Traitement de recours dans l’insuffisance cardiaque avancée

Lavoisier - 2015
D. Guijarro1, T. Lepoivre2, J.-P. Gueffet1, S. Pattier1, M. Michel1, J.-C. Roussel3, J.-N. Trochu1
1Service de cardiologie, hôpital Guillaume-et-René-Laennec, CHU de Nantes, Saint-Herblain, France
2Service d’anesthésie–réanimation, hôpital Guillaume-et-René-Laennec, CHU de Nantes, Saint-Herblain, France
3Service de chirurgie cardiaque et thoracique, hôpital Guillaume-et-René-Laennec, CHU de Nantes, Saint-Herblain, France

Tóm tắt

L’insuffisance cardiaque (IC) à fonction systolique altérée est une pathologie dont la mortalité reste élevée malgré les progrès du traitement médicamenteux des dernières décennies. Les patients connaissent généralement, au-delà de la période diagnostique de la maladie, une stabilisation clinique de plusieurs années. Une dégradation de l’IC au cours du temps peut entraîner une limitation fonctionnelle importante, un retentissement systémique important (dénutrition, insuffisance rénale), particulièrement en cas de congestion non maîtrisée. Cet état qualifié d’insuffisance cardiaque avancée (ICA) est souvent difficile à reconnaître pour le clinicien, alors qu’il s’agit d’une période charnière où le projet thérapeutique à plus long terme doit être envisagé précocement pour juger de l’éligibilité du patient à des soins lourds que sont la greffe cardiaque, l’implantation d’une assistance ventriculaire gauche. Le poids des comorbidités, le statut psychosocial et le retentissement de l’IC sur l’organisme conditionnent en effet les résultats de ces thérapeutiques. Les épisodes de décompensations aiguës avec états de choc cardiogénique et défaillance multiviscérale peuvent relever d’une prise en charge en réanimation vers un traitement invasif de la défaillance cardiaque par l’implantation de dispositif d’assistance mécanique et/ou une transplantation cardiaque en urgence. Après un rappel de la définition de l’ICA, nous aborderons les indications de prise en charge en réanimation des patients en état de choc cardiogénique, les thérapeutiques de support que l’on propose en réanimation et nous discuterons des conditions de réalisation des soins de long terme que sont la greffe cardiaque et l’assistance circulatoire.

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