Article

PDF
Access to the PDF text
Advertising


Free Article !

Archives of cardiovascular diseases
Volume 107, n° 5
pages 280-290 (mai 2014)
Doi : 10.1016/j.acvd.2014.04.002
Received : 18 January 2014 ;  accepted : 7 April 2014
Anterior-posterior versus anterior-lateral electrode position for external electrical cardioversion of atrial fibrillation: A meta-analysis of randomized controlled trials
Position de l’électrode de cardioversion électrique pour fibrillation atriale antéro-postérieure versus antéro-latérale : méta-analyse des essais contrôlés randomisés
 

Baowei Zhang, Xiaoli Li, Dongli Shen, Ya Zhen, Aibin Tao, Guohui Zhang
 Department of cardiology, The Affiliated People's hospital of Jiangsu university, 8 Dianli road, Zhenjiang, Jiangsu 212002, China 

Corresponding author.
Summary
Background

Several clinical trials have shown inconsistent results regarding the effect of electrode positions on the success of electrical cardioversion.

Aims

The aim of this meta-analysis was to investigate the effect of the anterior-posterior electrode position on the success of electrical cardioversion in patients undergoing external electrical cardioversion for atrial fibrillation.

Methods

Pubmed, EMBASE, the Cochrane Library and the Chinese National Knowledge Infrastructure were searched for randomized controlled trials. The effect of the anterior-posterior electrode position on cardioversion success is presented as a risk ratio with 95% confidence interval.

Results

Ten trials with 1281 patients were included in the analysis. The anterior-posterior electrode position had no advantages in terms of success of electrical cardioversion for atrial fibrillation compared with the anterior-lateral electrode position (risk ratio 1.02, 95% confidence interval 0.96–1.09; P =0.50). Subgroup analysis showed that patients with a left atrium diameter45mm and lone atrial fibrillation might derive benefits from the anterior-posterior electrode position in terms of success of cardioversion. No evidence of publication bias was detected.

Conclusions

The present analysis suggests that only patients with a left atrium diameter45mm and lone atrial fibrillation might derive benefits from the anterior-posterior electrode position compared with the anterior-lateral electrode position during external electrical cardioversion for atrial fibrillation. However, there was insufficient evidence to support any advantages for the anterior-posterior electrode position in other situations.

The full text of this article is available in PDF format.
Résumé
Justification

Plusieurs essais cliniques ont montré des résultats hétérogènes concernant le positionnement de l’électrode pour le succès d’une cardioversion électrique.

Objectif

L’objectif de cette méta-analyse est d’investiguer l’effet de la position antéro-postérieure de l’électrode sur le succès de la cardioversion électrique chez les patients ayant une indication à une cardioversion électrique externe pour fibrillation atriale.

Méthode

Les bases Pubmed, EMBASE, Cochrane, CNKI ont été systématiquement interrogées pour ce qui concerne les essais cliniques randomisés, contrôlés. L’effet du positionnement antéro-postérieur de l’électrode sur le taux de succès de la cardioversion a été présenté comme un rapport de risque avec les intervalles de confiance à 95 %.

Résultats

Dix études ayant inclus 1281 patients ont été considérées pour analyse. La position antéro-postérieure de l’électrode n’a pas d’avantage sur le taux de succès de la cardioversion électrique pour fibrillation atriale comparativement au positionnement antéro-latéral de l’électrode (rapport de risque 1,02, IC 95 % 0,96–1,09, p =0,50). L’analyse en sous-groupe montre que les patients ayant un diamètre atrial gauche>45mm et une fibrillation atriale isolée, pourraient tirer bénéfice du positionnement antéro-postérieur de l’électrode sur le taux de succès de la cardioversion. Il n’a pas été mis en évidence de publication pour expliquer ces résultats.

