Elimination of phrenic nerve stimulation occurring during CRT Follow-up in patients implanted with a novel quadripolar pacing lead Paresh A. Mehta & Anoop K. Shetty & Mark Squirrel & Julian Bostock & C. Aldo Rinaldi Received: 14 May 2011 /Accepted: 9 June 2011 /Published online: 21 July 2011 # Springer Science+Business Media, LLC 2011 Abstract Background Phrenic nerve stimulation (PNS) occurs at follow-up in approximately 20% of patients with bipolar leads. The quadripolar Quartet model 1458Q (St. Jude Medical, Sylmar, CA, USA) left ventricular lead (LV) has four electrodes (one distal tip and three ring) capable of ten different pacing vectors which may allow reprogramming to eliminate PNS. Methods Forty patients underwent attempted CRT-D implan- tation between October 2009 and October 2010 with the Quartet lead. Pacing parameters, lead position, complications and presence of PNS were collected at implant, pre-discharge and at 3 and 6 months follow-up. Results A quadripolar LV lead was successfully implanted in 95% (38/40) of patients. During follow-up, one patient (3%) had a lead displacement requiring reposition. LV pacing parameters remained stable at 6 months follow-up (mean threshold 1.3 V at 0.6 ms and impedance 948 Ω). PNS at the time of implant was observed in 12 patients (32%) all of which were overcome by using the additional vectors available on the quadripolar LV lead or by repositioning the lead at the time of index implant. During 6 months follow-up there were five (13%) cases of PNS, all of which were successfully treated by reprogramming to a different vector. No cases required reintervention, surgical epicardial lead placement, or that lead be turned off. Conclusion The quadripolar Quartet lead is associated with a high implant success rate, stable pacing parameters and a low displacement rate during the first 6 months after implant. The ten LV pacing vectors available with this lead allowed PNS and capture threshold problems to be overcome at implant, and importantly at follow-up, thus obviating the need for lead reposition. Keywords Phrenic nerve stimulation . CRT . Quadripolar lead 1 Introduction The prognosis of heart failure has improved over the past decade with advances in medical therapy; however, mortality rates remain high with up to 15% of patients dying within 6 months of diagnosis [1, 2]. Cardiac resynchronisation therapy (CRT) improves heart failure symptoms, associated hospitalisations and risk of death in patients with left ventricular (LV) dysfunction and a broad QRS [3–6]. Over the past decade significant improvements have been made in coronary sinus catheters, smaller calibre bipolar left ventricular (LV) leads and cathodal program- mability. Although such advances have resulted in an increase in successful implantation of this therapy, a significant proportion of cases remain limited by suboptimal or failed implantation due to technical failure, unsatisfactory pacing parameters and phrenic nerve stimulation (PNS) [7, 8]. PNS often occurs in the same site as optimal LV lead placement and occurs in over 20% of patients receiving CRT [7]. This can often be overcome using bipolar leads but P. A. Mehta : M. Squirrel : J. Bostock : C. A. Rinaldi Guys and St Thomas’ Hospital NHS Foundation Trust, London, UK A. K. Shetty : C. A. Rinaldi King’ s College London, London, UK P. A. Mehta (*) St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH, UK e-mail: paresh.mehta@gstt.nhs.uk J Interv Card Electrophysiol (2012) 33:43–49 DOI 10.1007/s10840-011-9598-5