Bipolar versus quadripolar left ventricular leads for cardiac resynchronization therapy: evidence to date

ABSTRACT

Introduction

In cardiac resynchronization therapy (CRT) devices, transvenous left ventricular (LV) leads are more prone to instability, high pacing thresholds, and phrenic nerve stimulation (PNS) that may necessitate lead revision, replacement in a suboptimal position, or deactivation of the lead. To overcome some of these challenges, quadripolar (QP) LV leads have been developed and accounted for over 90% of implanted LV leads 5 years after they were introduced.

Areas covered

This review provides an overview of the current evidence of implanting QP leads in CRT as compared with traditional bipolar (BP) leads including details about feasibility, safety and lead performance, clinical outcomes and cost-effectiveness.

Expert opinion

Based on the current literature, implantation with a QP lead decreases revision rates but does not affect any clinical outcomes including mortality, hospitalization, symptoms, or echocardiographic parameters. Feasibility and stability do not differ between QP and BP leads. A QP lead should be preferred as first choice over a BP lead due to lower rates of PNS and lower pacing thresholds leading to less frequent lead revisions and battery replacements. In addition, this strategy may be cost saving despite a higher price of QP leads.

KEYWORDS:

• Bipolar left ventricular leads
• cardiac resynchronization therapy
• congestive heart failure
• outcome
• quadripolar left ventricular leads

Article highlights

1. The use of quadripolar (QP) left ventricular (LV) leads in cardiac resynchronization therapy (CRT) devices has increased markedly as compared with bipolar (BP) leads, and accounted for over 90% of implanted LV leads 5 years after they were introduced in the marked.

2. Implantation feasibility, lead stability, procedural and fluoroscopy times do not differ between QP and BP LV leads.

3. Pacing threshold and the risk of phrenic nerve stimulation (PNS) is lower with QP LV leads as compared with BP LV leads.

4. There is no strong evidence that QP leads, including multi point pacing, improves survival or symptoms, reduces hospitalization for heart failure, or improves echocardiographic parameters in CRT recipients.

5. QP LV leads might be more cost-effective than BP LV leads due to lower readmission rate.

Declaration of Interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was funded by Aarhus University, the Danish Heart Foundation [grant number R140-A9482- B2407], Health Research Foundation of Central Denmark Region [grant number R64-A3194-B1667], and Gangstedfonden.