» – OAP unilatéral… hum… qu’est-ce que vous me racontez là ??! vous ne voulez pas que j’aille chercher la couverture antibiotique dans la réserve pour traiter sa pneumonie par hasard ?
– nan, nan je te jure ça existe, viens voir… »
Avant que j’apprenne l’échographie cardiaque, un OAP unilatéral me paraissait relever de la science-fiction. Aujourd’hui j’essaye de m’intéresser plus finement au coeur des patients et l’échographie m’ouvre les yeux.
En fait l’oedème aigu pulmonaire d’origine cardiaque peut très rarement se manifester de façon unilatérale. Cette bizarrerie survient lorsque la valve mitrale fuit sévèrement. Si le flux de régurgitation est massivement orienté vers une veine pulmonaire, il est possible que la surcharge hémodynamique se focalise dans un seul poumon. Il semble que ça soit plus souvent à droite. Ceci peut notamment se produire lorsqu’il existe un prolapsus sévère du feuillet postérieur de la valve mitrale.
http://youtu.be/CVTy6T8muHw
L’oedème peut même être suspendue au lobe supérieur alors qu’usuellement la surcharge s’exprime plus dans les bases des poumons.
En dehors du côté éblouissant de cette physiopath’ c’est quand même intéressant de se souvenir que cette entité existe car elle mime souvent une pneumonie cognée qui n’évolue pas favorablement. Les patients ont plus souvent une pression artérielle basse avec des recours à des amines d’après l’article d’Attias et al. Cette opacité suspendue peut donc tout à fait mimer une pneumonie sévère et l’auscultation cardiaque et l’échographie vous aideront à redresser le diagnostic.
Rigolo non ?
Philippe a publié un cas clinique d’OAP unilatéral sur son blog.
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5 réponses sur « L’OAP unilatéral »
Ça existait aussi dans les débuts de l’ablation atriale quand le trait d’ablation passait dans les veines pulmonaires. Une des complications était alors la sténose d’une ou plusieurs veines pulmonaires avec des OAP localisés au territoire de drainage de la veine sténosée.
Sinon on peut toujours trouver des causes exceptionnelles comme des myxomes atriaux gauches. L’écho systématique conduit parfois à des découvertes inattendues, il faut savoir regarder même ce qu’on a pas l’habitude de voir.
Hello,
D’une façon plus générale, je vous invite à lire cet article de Collins publié en septembre 2013 dans A&A : « The endothelial glycocalix : emerging concepts in pulmonary edema and lung injury. » Vous comprendrez que le mécanisme de l’OAP n’est pas simplement « hydrostatique » mais plus complexe. Le concept de Starling doit être adapté en fonction de cette couche qui tapisse l’endothelium : le glycocalix.
Merci pour les billets toujours stimulants !
A plus !
merci d’être passé par ici, je pense souvent à vous les copains
bye
Et l’OAP prédominant à droite s’explique d’autant mieux que le drainage lymphatique s’effectue principalement à gauche (canal thoracique/lymphatique), et donc un OAP avec épanchement pleural sera drainé plus rapidement à gauche je pense !
oui cette hypothèse est avancée dans les articles