Conclusions

Cette méta-analyse suggère que seuls les patients ayant un diamètre atrial gauche<45mm et une fibrillation atriale isolée pourraient bénéficier du positionnement antéro-postérieur de l’électrode, comparativement à un positionnement antéro-latéral pendant les cardioversions électriques externes pour fibrillation atriale. Cependant, il n’y a pas suffisamment de preuves pour retenir l’avantage du positionnement antéro-postérieur de l’électrode dans d’autres situations.

The full text of this article is available in PDF format.

Keywords : Electrical cardioversion, Electrode position, Atrial fibrillation, Meta-analysis

Mots clés : Cardioversion électrique, Position de l’électrode, Fibrillation atriale, Méta-analyse

Abbreviations : AF, AL, AP, CI, LAD, RCT, RR, TTI


Background

Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice, and is associated with an increased risk of cardiovascular morbidity and overall mortality [1]. Although the rate control strategy is acceptable, the rhythm control strategy may be preferable for some patients with AF, especially young patients with persistent AF [2]. In the European Society of Cardiology guidelines for the management of AF, direct-current cardioversion is recommended as an effective method of converting AF to sinus rhythm [3].

Two electrode positions are used currently for electrode placement: anterior-lateral (AL) and anterior-posterior (AP). As the left atrium is positioned behind the right atrium, an electrical shock filed between the anterior and posterior thorax may be more efficient than that delivered with electrodes in the AL position. Some trials have also shown that AP electrode placement results in a higher conversion rate with the minimum energy shock requirement [4, 5, 6]. However, other studies have found no difference [7, 8, 9, 10, 11, 12] or have even suggested that the AL electrode position may be better [13]. We therefore performed a meta-analysis of randomized clinical trials (RCTs) to test whether the AP electrode position facilitates cardioversion success compared with the AL electrode position during external cardioversion for AF.

Methods
Literature search

A literature search was performed for studies using Pubmed, EMBASE, the Cochrane Library and the Chinese National Knowledge Infrastructure (CNKI) in English and Chinese. The keywords we used were ‘atrial fibrillation’, and ‘electrical cardioversion’. For all relevant publications, the records retrieved with the ‘related articles’ link in Pubmed were reviewed; reference lists were checked for other relevant studies. The final literature search was finished on 31 May 2013. The major inclusion criteria were: the study was an RCT; the study examined the relative efficacy of different electrode positions in terms of electrical cardioversion success. The major reasons for exclusion of studies were: overlapping data; patients aged<18years; data published in the form of abstracts rather than in peer-reviewed manuscripts.

Data collection and quality assessment

Two investigators (B.Z., X.L.) independently reviewed all potentially eligible studies using predefined eligibility criteria and collected data from the included trials. Any discrepancy was resolved by consensus. Baseline characteristics of patients were extracted, as well as data on each trial's intervention and the outcomes assessed. Trial quality was assessed using the Cochrane Collaboration's tool for assessing risk of bias. The tool comprises the following dominants: random sequence generation; allocation concealment; blinding of participants and personnel; blinding of outcome assessment; incomplete outcome data; selective reporting; and other bias. Each domain was given a score of ‘high’, ‘unclear’ or ‘low’ by two reviewers, independently. The included trials were then sorted into three categories: low risk of bias (all criteria rated as having a low risk of bias); unclear risk of bias (at least one item unclear); or high risk of bias (at least one item at a high risk of bias) [14].

Statistical analyses

Statistical analyses were performed using Review Manager 5.0.4 software (available from The Cochrane Collaboration at www.cochrane.org/) and STATA 11.0 software (StataCorp LP, College Station, TX, USA). The effect of AP electrode position on cardioversion success was presented as a risk ratio (RR) with 95% confidence interval (CI); weighted mean differences and 95% CIs were calculated to investigate the effect of AP electrode position on transthoracic impedance (TTI) for the first shock, mean energy and number of shocks for successful cardioversion. Heterogeneity was evaluated with Cochran's Q statistic and quality was evaluated by the I2 statistic. A value of P <0.1 for the Q test or I2>50% indicated significant between-study heterogeneity. If no heterogeneity was present, a fixed-effect meta-analysis was performed. Alternatively, a random-effect meta-analysis was performed when heterogeneity existed. Publication bias was evaluated by Begg's and Egger's methods. Results were considered statistically significant if P <0.05. Sensitivity analyses were undertaken by omitting one study at a time to examine the influence of one study on the overall summary estimate, and fixed- or random-effect models described above were used.

