Kirchhof Paulus, Eckardt Lars, Loh Peter, Weber Karoline, Fischer Rudolf-Josef, Seidl Karl-Heinz, Böcker Dirk, Breithardt Günter, Haverkamp Wilhelm, Borggrefe Martin
Department of Cardiology and Angiology and Institute for Arteriosclerosis Research, University of Münster, Münster, Germany.
Lancet. 2002 Oct 26;360(9342):1275-9. doi: 10.1016/s0140-6736(02)11315-8.
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.
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.
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%).
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.
体外心脏复律是治疗持续性心房颤动的一种常用方法。尽管从解剖学和电生理学角度考虑，前后电极位置在整个心房中产生的电击场梯度应比前外侧位置更均匀，但目前的指南对这两种电极位置在体外心脏复律中均同样推荐。我们进行了一项随机试验，比较这两种位置，以成功心脏复律为终点。
108例连续的持续性心房颤动患者（平均年龄60岁[标准差16]，中位病程5个月，范围0.1 - 120个月）按照标准化的逐步增加电击强度（50 - 360 J）方案接受择期体外心脏复律。电极位置随机分配为前外侧或前后位。如果360 J能量未实现窦性心律，则用另一种电极配置施加单次交叉电击（360 J）。在招募这些患者后进行了计划中的中期分析；采用意向性分析。
前后位组心脏复律成功的比例高于前外侧组（52例中的50例[96%]对56例中的44例[78%]，差异23.7%（95%置信区间9.1 - 37.8，p = 0.009）。12例患者中有8例从前外侧电极位置转换为前后位电极位置成功，而在另一个方向的转换未成功（2例患者）。转换后，108例随机分组患者中有102例（94%）心脏复律成功。
对于持续性心房颤动的体外心脏复律，前后电极位置比前外侧位置更有效。在临床实践、除颤电极垫的设计以及心房颤动心脏复律指南更新时，应考虑这些结果。
