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Assistance circulatoire en réanimation

Circulatory support in the intensive care unit

  • Enseignement Supérieur en Réanimation
  • Médecin
  • Published:
Réanimation

Résumé

Les progrès technologiques accomplis depuis la fin des années 1990 ont conduit à l’amélioration de la survie des patients bénéficiant d’une assistance circulatoire à long terme pour insuffisance cardiaque terminale. Cela a suscité un engouement croissant pour toutes les techniques d’assistance circulatoire. Cette revue expose les principaux dispositifs d’assistance disponibles actuellement en France, leurs avantages et inconvénients respectifs et discute la stratégie de prise en charge globale des patients les plus graves, en choc cardiogénique réfractaire au traitement médical optimal. Chez ces patients, l’assistance circulatoire peut se décliner en deux étapes : 1) mise en place rapide d’une assistance dès l’indication posée, en privilégiant les dispositifs d’implantation aisée et les moins coûteux qui doivent permettre d’attendre (quelques semaines) soit la récupération myocardique, soit la mise en place d’une assistance de plus longue durée, soit la transplantation cardiaque. Il s’agit du ballon de contrepulsion intra-aortique, du système Impella® (pompe axiale ventriculaire gauche) ou de l’ECMO (extracorporeal membrane oxygenation); 2) après examen attentif des possibilités de récupération myocardique ou de celles de transplantation, mise en place d’une assistance de type « coeur artificiel » pour une durée plus longue (quelques mois, voire quelques années), autorisant parfois le retour à domicile et une vie sociale de qualité. Ces coeurs artificiels ne s’implantent que dans des centres spécialisés experts, disposant d’un plateau multidisciplinaire suffisant : il s’agit d’une thérapeutique d’exception. Il existe de nombreux modèles de « coeurs artificiels », ceux apportant une assistance monoventriculaire gauche ou biventriculaire, ceux implantables dans le thorax du patient (hormis l’alimentation en énergie) [de type CardioWest®] ou restant à l’extérieur et reliés au coeur par des canules. De nouvelles pompes électromagnétiques axiales ou centrifuges à flux continu, totalement implantables (hormis l’alimentation) et moins bruyantes sont en cours de développement et pourraient constituer une avancée importante dans le traitement de la défaillance monoventriculaire gauche.

Abstract

Since the late 90s, technological advances have led to an improvement in survival rates in patients receiving long-term circulatory support for terminal heart failure. As a result, there has been an increased interest in all circulatory support techniques. This review outlines the main support devices currently available in France, their respective advantages and disadvantages, and discusses the management of patients who are suffering from severe cardiogenic shock unresponsive to optimal medical treatment. For these patients, circulatory support can be split into two stages : (1) The rapid implementation of support, focusing on the easier-to-implant and less expensive devices, which will allow time (several weeks) for one of the following : myocardial recovery, implementation of a longer-term support solution, and a heart transplant. These devices include intraaortic balloon pump, Impella® system (left ventricular axial pump), and extracorporeal membrane oxygenation (EMCO). (2) After careful consideration of the possibility of either myocardial recovery or a heart transplant, implementation of long-term cardiac support (for several months or even a few years) via an “artificial heart” may allow patients to return home and regain a certain amount of normality to their life. This is an exceptional treatment; artificial hearts are only implanted in specialized centers, providing the necessary multidisciplinary expertise. There are a number of artificial heart models available, including those that provide monoventricular (left) or biventricular support, those implanted directly into the chest (excluding the power supply) (e.g., CardioWest®), and others that are external to the patient, which are connected to the heart via cannulae. New, completely implantable (apart from the power supply), less noisy axial or centrifugal continuous flow pumps are being developed, representing a significant advance in the treatment of left ventricular failure.

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Authors and Affiliations

  1. Chirurgie thoracique et cardiovasculaire, CHU de Rennes, Rennes, France

    E. Flécher

  2. Service d’anesthésie-réanimation 2, CHU de Rennes, Rennes, France

    P. Ménestret

  3. Réanimation CERIC, clinique Ambroise-Paré, 27, boulevard Victor-Hugo, F-92200, Neuilly-Sur-Seine, France

    P. Squara

Authors
  1. E. Flécher
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  2. P. Ménestret
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  3. P. Squara
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Correspondence to P. Squara.

Additional information

Cet article correspond à la conférence faite par l’auteur au congrès de la SRLF 2012 dans la session: Technologies du futur.

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Flécher, E., Ménestret, P. & Squara, P. Assistance circulatoire en réanimation. Réanimation 21 (Suppl 2), 445–454 (2012). https://doi.org/10.1007/s13546-011-0421-1

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  • DOI: https://doi.org/10.1007/s13546-011-0421-1

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