We explored possible explanations for heterogeneity according to a prior hypothesis, which included differences in baseline characteristics of patients, duration of AF, concurrent treatment with amiodarone, proportion with lone AF, type of electrode and type of defibrillator. Specially, we compared the result of studies grouped by the following factors: mean age; proportion of men; body mass index; duration of AF; proportion with lone AF; concomitant coronary disease; proportion of patients using amiodarone; left atrium diameter (LAD); type of electrode; and type of defibrillator. Recognizing that any cut-off point is arbitrary, we chose cut-off points before analysing the data using two criteria: thresholds had to be biologically sensible; and they had to divide the trials into two subgroups with a (more or less) similar number of trials. In addition, meta-regression analyses were conducted to identify factors contributing to the heterogeneity between studies, in which location of study, size of study, mean age, male sex, mean LAD, coronary artery disease and type of defibrillator, respectively, were introduced as covariants into meta-regressions.

Results
Search results

Our preliminary search yielded 343 potential literature citations. After the evaluation, a total of 333 articles were excluded for different reasons. Ten trials with 1281 patients (634 patients assigned to the AP group and 647 patients assigned to the AL group) were included in the analysis. Of the 10 studies, three studies reported that an AP electrode position was more effective than the AL position for external cardioversion for AF, one study showed that an AL electrode position was more effective than the AP position and six studies showed that AP and AL electrode positions had similar effects on external cardioversion for AF. The characteristics of included studies are shown in Table 1.

Baseline characteristics of patients and quality of the included studies

The baseline characteristics of patients enrolled are summarized in Table 2. There were no significant differences in the baseline characteristics of patients between the two groups. The mean age of patients in the individual trials ranged from 55 to 68years. The mean proportion of men was 64.9% among patients enrolled. The mean body mass index of patients in individual trials ranged from 24.5 to 29.6kg/m2. Hypertension was present in 38.9% of patients enrolled. We used the Cochrane Collaboration's tool to evaluate the quality of the included studies. According to the predefined quality assessment criteria indicated above, all trials were evaluated as having a high risk of bias, except for the trial conducted by Kirchhof et al. [5] (Figure 1).



Figure 1


Figure 1. 

Risk of bias in included studies.

Zoom

Effect of the anterior-posterior electrode position on the rate of successful electrical cardioversion

Figure 2 shows a forest plot comparing the rates of successful electrical cardioversion in the AP and AL groups. The I2 statistic and Q test showed that there was significant heterogeneity among the studies for the rate of successful electrical cardioversion (I2=63%, 95% CI 0.27–0.81, X2=24.53; P =0.004), so the random-effect model was used to pool the data. Electrical cardioversion at the AP position had no advantages compared with at the AL position in terms of rate of successful electrical cardioversion in patients with AF (RR 1.02, 95% CI 0.96–1.09; P =0.50; Figure 2). In addition, we pooled the data by the fixed-effect model as supplementary to the result. The result of the fixed-effect model also confirmed the previous finding (RR 1.02; 95% CI 0.98–1.09; P =0.40).



Figure 2


Figure 2. 

Forest plot of risk ratio for the effect of anterior-posterior (AP) electrode position on the success rate of electrical cardioversion. AL: anterior-lateral; CI: confidence interval; M-H: Mantel-Haenszel.

