For personal use. Only reproduce with permission from The Lancet Publishing Group. ARTICLES THE LANCET • Vol 360 • October 26, 2002 • www.thelancet.com 1275 Summary Background External cardioversion is a readily available treatment for persistent atrial fibrillation. Although anatomical and electrophysiological considerations suggest that an anterior-posterior electrode position should create a more homogeneous shock-field gradient throughout the atria than an anterior-lateral position, both electrode positions are equally recommended for external cardioversion in current guidelines. We undertook a randomised trial comparing the two positions with the endpoint of successful cardioversion. Methods 108 consecutive patients (mean age 60 years [SD 16]) with persistent atrial fibrillation (median duration 5 months, range 0·1–120) underwent elective external cardioversion by a standardised step-up protocol with increasing shock strengths (50–360 J). Electrode positions were randomly assigned as anterior-lateral or anterior- posterior. If sinus rhythm was not achieved with 360 J energy, a single cross-over shock (360 J) was applied with the other electrode configuration. A planned interim analysis was done after these patients had been recruited; it was by intention to treat. Findings Cardioversion was successful in a higher proportion of the anterior-posterior than the anterior-lateral group (50 of 52 [96%] vs 44 of 56 [78%], difference 23·7% (95% CI 9·1–37·8, p=0·009). Cross-over from the anterior-lateral to the anterior-posterior electrode position was successful in eight of 12 patients, whereas cross-over in the other direction was not successful (two patients). After cross-over, cardioversion was successful in 102 of 108 randomised patients (94%). Interpretation An anterior-posterior electrode position is more effective than the anterior-lateral position for external cardioversion of persistent atrial fibrillation. These results should be considered in clinical practice, for the design of defibrillation electrode pads, and when guidelines for cardioversion of atrial fibrillation are updated. Lancet 2002; 360: 1275–79 See Commentary page 1263 Department of Cardiology and Angiology and Institute for Arteriosclerosis Research (P Kirchhof MD, L Eckardt MD, P Loh MD, K Weber MD, D Böcker MD, G Breithardt MD, W Haverkamp MD) and Department of Medical Informatics and Biomathematics (R-J Fischer PhD), University of Münster, Münster, Germany; Department of Cardiology, City Hospital Ludwigshafen (K-H Seidl MD); and Department of Cardiology and Angiology, University of Mannheim, Mannheim (M Borggrefe MD) Correspondence to: Dr Paulus Kirchhof, Medizinische Klinik und Poliklinik, Innere Medizin C–Kardiologie und Angiologie, Universitätskliniken Münster, D-48129, Münster, Germany (e-mail: kirchhp@uni-muenster.de) Introduction Atrial fibrillation is the most common sustained cardiac arrhythmia, and incidence is increasing in an ageing population. 1 Atrial fibrillation causes important morbidity and mortality through loss of haemodynamic function of the atria, uncontrolled ventricular rate, and risk of stroke. 2,3 Restoration of sinus rhythm is therefore a main treatment goal in patients with persistent atrial fibrillation. 4 Transthoracic external electrical cardio- version is the standard method to restore sinus rhythm in such patients, 5,6 but it is not successful in every case. 4,7,8 Means of improving the method of external cardioversion are therefore clinically and socioeconomically important. Termination of fibrillatory activity can be achieved by creation of a shock-field gradient of at least 5 V/cm throughout the fibrillating myocardium for a few milliseconds. 9–11 Since the right and left atria are positioned one behind the other, an electrical shock field between the anterior and posterior thorax may be more efficient at achieving such a shock-field gradient in the atria than that with electrodes positioned anteriorly and laterally on the anterior thorax. Furthermore, some evidence suggests that transthoracic impedance is lower for anterior-posterior electrodes. 12,13 Botto and colleagues 14 suggested that anterior-posterior paddle positions may increase cardioversion success rates, but others have found no difference 7,15 or have even suggested that anterior-lateral electrode positions may be better. 16 Present guidelines therefore equally recommend either electrode position for external cardioversion. 8,17 In a 1998 statement by a study group of the Working Group on Arrhythmias of the European Society of Cardiology, 4 the need for better classification of atrial fibrillation was emphasised, as were the implications for studies that assess maintenance of sinus rhythm. These considerations were not taken into account fully by previous studies. We therefore designed a prospective randomised trial to test whether an anterior-posterior electrode position improves cardioversion success compared with an anterior-lateral position during external cardioversion of persistent atrial fibrillation. Methods Patients We screened all patients aged 18–80 years who were undergoing cardioversion at the Department of Cardiology of the University of Münster, Germany between May, 1999, and November, 2000. Patients with a pectorally implanted pacemaker or defibrillator were not included in this trial, but were cardioverted in the anterior-posterior position. 8 Care was taken to exclude patients with atrial flutter or rapid atrial tachycardias; skilled cardiologists, including at least one electrophysiologically trained attending physician of our department analysed a 12-lead electrocardiogram (ECG) recorded on the day before cardioversion. Patients were Anterior-posterior versus anterior-lateral electrode positions for external cardioversion of atrial fibrillation: a randomised trial Paulus Kirchhof, Lars Eckardt, Peter Loh, Karoline Weber, Rudolf-Josef Fischer, Karl-Heinz Seidl, Dirk Böcker, Günter Breithardt, Wilhelm Haverkamp, Martin Borggrefe