Heart, Lung and Circulation

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

Published:September 24, 2022DOI:


      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.


      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.


      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.


      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.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Heart, Lung and Circulation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Andrade J.
        • Khairy P.
        • Dobrev D.
        • Nattel S.
        The clinical profile and pathophysiology of atrial fibrillation: relationships among clinical features, epidemiology, and mechanisms.
        Circ Res. 2014; 114: 1453-1468
        • Dalzell G.W.
        • Anderson J.
        • Adgey A.J.
        Factors determining success and energy requirements for cardioversion of atrial fibrillation.
        QJM. 1990; 76: 903-913
        • Hindricks G.
        • Potpara T.
        • Dagres N.
        • Arbelo E.
        • Bax J.
        • Blomström-Lundqvist C.
        • et al.
        2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS) The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC.
        Eur Heart J. 2021; 42: 373-498
        • Higgins J.P.
        • Savović J.
        • Page M.J.
        • Elbers R.G.
        • Sterne J.A.
        Assessing risk of bias in a randomized trial.
        Cochrange handbook for systematic reviews of interventions. 2019; : 205-228
        • Wan X.
        • Wang W.
        • Liu J.
        • Tong T.
        Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range.
        BMC Med Res Methodology. 2014; 14: 1-13
        • Begg C.B.
        • Mazumdar M.
        Operating characteristics of a rank correlation test for publication bias.
        Biometrics. 1994; : 1088-1101
        • Alp N.J.
        • Rahman S.
        • Bell J.A.
        • Shahi M.
        Randomised comparison of antero-lateral versus antero-posterior paddle positions for DC cardioversion of persistent atrial fibrillation.
        Int J Cardiol. 2000; 75: 211-216
        • Botto G.L.
        • Politi A.
        • Bonini W.
        • Broffoni T.
        • Bonatti R.
        External cardioversion of atrial fibrillation: role of paddle position on technical efficacy and energy requirements.
        Heart. 1999; 82: 726-730
        • Brazdzionyte J.
        • Babarskiene R.M.
        • Stanaitiene G.
        Anterior-posterior versus anterior-lateral electrode position for biphasic cardioversion of atrial fibrillation.
        Medicina. 2006; 42: 994-998
        • Chen C.J.
        • Guo G.B.-F.
        External cardioversion in patients with persistent atrial fibrillation: a reappraisal of the effects of electrode pad position and transthoracic impedance on cardioversion success.
        Jap Heart J. 2003; 44: 921-932
        • Kirchhof P.
        • Borggrefe M.
        • Breithardt G.
        Effect of electrode position on the outcome of cardioversion.
        Card Electrophys Rev. 2003; 7: 292-296
        • Mathew T.
        • Moore A.
        • McIntyre M.
        • Harbinson M.T.
        • Campbell N.P.
        • Adgey A.A.
        • et al.
        Randomised comparison of electrode positions for cardioversion of atrial fibrillation.
        Heart. 1999; 81: 576-579
        • Schmidt A.S.
        • Lauridsen K.G.
        • Moller D.S.
        • Christensen P.D.
        • Dodt K.K.
        • Rickers H.
        • et al.
        Anterior-lateral versus anterior-posterior electrode position for cardioverting atrial fibrillation.
        Circulation. 2021; 144: 1995-2003
        • Siaplaouras S.
        • Buob A.
        • Rotter C.
        • Böhm M.
        • Jung J.
        Randomized comparison of anterolateral versus anteroposterior electrode position for biphasic external cardioversion of atrial fibrillation.
        Am Heart J. 2005; 150: 150-152
        • Stiell I.G.
        • Sivilotti M.L.A.
        • Taljaard M.
        • Birnie D.
        • Vadeboncoeur A.
        • Hohl C.M.
        • et al.
        Electrical versus pharmacological cardioversion for emergency department patients with acute atrial fibrillation (RAFF2): a partial factorial randomised trial.
        Lancet. 2020; 395: 339-349
        • Vogiatzis I.A.
        • Sachpekidis V.
        • Vogiatzis I.M.
        • Kambitsi E.
        • Karamitsos T.
        • Samanidis D.
        • et al.
        External cardioversion of atrial fibrillation: the role of electrode position on cardioversion success.
        Int J Cardiol. 2009; 137: e8-e10
        • Voskoboinik A.
        • Moskovitch J.
        • Plunkett G.
        • Bloom J.
        • Wong G.
        • Nalliah C.
        • et al.
        Cardioversion of atrial fibrillation in obese patients: results from the Cardioversion-BMI randomized controlled trial.
        J Cardiovasc Electrophysiol. 2019; 30: 155-161
        • Walsh S.J.
        • McCarty D.
        • McClelland A.J.J.
        • Owens C.G.
        • Trouton T.G.
        • Harbinson M.T.
        • et al.
        Impedance compensated biphasic waveforms for transthoracic cardioversion of atrial fibrillation: a multi-centre comparison of antero-apical and antero-posterior pad positions.
        Eur Heart J. 2005; 26: 1298-1302
        • Ewy G.A.
        Optimal technique for electrical cardioversion of atrial fibrillation.
        Circulation. 1992; 86: 1645-1647
        • Page R.L.
        • Kerber R.E.
        • Russell J.K.
        • Trouton T.
        • Waktare J.
        • Gallik D.
        • et al.
        Biphasic versus monophasic shock waveform for conversion of atrial fibrillation: the results of an international randomized, double-blind multicenter trial.
        J Am Coll Cardiol. 2002; 39: 1956-1963
        • Lévy S.
        • Lauribe P.
        • Dolla E.
        • Kou W.
        • Kadish A.
        • Calkins H.
        • et al.
        A randomized comparison of external and internal cardioversion of chronic atrial fibrillation.
        Circulation. 1992; 86: 1415-1420
        • Volgman A.S.
        • Nair G.
        • Lyubarova R.
        • Merchant F.M.
        • Mason P.
        • Curtis A.B.
        • et al.
        Management of atrial fibrillation in patients 75 years and older: JACC state-of-the-art review.
        J Am Coll Cardiol. 2022; 79: 166-179