Zoom

Effects of the anterior-posterior electrode position on transthoracic impedance for the first shock, mean energy and number of shocks for successful cardioversion

Seven studies compared the mean energy for successful cardioversion, three studies evaluated the TTI for the first shock and five studies reported information on the number of shocks between the two electrode positions. The pooled data showed that TTI for the first shock in the AP group was lower than that in the AL group (RR –5.46, 95% CI –8.88–2.03; P =0.002; Figure 3). However, external cardioversion at the AP position had no advantages in terms of mean energy for successful cardioversion in patients with AF (RR –31.66, 95% CI –71.48–8.17; P =0.12; Figure 4). In addition, the pooled data showed that the number of shocks for successful cardioversion was not significantly different between the two groups (RR –0.10, 95% CI –0.35–0.5; P =0.42; Figure 5).



Figure 3


Figure 3. 

Forest plot of weighted mean differences for the effect of anterior-posterior (AP) electrode position on transthoracic impedance for the first shock. AL: anterior-lateral; CI: confidence interval; IV: inverse variance; SD: standard deviation.

Zoom



Figure 4


Figure 4. 

Forest plot of weighted mean differences for the effect of anterior-posterior (AP) electrode position on mean energy for successful cardioversion. AL: anterior-lateral; CI: confidence interval; IV: inverse variance; SD: standard deviation.

Zoom



Figure 5


Figure 5. 

Forest plot of weighted mean differences for the effect of anterior-posterior (AP) electrode position on the number of shocks for successful cardioversion. AL: anterior-lateral; CI: confidence interval; IV: inverse variance; SD: standard deviation.

Zoom

Sensitivity analyses

Firstly, sensitivity analyses were performed by omitting one study at a time and calculating the pooled RR for the remaining studies. This procedure was used to ensure that no individual study was entirely responsible for the combined results. Secondly, the pooled RR was estimated using the fixed-effect model and the random-effect model, respectively. Sensitivity analysis indicated that the results of the meta-analysis were reliable and stable.

Subgroup and metaregression analyses

Subgroup analyses were performed separately to investigate heterogeneity. The results showed that LAD and proportion with lone AF may influence the effect of AP electrode position on the success of cardioversion. Patients with LAD45mm (RR 1.08, 95% CI 0.99–1.17; P =0.09) and lone AF (RR 1.12, 95% CI 1.01–1.24; P =0.03) might derive benefits from the AP electrode position (Table 3). Metaregression analyses suggested that only mean age might dominate the heterogeneity. The regression coefficient was –0.020 (P =0.049; Table 4).

Risk of publication bias

Funnel plots were performed to assess the risk of publication bias for 10 studies with the outcome of success rate of electrical cardioversion. Results showed that the funnel plot was symmetrical (Figure 6). Egger's and Begg's tests showed that no potential publication bias existed among the included trials (Egger's test: P =0.78; Begg's test: P =0.53).



Figure 6


Figure 6. 

Publication bias assessment in studies with outcome of success rate of electrical cardioversion. rr and RR: relative risk; se: standard error.

Zoom

Discussion

We performed this meta-analysis of 10 RCTs with 1281 patients to investigate the beneficial effects of AP electrode position on external electrical cardioversion in patients with AF. The results showed that TTI was lower in the AP group than in the AL group. However, there were no beneficial effects of AP electrode position in terms of success rate of electrical cardioversion, mean energy or number of shocks for successful cardioversion. The heterogeneity of the studies was significant. Subgroup analysis showed that patients with LAD45mm and lone AF would derive benefits from electrical cardioversion at the AP position. For assurance, we performed Egger's and Begg's tests to exclude the influence of publication bias on the analysis.

Termination of fibrillatory activity can be achieved by creation of a shock-field gradient throughout the fibrillating myocardium for a few milliseconds [15]. The pulmonary veins and left atrium are the trigger and substrate of AF. Therefore, the left atrium shock-field gradient is crucial for successful cardioversion for AF. The left atrium is positioned behind the right atrium in the thoracic cavity. Cardioversion at the AP electrode position can achieve high shock-field gradients more easily than at the AL electrode position. In addition, the position of the electrodes can influence TTI. A previous study showed that TTI was lower in patients treated at the AP electrode position than in patients treated at the AL electrode position [16]. Upon defibrillator capacitor discharge, the amount of current delivered depends on the impedance between the electrodes. Therefore, a lower TTI might facilitate the delivery of more current to the heart. However, during the period of cardioversion, <4% of current is delivered to the heart; the majority of the current is shunted around the heart [17]. The small percentage of current delivered to the heart would impair the beneficial effects of the AP electrode position on current delivery.

