Antero-lateral vs. antero-posterior electrode position for cardioversion of atrial fibrillation: a systematic review and meta-analysis of randomized controlled trials

Background Multiple randomized controlled trials (RCTs) have compared the success of antero-lateral vs. antero-posterior electrode position for cardioversion of atrial fibrillation (AF). However, due to small sample size and conflicting results of these RCTs, the optimal electrode positioning for successful cardioversion remains uncertain. Methods A systematic search of MEDLINE and EMBASE was conducted. Outcomes of interest included overall success of cardioversion with restoration of sinus rhythm, 1 st shock success, 2 nd shock success, mean shock energy required for successful cardioversion, mean number of shocks required for successful cardioversion, success of cardioversion at high energy (> 150 J) and success of cardioversion at low energy (< 150 J). Mantel–Haenszel risk ratios (RR) with 95% confidence intervals were calculated using random-effects model. Results A total of 14 RCTs comprising 2445 patients were included. There was no statistically significant difference between two cardioversion approaches in the overall success of cardioversion (RR 1.02; 95% CI [0.97–1.06]; p = 0.43), first shock success (RR 1.14; 95% CI [0.99–1.32]), second shock success (RR 1.08; 95% CI [0.94–1.23]), mean shock energy required (mean difference 6.49; 95% CI [-17.33–30.31], success at high energy > 150 J (RR 1.02; 95% CI [0.92–1.14] and success at low energy < 150 J (RR 1.09; 95% CI [0.97–1.22]). Conclusions This meta-analysis of RCTs shows no significant difference in the success of cardioversion between antero-lateral vs. antero-posterior electrode position for cardioversion of AF. Large well-conducted and adequately powered randomized clinical trials are needed to definitively address this question.