Background: Smaller randomized studies have reported conflicting results regarding the optimal electrode position for cardioverting atrial fibrillation. However, anterior-posterior electrode position is widely used as a standard and believed to be superior to anterior-lateral electrode position. Therefore, we aimed to compare anterior-lateral and anterior-posterior electrode position for cardioverting atrial fibrillation in a multicenter randomized trial. Methods: In this multicenter, investigator-initiated, open-label trial, we randomly assigned patients with atrial fibrillation scheduled for elective cardioversion to anterior-lateral or anterior-posterior electrode position. The primary outcome was the proportion of patients in sinus rhythm after the first shock. The secondary outcome was the proportion of patients in sinus rhythm after up to four shocks escalating to maximum energy. Safety outcomes were any cases of arrhythmia during or after cardioversion, skin redness, and patient-reported peri-procedural pain. Results: We randomized 468 patients. The primary outcome occurred in 126 patients (54%) assigned to anterior-lateral electrode position and in 77 patients (33%) assigned to anterior-posterior electrode position, a risk difference of 22 percentage-points, 95%-confidence interval: 13-30, P<0.001. The number of patients in sinus rhythm after the final cardioversion shock was 216 patients (93%) assigned to anterior−lateral electrode position and 200 patients (85%) assigned to anterior-posterior electrode position, a risk difference of 7 percentage−points, 95%−confidence interval: 2−12. There were no significant differences between groups in any safety outcomes. Conclusions: Anterior-lateral electrode position was more effective than anterior-posterior electrode position for biphasic cardioversion of atrial fibrillation. There were no significant differences in any safety outcome.

Implantation of an LV lead for CRT is possible in patients with congestive heart failure and associated with an acceptable low complication rate. LV lead implantation is associated with a learning curve. At mid-term follow-up, LV lead performance is stable and unrelated to the LV implantation site.

BiV pacing minimizes LV dyssynchrony, preserves LV function, and reduces NT-proBNP in contrast to DDD(R) pacing in patients with high-grade AV block.

In a real-world clinical setting with anticoagulation handled in a structured multidisciplinary AF clinic, the waiting time to cardioversion was shorter with NOACs compared to warfarin. The rates of thromboembolism and major bleeding events were low, with NOACs shown to be as effective and safe as warfarin.

A presumed optimal LV-Ps between 2 and 5 o'clock in the short-axis circumference and basal or mid-ventricular in the long axis is not associated with a lower mortality or a better clinical response in patients treated with CRT.