Clinical studies exploring the benefits of cardioversion at the AP electrode position have also reported conflicting results. The study by Botto et al. showed that an AP electrode position was superior to an AL location with regard to technical success of electrical cardioversion for AF, and had a lower mean energy requirement [4]. The study by Kerber et al. showed that the AL electrode position was as effective as the AP electrode position for elective cardioversion for AF [18]. A study with 59 patients undergoing their first electrical cardioversion for persistent AF found that the AL electrode position was more effective for electrical cardioversion for persistent AF than the AP electrode position, and the two groups had a similar mean energy for successful cardioversion [13]. Another study showed that both electrode positions had similar success rates of cardioversion for AF, but that the AP electrode position had a lower mean energy and fewer shocks for successful cardioversion [9] The defibrillator used in these trials was a monophasic defibrillator. The biphasic defibrillator has greater efficacy than the monophasic defibrillator [19]. Regarding monophasic defibrillators, one randomized trial showed that the AP electrode position was more effective in achieving restoration of sinus rhythm in patients with AF [6], but another two studies showed that both electrode positions had similar success rates of electrical cardioversion for AF [7, 11]. Our comprehensive meta-analysis of RCTs also showed that both electrode positions had similar success rates of electrical cardioversion for AF.

Many factors might influence the success rate of electrical cardioversion for AF and the results of the meta-analysis. First, the patient's sex might influence the success rate of electrical cardioversion. A previous study showed that the breast increased the TTI during cardioversion at the AL electrode position in women [20]; so the success rate might be affected by the proportion of women in the study. However, our subgroup analysis found that the proportion of women did not influence the results of the meta-analysis. This may be explained by the fact that polarization of the membrane during defibrillation is influenced by tissue anisotropy and the curvature of myofibres [21], and TTI might be a less important determinant of successful cardioversion.

Second, the patient's weight is an independent predictor of successful cardioversion in patients with persistent AF. Overweight patients undergoing external cardioversion were at twice the risk of having an unsuccessful result compared with patients of normal weight [22]. Although our subgroup analysis found that the results of our meta-analysis were not affected by the mean body mass index of the patients, the mean body mass index of the patients in almost all the studies enrolled was>25kg/m2, which may have affected the results of our subgroup analysis. The duration of AF is another predictor of the success of electrical cardioversion. Patients with AF duration>6months undergoing external cardioversion were at high risk of having an unsuccessful result [23]. Our subgroup analysis found that duration of AF>24weeks had no significant influence on the results of the meta-analysis.

Left atrial volume is another important factor that might influence the success rate of electrical cardioversion for AF. Lower left atrial volume before cardioversion is a strong and independent predictor of the success of cardioversion [24]. Our subgroup showed that there was a trend that patients with LAD45mm would derive benefits from cardioversion at the AP electrode position. When patients had a larger left atrial volume, the advantages of cardioversion at the AP electrode position disappeared. The aetiology of AF might also influence the success rate of electrical cardioversion. Our subgroup analysis results showed that patients with lone AF had a higher success rate of cardioversion at the AP electrode position than at the AL position. However, similar findings have not been reported previously and this result needs to be investigated further.

Prophylactic antiarrhythmic drugs could also improve the success rate of electrical cardioversion for AF. Studies have showed that treatment with amiodarone can facilitate successful electrical cardioversion [25]. However, our subgroup analysis showed that the proportion of patients with prophylactic amiodarone had no influence on the results of the meta-analysis. In addition, the type of defibrillator and the type of electrode paddles might also influence the success rate of electrical cardioversion [26, 27]. However, the subgroup analysis found that neither the type of defibrillator nor the type of electrode paddles influenced the effect of electrode position on the success rate of cardioversion.

