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Right atrial and RV CM will not adjust pacing outputs >5 V with a 1.0 ms pulse width.
One patient suffered from diaphragmatic stimulation at high pacing output (10 V) but the lead required no repositioning because of the lack of diaphragmatic capture with lower output (7.5 V).
Pacing parameters had improved at pre-discharge pacing check (threshold 1.75 V at 0.5 ms pulse width, impedance 510 Ω) and were better still at 6-week pacing check (threshold 1.25 V at 0.5 ms, impedance 540 Ω).
During bipolar stimulation, a pacing threshold of 2.25 V at 1.0 ms was measured, and the device was reprogrammed to bipolar pacing with an output of 4.5 V at 1.0 ms (Fig. 3).
The Quartet lead was placed in a similar position to the discarded LV lead but satisfactory pacing parameters (threshold 0.75 V at 0.5 ms; impedance 740 Ω) and no PNS was found when pacing using the M3 M2 vector.
Postoperative device interrogation demonstrated a stable unipolar pacing threshold of 0.5 V at 0.5 ms.
First, in case of a high (>2.0 V) LV pacing threshold, a sufficient safety margin should be programmed to ensure continuous LV capture.
In these cases, when programmed to the Adaptive mode, the algorithm adjusts pacing output to 5 V with a 1.0 ms pulse width.
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Device interrogation prior to hospital discharge had been inconspicuous with a RV pacing threshold less than 1.0 V at 0.4 ms during unipolar stimulation (Fig. 2), a pacing impedance of 612 Ohms and an R wave amplitude sensing of >22 mV.
