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Dysfonction cardiaque au cours du sepsis : mythe ou réalité ?

Cardiac dysfunction in sepsis: Myth or reality?

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Réanimation

Résumé

L’atteinte cardiaque induite par le sepsis sévère et le choc septique est systématique et réversible. Elle touche la fonction systolique et diastolique des deux ventricules. Le diagnostic repose principalement sur l’échocardiographie doppler. Les paramètres de fonction cardiaque utilisés en routine dépendent des conditions de charge ventriculaire, et notamment de la postcharge. C’est pourquoi une évaluation hémodynamique répétée est nécessaire à la phase aiguë du choc septique. La fréquence de la dysfonction systolique jugée sur la fraction d’éjection du ventricule gauche (FEVG) en échocardiographie varie entre 27 et 67 % des cas. Elle ne semble pas être associée à la survie comme suggéré initialement, tout comme la dilatation ventricule gauche (VG) dès lors que la taille de cavité ventriculaire est indexée à la surface corporelle. En revanche, l’hyperkinésie VG, qui reflète une vasoplégie intense, pourrait être un signe de gravité. L’anomalie de relaxation du VG est observée dans 37 à 62 % des cas. Elle semble constituer un facteur de mauvais pronostic indépendant, sous réserve de confirmer la validité externe des études publiées. La dysfonction ventriculaire droite est également décrite au cours du choc septique, qu’il existe une insuffisance respiratoire aiguë associée ou non. Elle peut être particulièrement sévère en cas de syndrome de détresse respiratoire aiguë chez un patient sous ventilation mécanique. Des études portant sur de larges cohortes sont nécessaires pour établir ou confirmer le rôle pronostique de la cardiomyopathie septique et personnaliser la prise en charge des patients en choc septique en fonction du profil de la défaillance cardiocirculatoire.

Abstract

Severe sepsis and septic shock systematically result in a cardiac impairment, which involves the systolic and diastolic function of both ventricles. Diagnosis mainly relies on doppler echocardiography. Parameters of cardiac function routinely used on clinical grounds are loaddependent and are particularly sensitive to afterload. Accordingly, serial hemodynamic assessments should be performed if necessary during the initial management of septic shock. The frequency of systolic dysfunction assessed using left ventricular (LV) ejection fraction ranges from 27 to 67% of patients. It does not appear to be associated with survival as initially suggested, such as LV dilatation, when the ventricular cavity size is indexed to body area. In contrast, LV hyperkinesia that reflects underlying profound vasoplegia could be a warning sign. Abnormal LV relaxation is observed in 37–62% of septic patients. Published studies suggest that it could be an independent predictor of death pending further external validation confirmation. Right ventricular dysfunction is also observed in patients with septic shock, irrespective of the presence of associated acute respiratory failure. Severe presentation may be encountered especially in patients with sepsis-associated acute respiratory distress syndrome who are under positive-pressure ventilation. Further large-scale studies including large cohorts of patients are required to establish or confirm the prognostic role of septic cardiomyopathy, and to tailor the acute management of septic shock patients according to their hemodynamic profile.

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  1. Réanimation polyvalente, CHU Dupuytren, 2, avenue Martin-Luther-King, F-87042, Limoges, CIC-P 1435, Limoges, France

    E. Begot & P. Vignon

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  1. E. Begot
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  2. P. Vignon
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Begot, E., Vignon, P. Dysfonction cardiaque au cours du sepsis : mythe ou réalité ?. Réanimation 25, 340–347 (2016). https://doi.org/10.1007/s13546-015-1166-z

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