Study limitations

Our study has limitations. Lack of patient-specific data and the inclusion of trials of varying quality and design are limitations common to all meta-analyses. However, to nullify the latter factors, at least in part, we included only RCTs. In addition, the definition of successful cardioversion was arbitrary in the studies included in this analysis. The definition of successful electrical cardioversion was outlined in the European Society of Cardiology 2010 guidelines for the management of atrial fibrillation. In this guideline, successful cardioversion was defined as termination of AF, documented as the presence of two or more consecutive P-waves after shock delivery [3]. In addition, the type of AF is also an important confounding factor. However, the classification of AF in the studies enrolled was non-unified. The confounding classification of AF might also have affected the results of our study.

Conclusion

The present analysis suggests that only patients with LAD45mm and lone AF might derive benefits from the AP electrode position compared with the AL electrode position during external electrical cardioversion for AF. However, there was insufficient evidence to support any advantages of the AP electrode position in other situations.

Disclosure of interest

The authors declare that they have no conflicts of interest concerning this article.


Acknowledgements

We thank all of our colleagues working in the department of cardiology, The Affiliated People's hospital of Jiangsu university.


Appendix A. Supplementary data

(63 Ko)
  
(77 Ko)
  
References

Lip G.Y., Tse H.F., Lane D.A. Atrial fibrillation Lancet 2012 ;  379 : 648-661 [cross-ref]
Chen S., Dong Y., Fan J., and al. Rate vs. rhythm control in patients with atrial fibrillation--an updated meta-analysis of 10 randomized controlled trials Int J Cardiol 2011 ;  153 : 96-98 [cross-ref]
Camm A.J., Kirchhof P., Lip G.Y., and al. Guidelines for the management of atrial fibrillation: the Task Force for the management of atrial fibrillation of the European Society of Cardiology (ESC) Europace 2010 ;  12 : 1360-1420
Botto G.L., Politi A., Bonini W., and al. External cardioversion of atrial fibrillation: role of paddle position on technical efficacy and energy requirements Heart 1999 ;  82 : 726-730
Kirchhof P., Eckardt L., Loh P., and al. Anterior-posterior versus anterior-lateral electrode positions for external cardioversion of atrial fibrillation: a randomised trial Lancet 2002 ;  360 : 1275-1279 [cross-ref]
Vogiatzis I.A., Sachpekidis V., Vogiatzis I.M., and al. External cardioversion of atrial fibrillation: the role of electrode position on cardioversion success Int J Cardiol 2009 ;  137 : e8-e10
Brazdzionyte J., Babarskiene R.M., Stanaitiene G. Anterior-posterior versus anterior-lateral electrode position for biphasic cardioversion of atrial fibrillation Medicina (Kaunas) 2006 ;  42 : 994-998
Chen C.J., Guo G.B. External cardioversion in patients with persistent atrial fibrillation: a reappraisal of the effects of electrode pad position and transthoracic impedance on cardioversion success Jpn Heart J 2003 ;  44 : 921-932 [cross-ref]
Li J., Fu L., Ge H.L., and al. [Comparison of two kinds of direct current cardioversion on the treatment of atrial fibrillation] Chin J Crit Care Med 2006 ;  26 : 170-171
Mathew T.P., Moore A., McIntyre M., and al. Randomised comparison of electrode positions for cardioversion of atrial fibrillation Heart 1999 ;  81 : 576-579
Siaplaouras S., Buob A., Rotter C., and al. Randomized comparison of anterolateral versus anteroposterior electrode position for biphasic external cardioversion of atrial fibrillation Am Heart J 2005 ;  150 : 150-152 [inter-ref]
Walsh S.J., McCarty D., McClelland A.J., and 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 [cross-ref]
