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Comparison of different pacing strategies to minimize phrenic nerve stimulation in cardiac resynchronization therapy.

ABSTRACT: 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.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 (V) 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 V above LV threshold, and triple PW at LV threshold had similar probability of PNS between LV configurations. However, 1 V 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.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.

SUBMITTER: Huizar JF

PROVIDER: S-EPMC4583217 | biostudies-literature | 2013 Sep

REPOSITORIES: biostudies-literature

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Comparison of different pacing strategies to minimize phrenic nerve stimulation in cardiac resynchronization therapy.

Huizar Jose F JF Kaszala Karoly K Koneru Jayanthi N JN Thacker Leroy R LR Ellenbogen Kenneth A KA

Journal of cardiovascular electrophysiology 20130426 9

<h4>Introduction</h4>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.<h4>Methods and results</h4>PN and LV thresholds were obtained using 6 LV configurations in 28 patients with an ...[more]

PMID: 23621543

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Project description:Background The hemodynamic effects of cardiac resynchronization therapy in patients with left ventricular assist devices (LVADs) are uncharacterized. We aimed to quantify the hemodynamic effects of different ventricular pacing configurations in patients with LVADs, focusing on short-term changes in load-independent right ventricular (RV) contractility. Methods and Results Patients with LVADs underwent right heart catheterization during spontaneous respiration without sedation and with pressures recorded at end expiration. Right heart catheterization was performed at different pacemaker configurations (biventricular pacing, left ventricular pacing, RV pacing, and unpaced conduction) in a randomly generated sequence with >3 minutes between configuration change and hemodynamic assessment. The right heart catheterization operator was blinded to the sequence. RV maximal change in pressure over time normalized to instantaneous pressure was calculated from digitized hemodynamic waveforms, consistent with a previously validated protocol. Fifteen patients with LVADs who were in sinus rhythm were included. Load-independent RV contractility, as assessed by RV maximal change in pressure over time normalized to instantaneous pressure, was higher in biventricular pacing compared with unpaced conduction (15.7±7.6 versus 11.0±4.0 s-1; P=0.003). Thermodilution cardiac output was higher in biventricular pacing compared with unpaced conduction (4.48±0.7 versus 4.38±0.8 L/min; P=0.05). There were no significant differences in heart rate, ventricular filling pressures, or atrioventricular valvular regurgitation across all pacing configurations. Conclusions Biventricular pacing acutely improves load-independent RV contractility in patients with LVADs. Even in these patients with mechanical left ventricular unloading via LVAD who were relative pacing nonresponders (required LVAD support despite cardiac resynchronization therapy), biventricular pacing was acutely beneficial to RV contractility.

Dataset Information

Comparison of different pacing strategies to minimize phrenic nerve stimulation in cardiac resynchronization therapy.

Publications

Comparison of different pacing strategies to minimize phrenic nerve stimulation in cardiac resynchronization therapy.

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