Mörsenbroich-Rath, Düsseldorf, Germany.
authors.forename: Bernfried
authors.initials: B
authors.lastname: Schulte-Pitzke
authors.affiliation: Klinikum Coburg, Coburg, Germany.
authors.forename: Johannes
authors.initials: J
authors.lastname: Brachmann
mesh_terms: D000368:Aged; D058406:Cardiac Resynchronization Therapy; D058409:Cardiac Resynchronization Therapy Devices; D005260:Female; D006333:Heart Failure / Q000628:therapy*; D006801:Humans; D008297:Male; D010791:Phrenic Nerve; D011446:Prospective Studies; D015203:Reproducibility of Results; D016896:Treatment Outcome
keywords: CRT; cardiac resynchronization therapy; left ventricular lead; phrenic nerve; quadripolar lead