Alp N.J., Rahman S., Bell J.A., and al. Randomised comparison of antero-lateral versus antero-posterior paddle positions for DC cardioversion of persistent atrial fibrillation Int J Cardiol 2000 ;  75 : 211-216 [cross-ref]
Chen Y., Nie S., Gao H., and al. The effects of Wenxin Keli on P-wave dispersion and maintenance of sinus rhythm in patients with paroxysmal atrial fibrillation: a meta-analysis of randomized controlled trials Evid Based Complement Alternat Med 2013 ;  2013 : 245958
Walcott G.P., Knisley S.B., Zhou X., and al. On the mechanism of ventricular defibrillation Pacing Clin Electrophysiol 1997 ;  20 : 422-431
Krasteva V., Matveev M., Mudrov N., and al. Transthoracic impedance study with large self-adhesive electrodes in two conventional positions for defibrillation Physiol Meas 2006 ;  27 : 1009-1022 [cross-ref]
Lerman B.B., Deale O.C. Relation between transcardiac and transthoracic current during defibrillation in humans Circ Res 1990 ;  67 : 1420-1426 [cross-ref]
Kerber R.E., Jensen S.R., Grayzel J., and al. Elective cardioversion: influence of paddle-electrode location and size on success rates and energy requirements N Engl J Med 1981 ;  305 : 658-662 [cross-ref]
Page R.L., Kerber R.E., Russell J.K., and 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 [cross-ref]
Pagan-Carlo L.A., Spencer K.T., Robertson C.E., and al. Transthoracic defibrillation: importance of avoiding electrode placement directly on the female breast J Am Coll Cardiol 1996 ;  27 : 449-452 [cross-ref]
Ideker R.E., Chattipakorn T.N., Gray R.A. Defibrillation mechanisms: the parable of the blind men and the elephant J Cardiovasc Electrophysiol 2000 ;  11 : 1008-1013 [cross-ref]
Frick M., Frykman V., Jensen-Urstad M., and al. Factors predicting success rate and recurrence of atrial fibrillation after first electrical cardioversion in patients with persistent atrial fibrillation Clin Cardiol 2001 ;  24 : 238-244 [cross-ref]
Toso E., Blandino A., Sardi D., and al. Electrical cardioversion of persistent atrial fibrillation: acute and long-term results stratified according to arrhythmia duration Pacing Clin Electrophysiol 2012 ;  35 : 1126-1134 [cross-ref]
Akdemir B., Altekin R.E., Kucuk M., and al. The significance of the left atrial volume index in cardioversion success and its relationship with recurrence in patients with non-valvular atrial fibrillation subjected to electrical cardioversion: a study on diagnostic accuracy Anadolu Kardiyol Derg 2013 ;  13 : 18-25
Singh S.N., Tang X.C., Reda D., and al. Systematic electrocardioversion for atrial fibrillation and role of antiarrhythmic drugs: a substudy of the SAFE-T trial Heart Rhythm 2009 ;  6 : 152-155 [cross-ref]
Kirchhof P., Monnig G., Wasmer K., and al. A trial of self-adhesive patch electrodes and hand-held paddle electrodes for external cardioversion of atrial fibrillation (MOBIPAPA) Eur Heart J 2005 ;  26 : 1292-1297 [cross-ref]
Pisters R., Nieuwlaat R., Prins M.H., and al. Clinical correlates of immediate success and outcome at 1-year follow-up of real-world cardioversion of atrial fibrillation: the Euro Heart Survey Europace 2012 ;  14 : 666-674 [cross-ref]



© 2014  Elsevier Masson SAS. All Rights Reserved.
EM-CONSULTE.COM is registrered at the CNIL, déclaration n° 1286925.
As per the Law relating to information storage and personal integrity, you have the right to oppose (art 26 of that law), access (art 34 of that law) and rectify (art 36 of that law) your personal data. You may thus request that your data, should it be inaccurate, incomplete, unclear, outdated, not be used or stored, be corrected, clarified, updated or deleted.
Personal information regarding our website's visitors, including their identity, is confidential.
The owners of this website hereby guarantee to respect the legal confidentiality conditions, applicable in France, and not to disclose this data to third parties.
Close
Article Outline