Skip to main content
SpringerLink
Log in

Effect of Electrode Position on the Outcome of Cardioversion

  • Published:
Cardiac Electrophysiology Review

Abstract

Acute termination of atrial fibrillation is the starting point of any therapy aimed at preventing atrial fibrillation and improves cardiac output in patients with hemodynamic compromise due to the arrhythmia. External electrical cardioversion is a simple procedure to terminate persistent atrial fibrillation in the majority of cases. Initially, Lown et al. used an anterior-lateral position of electrodes to apply a cardioversion shock. Recent pathophysiological studies have shown that atrial fibrillation is maintained by functional re-entry circuits anchored in the left atrium. As the left atrium is located posteriorly in the thorax, an anterior-posterior electrode position may be more efficient for external cardioversion of atrial fibrillation than the commonly used anterior-lateral electrode position. Several recent studies have confirmed that an anterior-posterior electrode position is superior to an anterior-lateral electrode position for external cardioversion of atrial fibrillation. There are no indications that an anterior-posterior electrode position is less safe than an anterior-lateral electrode position. We therefore suggest that an anterior-posterior electrode position should initially be used for external cardioversion of atrial fibrillation.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Fuster V, Ryden LE, Asinger RW, Cannom DS, Crijns HJ, Frye RL, Halperin JL, Kay GN, Klein WW, Levy S, McNamara RL, Prystowsky EN, Wann LS, Wyse DG. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to develop guidelines for the management of patients with atrial fibrillation) developed in collaboration with the North American Society of Pacing and Electrophysiology. Eur Heart J 2001;22:1852-1923.

    Google Scholar 

  2. Kannel WB, Wolf PA, Benjamin EJ, Levy D. Prevalence, incidence, prognosis, and predisposing conditions for atrial fibrillation: Population-based estimates. Am J Cardiol 1998;82:2N-9N.

    Google Scholar 

  3. Benjamin EJ, Wolf PA, D'Agostino RB, Silbershatz H, Kannel WB, Levy D. Impact of atrial fibrillation on the risk of death: The Framingham Heart Study. Circulation 1998;98:946-952.

    Google Scholar 

  4. Wolf PA, Benjamin EJ, Belanger AJ, Kannel WB, Levy D, D'Agostino RB. Secular trends in the prevalence of atrial fibrillation: The Framingham Study. Am Heart J 1996;131:790-795.

    Google Scholar 

  5. Wang TJ, Larson MG, Levy D, Vasan RS, Leip EP, Wolf PA, D'Agostino RB, Murabito JM, Kannel WB, Benjamin EJ. Temporal relations of atrial fibrillation and congestive heart failure and their joint influence on mortality: The Framingham Heart Study. Circulation 2003;107:2920-2925.

    Google Scholar 

  6. Hohnloser SH, Kuck KH, Lilienthal J. Rhythm or rate control in atrial fibrillation-Pharmacological Intervention in Atrial Fibrillation (PIAF): A randomised trial. Lancet 2000;356:1789-1794.

    Google Scholar 

  7. AFFIRM I. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 2002;347:1825-1833.

    Google Scholar 

  8. Van Gelder I, Hagens VE, Bosker HA, Kingma H, Kamp O, Kingma T, Said SA, Darmanata JI, Timmermanns AJM, Tijssen JGP, Crijns HJ. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med 2002;347:1834-1840.

    Google Scholar 

  9. Carlsson J, Miketic S, Windeler J, Cuneo A, Haun S, Micus S, Walter S, Tebbe U, Investigators S. Randomzied trial of rate-control versus rhythm-control in paersistent atrial fibrillation. J AmColl Cardiol 2003;41:1690-1696.

    Google Scholar 

  10. Wijffels MC, Kirchhof CJ, Dorland R, Allessie MA. Atrial fibrillation begets atrial fibrillation. A study in awake chronically instrumented goats. Circulation 1995;92:1954-1968.

    Google Scholar 

  11. Nattel S, Allessie M, Haissaguerre M. Spotlight on atrial fibrillation-the ‘complete arrhythmia’. Cardiovasc Res 2002;54:197-203.

    Google Scholar 

  12. Schotten U, Duytschaever M, Ausma J, Eijsbouts S, Neuberger HR, Allessie M. Electrical and contractile remodeling during the first days of atrial fibrillation go hand in hand. Circulation 2003;107:1433-1439.

    Google Scholar 

  13. Wozakowska-Kaplon B, Opolski G. Concomitant recovery of atrial mechanical and endocrine function after cardioversion in patients with persistent atrial fibrillation. J Am Coll Cardiol 2003;41:1716-1720.

