Anteroposterior Versus Anterolateral Electrode Position for Direct Current Cardioversion of Atrial Fibrillation: A Meta-Analysis of Randomised Controlled Trials

Sohaib A Virk; Imants Rubenis; David Brieger; Hariharan Raju

doi:10.1016/j.hlc.2022.08.016

Anteroposterior Versus Anterolateral Electrode Position for Direct Current Cardioversion of Atrial Fibrillation: A Meta-Analysis of Randomised Controlled Trials

Heart Lung Circ. 2022 Dec;31(12):1640-1648. doi: 10.1016/j.hlc.2022.08.016. Epub 2022 Sep 24.

Authors

Sohaib A Virk¹, Imants Rubenis¹, David Brieger¹, Hariharan Raju²

Affiliations

¹ Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia.
² Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia; Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia. Electronic address: hari.raju@mqhealth.org.au.

PMID: 36163316
DOI: 10.1016/j.hlc.2022.08.016

Abstract

Objective: Data regarding optimal electrode positioning for direct current cardioversion (DCCV) of atrial fibrillation (AF) has been inconsistent. This meta-analysis was conducted to systematically compare the efficacy of anteroposterior (AP) versus anterolateral (AL) electrode placement for DCCV of AF.

Methods: Electronic databases were searched for randomised controlled trials (RCTs) comparing AP versus AL electrode positioning in patients undergoing DCCV for AF. Primary endpoints were first-shock success and overall DCCV success. Subgroup analysis was performed by defibrillator waveform (monophasic versus biphasic). Meta-regression analyses were performed to assess for significant moderators.

Results: Twelve (12) RCTs, including a total of 2,046 patients, met inclusion criteria. Neither first-shock success (relative risk [RR] 0.92; 95% CI 0.79-1.07; p=0.28) nor overall DCCV success (RR 1.01; 95% CI 0.96-1.05; p=0.78) were significantly different with AP versus AL electrode positioning. The mean number of shocks (mean difference [MD] 0.3, 95% CI -0.4 to 0.9), energy level of first successful shock (MD 3 joules; 95% CI -20 to 27) and cumulative energy delivered (MD 39 joules; 95% CI -168 to 246) were similar in AP versus AL arms. In subgroup analysis of six RCTs using biphasic defibrillators, improvement in first-shock success (RR 0.85; 95% CI 0.69-1.03; p=0.10) and overall DCCV success (RR 0.97; 95% CI 0.93-1.01; p=0.09) with AL electrode positioning did not reach statistical significance. Meta-regression analyses identified older age, higher body mass index, and longer AF duration as significant moderators favouring AL electrode positioning.

Conclusions: Pooled analysis of randomised data overall does not show a significant difference in efficacy between AP versus AL electrode positioning. Meta-regression and subgroup analyses suggest that, in contemporary practice with use of biphasic defibrillators, there may be a subset of AF patients in whom AL electrode positioning improves efficacy of DCCV.

Keywords: Atrial fibrillation; Direct current cardioversion; Electrode position; Meta-analysis.

Publication types

Meta-Analysis

MeSH terms

Atrial Fibrillation* / therapy
Body Mass Index
Electric Countershock*
Electrodes
Humans
Randomized Controlled Trials as Topic
Time Factors
Treatment Outcome