Assistance circulatoire périphérique au cours des intoxications aiguës par cardiotropes

Despite significant improvement in critical care, drug-induced cardiovascular failure remains a leading cause of death. Usually, severe cardiotoxicity appears either at presentation or during the course of poisoning with the sudden onset of hypotension, intraventricular and high-degree atrioventricular block, asystole, pulseless ventricular tachycardia or fibrillation. Supportive and antidotal treatments are usually efficient. However, ventricular arrhythmia, sudden cardiac arrest and refractory cardiovascular failure may cause death, despite aggressive resuscitative measures, vasopressors and antidotes. The interest of ventricular pacing can only be considered if the inotropic heart function is preserved. Similarly, the interest of intra-aortic balloon pumps appears limited due to the need for intrinsic cardiac rhythm for synchronization and diastolic augmentation. Thus, reversibility of drug-associated refractory cardiac failure despite prolonged arrest makes extracorporeal life support (ECLS) promising, although it should still be classified as weak recommendation, as only based on case reports and small series. Once implemented, ECLS purpose is to take over heart function until recovery can occur, thus minimizing myocardial work, improving organ perfusion and maintaining the renal and biliary elimination of the toxicant. However, predictive factors predictive of refractoriness to conventional treatments are lacking. Moreover, femoral cannulation for ECLS remains an invasive technique, not lacking in potential risks. We thus believe that this technique should only be performed by trained multidisciplinary medicosurgical teams. In conclusion, due to the persistence of a high-rate mortality following cardiotoxicant poisonings, there is a clear need for a more aggressive management in patients not responding to conventional treatments. Clarification of prognosticators of refractoriness to conventional treatment remains thus mandatory.