In a patient implanted with a triple chamber defibrillator and a bipolar left ventricular lead, 4 pacing configurations are programmable. Four factors can influence the choice of a pacing configuration: the presence of a diaphragmatic stimulation, the hemodynamic impact, the pacing threshold and the impedance. In this patient, the left ventricular lead was positioned in a anterolateral vein and no pacing configuration was associated with a phrenic stimulation, even for high amplitudes. With this type of bipolar left ventricular lead, the 2 electrodes are close, and will provide identical electrocardiographic appearance (confirmed on a 12-lead ECG) whatever the chosen configuration is. Therefore, it seems logical to assume that the chosen pacing configuration will have only few influences on the hemodynamic impact. The third parameter of comparison between the four configurations seem however decisive in this patient. When the distal electrode is active (LV tip – RV coil LV tip – RV ring), the stimulation threshold is lower than 1 volt at 0.4 ms. When the LV anode is active (LV ring – LV tip, LV ring – RV coil), the threshold is higher (> 2 volts to 0.4 ms). Indeed, the 4194 lead has a large anodal ring surface area which reduces the current density at the electrode edges and therefore increases the threshold. The choice of pacing configuration will have a significant influence on the pacing amplitude necessary to obtain a sufficient margin and therefore a major influence on consumption and the device longevity. The fourth parameter is the impedance of stimulation. All things being equal, it is preferable to program the pacing configuration that provides the higher impedance, since the drain of the battery is inversely proportional to the value of the impedance. When the LV threshold is high, this is an important parameter to consider.