    Google Scholar 

  14. Maisel WH, Stevenson LW. Atrial fibrillation in heart failure: Epidemiology, pathophysiology, and rationale for therapy. Am J Cardiol 2003;91:2D-8D.

    Google Scholar 

  15. Lown B, Perlroth M, Kaidbey S, Abe T, Harken DE. Cardioversion of atrial firbrillation. A report on the treatment of 65 episodes in 59 patients. N Engl J Med 1963;269:325-331.

    Google Scholar 

  16. Mittal S, Ayati S, Stein KM, Schwartzman D, Cavlovich D, Tchou PJ, Markowitz SM, Slotwiner DJ, Scheiner MA, Lerman BB. Transthoracic cardioversion of atrial fibrillation: Comparison of rectilinear biphasic versus damped sine wave monophasic shocks. Circulation 2000;101:1282-1287.

    Google Scholar 

  17. Kirchhof P, Eckardt L, Loh P, Weber K, Fischer RJ, Seidl KH, Bocker D, Breithardt G, Haverkamp W, Borggrefe M. Anterior-posterior versus anterior-lateral electrode positions for external cardioversion of atrial fibrillation: A randomised trial. Lancet 2002;360:1275-1279.

    Google Scholar 

  18. Kerber RE. Transthoracic cardioversion of atrial fibrillation and flutter: Standard techniques and new advances. Am J Cardiol 1996;78:22-26.

    Google Scholar 

  19. Levy S, Breithardt G, Campbell RW, Camm AJ, Daubert JC, Allessie M, Aliot E, Capucci A, Cosio F, Crijns H, Jordaens L, Hauer RN, Lombardi F, Luderitz B. Atrial fibrillation: Current knowledge and recommendations for management. Working Group on Arrhythmias of the European Society of Cardiology. Eur Heart J 1998;19:1294-12320.

    Google Scholar 

  20. Lown B, Amarasinghem R, Neumann J. New method for termination cardiac arrhythmias: Use of synchronized capacitor discharge. JAMA 1962;182:548-555.

    Google Scholar 

  21. Murgatroyd FD, Slade AK, Sopher SM, Rowland E, Ward DE, Camm AJ. Efficacy and tolerability of transvenous low energy cardioversion of paroxysmal atrial fibrillation in humans. J AmColl Cardiol 1995;25:1347-1353.

    Google Scholar 

  22. Levy S, Lauribe P, Dolla E, Kou W, Kadish A, Calkins H, Pagannelli F, Moyal C, Bremondy M, Schork A. A randomized comparison of external and internal cardioversion of chronic atrial fibrillation. Circulation 1992;86:1415-1420.

    Google Scholar 

  23. Marrouche NF, Bardy GH, Frielitz HJ, Gunther J, Brachmann J. Quadruple pads approach for external cardioversion of atrial fibrillation. Pacing Clin Electrophysiol 2001;24:1321-1324.

    Google Scholar 

  24. Haissaguerre M, Jais P, Shah DC, Takahashi A, Hocini M, Quiniou G, Garrigue S, LeMouroux A, LeMetayer P, Clementy J. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 1998;339:659-666.

    Google Scholar 

  25. Chen YH, Xu SJ, Bendahhou S, Wang XL, Wang Y, Xu WY, Jin HW, Sun H, Su XY, Zhuang QN, Yang YQ, Li YB, Liu Y, Xu HJ, Li XF, Ma N, Mou CP, Chen Z, Barhanin J, Huang W. KCNQ1 gain-of-function mutation in familial atrial fibrillation. Science 2003;299:251-254.

    Google Scholar 

  26. Kirchhof P, Eckardt L, Monnig G, Johna R, Loh P, Schulze-Bahr E, Breithardt G, Borggrefe M, Haverkamp W. A patient with “atrial torsades de pointes”. J Cardiovasc Electrophysiol 2000;11:806-811.

    Google Scholar 

  27. Kirchhof P, Eckardt L, Franz MR, M¨onnig G, Loh P, Wedekind H, Schulze-Bahr E, Breithardt G, Haverkamp W. Prolonged atrial action potential durations and polymorphic atrial tachyarrhythmias in patients with long QT syndrome. J Cardiovasc Electrophysiol 2003;14:1027-1033.

    Google Scholar 

  28. Nattel S, Li D, Yue L. Basic mechanisms of atrial fibrillation-Very new insights into very old ideas. Annu Rev Physiol 2000;62:51-77.

