{"id":176,"date":"2025-07-09T09:58:35","date_gmt":"2025-07-09T09:58:35","guid":{"rendered":"https:\/\/cardiocases.com\/?page_id=176"},"modified":"2025-11-09T14:22:24","modified_gmt":"2025-11-09T14:22:24","slug":"shocks-in-vf-zone","status":"publish","type":"page","link":"https:\/\/cardiocases.com\/fr\/pacing-defibrillation\/basic-concepts\/icd\/shocks-in-vf-zone\/","title":{"rendered":"Chocs \u00e9lectriques en zone de FV"},"content":{"rendered":"
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Chocs \u00e9lectriques en zone de FV<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t
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Chocs \u00e9lectriques dans la zone VF<\/strong><\/p>

Les d\u00e9fibrillateurs ont \u00e9t\u00e9 historiquement d\u00e9velopp\u00e9s pour r\u00e9duire des arythmies ventriculaires malignes par choc \u00e9lectrique. En th\u00e9orie, il est possible de distinguer le choc de cardioversion, qui correspond \u00e0 un choc de faible \u00e9nergie synchronis\u00e9 sur la pente ascendante de l\u2019onde R de l\u2019EGM, du choc de d\u00e9fibrillation, qui correspond \u00e0 un choc de forte \u00e9nergie non synchronis\u00e9. En effet, dans la zone de fibrillation ventriculaire, la synchronisation est parfois impossible devant l\u2019instabilit\u00e9 des ventriculogrammes. En pratique, les diff\u00e9rents d\u00e9fibrillateurs cherchent toujours \u00e0 se synchroniser sur l\u2019onde R m\u00eame en zone de FV.<\/p>

L\u2018effet d\u2019un choc \u00e9lectrique varie en fonction de l\u2019\u00e9nergie d\u00e9livr\u00e9e. Pour une \u00e9nergie faible, de l\u2019ordre du Joule, le choc \u00e9lectrique en p\u00e9riode vuln\u00e9rable peut induire une arythmie. La valeur sup\u00e9rieure de vuln\u00e9rabilit\u00e9 correspond \u00e0 l\u2019\u00e9nergie la plus faible, appliqu\u00e9e en p\u00e9riode vuln\u00e9rable ventriculaire, qui n\u2019entraine pas de fibrillation ventriculaire. Cette valeur est corr\u00e9l\u00e9e au seuil de d\u00e9fibrillation. La probabilit\u00e9 de r\u00e9duction augmente ensuite suivant une courbe de probabilit\u00e9 exponentielle en fonction de l\u2019amplitude du choc d\u00e9livr\u00e9 (synchronis\u00e9 sur l\u2019onde R). A partir d\u2019une certaine valeur, le risque de r\u00e9induire une arythmie augmente \u00e9galement limitant les chances de succ\u00e8s de la th\u00e9rapie. Un choc d\u2019amplitude trop importante peut l\u00e9ser les tissus myocardiques.\u00a0<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t

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L\u2019\u00e9nergie stock\u00e9e puis d\u00e9livr\u00e9e par un d\u00e9fibrillateur r\u00e9pond \u00e0 la formule suivante :<\/p>

\u00e9nergie stock\u00e9e = \u00bd CV<\/em>o\u00f9 C = capacit\u00e9 et V = tension ;<\/p>

Diverses caract\u00e9ristiques de la forme d'onde de choc, du vecteur de choc, de l'amplitude du choc et du nombre de chocs d\u00e9livr\u00e9s d\u00e9terminent le succ\u00e8s de la d\u00e9fibrillation et peuvent \u00eatre programm\u00e9es ou non.<\/p>

Plusieurs variables relatives \u00e0 la forme d'onde du choc, sa polarit\u00e9, son vecteur et son amplitude, ainsi que le nombre de chocs d\u00e9livr\u00e9s sont programmables selon les fabricants.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t

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Forme d'onde de choc<\/strong><\/p>

Longtemps monophasique, l\u2019onde de choc est devenue biphasique dans les d\u00e9fibrillateurs modernes, ce qui permet d'abaisser les seuils de d\u00e9fibrillation. La premi\u00e8re phase d\u2019un choc biphasique est \u00e9quivalente \u00e0 celle d\u2019un choc monophasique avec toutefois une masse critique moindre ; la seconde phase ram\u00e8ne le potentiel membranaire le plus pr\u00e8s possible de z\u00e9ro pour \u00e9viter une r\u00e9induction de tachycardie ou fibrillation ventriculaire. La forme de l'onde (mono ou biphasique) est programmable en fonction des constructeurs. En nominal, l\u2019onde de choc est biphasique et il n\u2019est pas conseill\u00e9 de modifier cette programmation m\u00eame en pr\u00e9sence de seuils de d\u00e9fibrillation \u00e9lev\u00e9s, les seuils \u00e9tant plus \u00e9lev\u00e9s pour un choc monophasique mais surtout le risque de r\u00e9induction \u00e9tant plus important.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t

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Polarit\u00e9 du choc<\/strong><\/p>