    Google Scholar 

  29. Nattel S. New ideas about atrial fibrillation 50 years on. Nature 2002;415:219-226.

    Google Scholar 

  30. SkanesAC, Gray RA, Zuur CL, Jalife J. Effects of postshock atrial pacing on atrial defibrillation outcome inthe isolated sheep heart. Circulation 1998;98:64-72.

    Google Scholar 

  31. Jalife J, Berenfeld O, Skanes A, Mandapati R. Mechanisms of atrial fibrillation: Mother rotors or multiple daughterwavelets, or both? J Cardiovasc Electrophysiol 1998;9:S2-S12.

    Google Scholar 

  32. Ideker RE, Chattipakorn TN, Gray RA. Defibrillation mechanisms: The parable of the blind men and the elephant. J Cardiovasc Electrophysiol 2000;11:1008-1013.

    Google Scholar 

  33. Karagueuzian HS, Chen PS. Fibrillation and defibrillation: The odd couple? J Cardiovasc Electrophysiol 2000;11:642-624.

    Google Scholar 

  34. Kirchhof P, Milberg P, Eckardt L, Breithardt G, Haverkamp W. Effect of sotalol and acute ventricular dilatation on action potential duration and dispersion of repolarization after defibrillation shocks. J Cardiovasc Pharmacol 2003;41:640-648.

    Google Scholar 

  35. Evans FG, Ideker RE, Gray RA. Effect of shock-induced changes in transmembrane potential on reentrant waves and outcome during cardioversion of isolated rabbit hearts. J Cardiovasc Electrophysiol 2002;13:1118-1127.

    Google Scholar 

  36. Chattipakorn N, KenKnight BH, Rogers JM, Walker RG, Walcott GP, Rollins DL, Smith WM, Ideker RE. Locally propagated activation immediately after internal defibrillation. Circulation 1998;97:1401-1410.

    Google Scholar 

  37. Efimov IR, Cheng Y, Yamanouchi Y, Tchou PJ. Direct evidence of the role of virtual electrode-induced phase singularity in success and failure of defibrillation. J Cardiovasc Electrophysiol 2000;11:861-868.

    Google Scholar 

  38. Chen PS, Wolf PD, Claydon FJ, Dixon EG, Vidaillet HJ, Danieley ND, Pilkington TC, Ideker RE. The potential gradient field created by epicardial defibrillation electrodes in dogs. Circulation 1986;74:626-636.

    Google Scholar 

  39. Walcott GP, Knisley SB, Zhou X, Newton JC, Ideker RE. On the mechanism of ventricular defibrillation. PACE 1997;20:422-431.

    Google Scholar 

  40. Ewy GA. The optimal technique for electrical cardioversion of atrial fibrillation. Clin Cardiol 1994;17:79-84.

    Google Scholar 

  41. Kerber RE, Grayzel J, Hoyt R, Marcus M, Kennedy J. Transthoracic resistance in human defibrillation. Influence of body weight, chest size, serial shocks, paddle size and paddle contact pressure. Circulation 1981;63:676-682.

    Google Scholar 

  42. Kerber RE, Jensen SR, Grayzel J, Kennedy J, Hoyt R. Elective cardioversion: Influence of paddle-electrode location and size on success rates and energy requirements. N Engl J Med 1981;305:658-662.

    Google Scholar 

  43. Ewy GA. Optimal technique for electrical cardioversion of atrial fibrillation [editorial; comment]. Circulation 1992;76:1645-1647.

    Google Scholar 

  44. Botto GL, 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.

    Google Scholar 

  45. Mathew TP, Moore A, McIntyre M, Harbinson MT, Campbell NP, Adgey AA, Dalzell GW. Randomised comparison of electrode positions for cardioversion of atrial fibrillation. Heart 1999;81:576-579.

    Google Scholar 

  46. Alp N, Rahman S, Bell J, 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.

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Cardiology and Angiology, Hospital of the University of Münster, Germany

    Paulus Kirchhof & Günter Breithardt

  2. Department of Cardiology and Angiology, Hospital of the University of Mannheim, Medical Faculty of Heidelberg, Germany

    Martin Borggrefe

Authors
  1. Paulus Kirchhof
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Martin Borggrefe
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Günter Breithardt
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Kirchhof, P., Borggrefe, M. & Breithardt, G. Effect of Electrode Position on the Outcome of Cardioversion. Card Electrophysiol Rev 7, 292–296 (2003). https://doi.org/10.1023/B:CEPR.0000012399.96959.ab

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1023/B:CEPR.0000012399.96959.ab

Search

Navigation