Deux polarit\u00e9s sont possibles ; un choc anodal correspond \u00e0 un choc avec l'\u00e9lectrode ventriculaire droite comme anode dans la premi\u00e8re phase d'un choc biphasique et comme cathode dans la seconde phase ; en revanche, un choc cathodal correspond \u00e0 un choc avec l'\u00e9lectrode ventriculaire droite comme cathode dans la premi\u00e8re phase d'un choc biphasique et comme anode dans la seconde phase. La polarit\u00e9 nominale des chocs des dispositifs Medtronic, Abbott et Microport CRM-Sorin est anodale. En revanche, elle est cathodique dans les dispositifs Biotronik et Boston Science. La sup\u00e9riorit\u00e9 d'une polarit\u00e9 donn\u00e9e (anodale ou cathodique) est encore d\u00e9battue, la nature probabiliste de la d\u00e9fibrillation rendant les \u00e9tudes cliniques comparant ces 2 polarit\u00e9s tr\u00e8s difficiles \u00e0 r\u00e9aliser. La litt\u00e9rature sugg\u00e8re que les seuils de d\u00e9fibrillation peuvent \u00eatre plus bas avec une \u00e9lectrode ventriculaire droite utilis\u00e9e comme anode pour la premi\u00e8re phase d'un choc biphasique, en particulier lorsque le DFT est \u00e9lev\u00e9. Selon le fabricant, la polarit\u00e9 peut ou non \u00eatre invers\u00e9e pendant l'administration d'une s\u00e9rie de chocs.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t

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Vecteur de choc<\/strong><\/p>

La programmation de ce param\u00e8tre d\u00e9pend du nombre d'\u00e9lectrodes de choc disponibles. Le choc de d\u00e9fibrillation est d\u00e9livr\u00e9 via une d\u00e9rivation d\u00e9di\u00e9e, qui peut \u00eatre une simple bobine (une \u00e9lectrode de d\u00e9fibrillation ou une bobine plac\u00e9e dans le ventricule droit) ou une double bobine (une \u00e9lectrode de d\u00e9fibrillation distale plac\u00e9e dans le ventricule droit et une \u00e9lectrode de d\u00e9fibrillation plus proximale plac\u00e9e dans la veine cave sup\u00e9rieure). Les chocs \u00e0 simple bobine sont d\u00e9livr\u00e9s entre la bobine distale de la sonde ventriculaire droite et la canette, tandis que les chocs \u00e0 double bobine sont d\u00e9livr\u00e9s entre 1) la bobine distale, 2) la bobine proximale et 3) le g\u00e9n\u00e9rateur d'impulsions. Avec une \u00e9lectrode \u00e0 double bobine, le vecteur de choc peut \u00eatre modifi\u00e9 en incluant ou en excluant l'\u00e9lectrode proximale dans la veine cave sup\u00e9rieure ou en excluant le g\u00e9n\u00e9rateur d'impulsions (bo\u00eete froide). La plus grande efficacit\u00e9 de d\u00e9fibrillation apport\u00e9e par une \u00e9lectrode \u00e0 double bobine est actuellement d\u00e9battue. L'orientation du vecteur de choc doit couvrir uniform\u00e9ment le ventricule gauche ; ce vecteur d\u00e9pend de la position de la (des) bobine(s) de d\u00e9fibrillation et du g\u00e9n\u00e9rateur d'impulsions par rapport au coeur. La bobine ventriculaire droite distale doit \u00eatre enti\u00e8rement contenue dans la cavit\u00e9 ventriculaire, tandis que la bobine proximale d'une \u00e9lectrode \u00e0 double bobine doit \u00eatre plac\u00e9e suffisamment haut pour \u00e9viter la dissipation du courant au niveau de la cavit\u00e9 auriculaire droite. Le placement de la bobine proximale \u00e0 l'int\u00e9rieur de la veine cave sup\u00e9rieure peut s'av\u00e9rer difficile. Si elle flotte dans l'oreillette droite, il peut \u00eatre pr\u00e9f\u00e9rable d'utiliser la sonde comme une simple bobine.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t

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Amplitude du choc<\/strong><\/p>

Dans la zone de FV, l'intensit\u00e9 du premier choc et des chocs suivants est g\u00e9n\u00e9ralement programm\u00e9e \u00e0 la valeur la plus \u00e9lev\u00e9e que l'appareil est capable de d\u00e9livrer. La programmation de l'amplitude du choc de d\u00e9fibrillation peut \u00eatre guid\u00e9e par le seuil de d\u00e9fibrillation, d\u00e9fini comme la plus petite quantit\u00e9 d'\u00e9nergie permettant de convertir la FV en rythme sinusal. Selon le fabricant, l'amplitude correspond \u00e0 la quantit\u00e9 d'\u00e9nergie d\u00e9livr\u00e9e ou stock\u00e9e.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>","protected":false},"excerpt":{"rendered":"

Shocks in VF zone Electrical shocks in VF zone Defibrillators were originally developed to terminate life-threatening ventricular arrhythmias with an electrical shock. Cardioversion, which consists of delivering a low-energy shock synchronized to the upstroke of the R wave of an EGM, is distinguished from defibrillation, which consists of delivering a non-synchronized, high-energy shock. In the […]<\/p>","protected":false},"author":1,"featured_media":0,"parent":19,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-176","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"\nICD Shocks in VF Zone | Programming | Cardiocases<\/title>\n<meta name=\"description\" content=\"ICD shock therapy in VF zone \u2014 energy, waveform, polarity, committed vs uncommitted shocks & ECG tracings.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/cardiocases.com\/fr\/pacing-defibrillation\/basic-concepts\/icd\/shocks-in-vf-zone\/\" \/>\n<meta property=\"og:locale\" content=\"fr_FR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"ICD Shocks in VF Zone | Programming | Cardiocases\" \/>\n<meta property=\"og:description\" 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