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https://tel.archives-ouvertes.fr/tel-01124196
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Caractérisation physiopathologique et pharmacologique
d’un modèle porcin de dysfonction diastolique avec
éjection préservée.
Mario Rienzo
To cite this version:
Mario Rienzo. Caractérisation physiopathologique et pharmacologique d’un modèle porcin de dys-fonction diastolique avec éjection préservée.. Médecine humaine et pathologie. Université Paris-Est, 2013. Français. �NNT : 2012PEST0072�. �tel-01124196�
UNIVERSITE PARIS-EST
ECOLE DOCTORALE : SCIENCES DE LA VIE ET DE LA SANTƒ
PïLE : PHARMACOLOGIE et BIOTHƒRAPIES
ANNƒE : 2013
SERIE DOCTORAT N¡
THéSE
PrŽsentŽe
Ë LÕUNITƒ DE FORMATION ET DE RECHERCHE
FACULTE DE MEDECINE PARIS-EST
pour lÕobtention du grade de
DOCTEUR DE LÕUNIVERSITƒ PARIS-EST
par
Monsieur Mario RIENZO
CARACTERISATIONS PHYSIOPATHOLOGIQUE ET
PHARMACOLOGIQUE DÕUN MODELE PORCIN DE DYSFONCTION
DIASTOLIQUE AVEC EJECTION PRESERVEE
soutenue le 26 novembre 2013
JURY:
Mr. le Pr A. BERDEAUX
PrŽsident du jury
Mme. le Dr Jane-Lise SAMUEL
Rapporteur
Mr. le Pr Xavier MONNET
Rapporteur
Mr. le Pr Jean Jacques MERCADIER
Examinateur
Mr. le Pr Bernard CHOLLEY
Examinateur
Ë mes grands-parents Maddalena et Salvatore, Maria Luigia et Giuseppe
Ë mes parents A ngela et A ntonio
Ë ma sÏur Marilisa
Ë mon neveu A ndrea
Time is a necessary representation on which all intuitions depend. We cannot take away time from phenomena in general, though we can well take away phenomena out of time. Time therefore is given a priori. In time alone is reality of phenomena possible.
Immanuel Kant
The true discovery trip is not to search for new land, but to see with new eyesight.
Fran•ois-Marie A rouet (V oltaire)
DonÕt only practice your art, but force your way into its secrets, for it and knowledge can rise men to the Divine
Ludwig van Beethoven
"Staying young requires the unceasing cultivation of the ability to unlearn old falsehoods."
Robert A nson Heinlein
The mind is like a parachute; it only functions when it's open.
JÕadresse tous mes remerciements,
A Monsieur le Professeur Alain Berdeaux,
pour mÕavoir ouvert les portes de son laboratoire dans un moment pas tr•s facile de ma vie professionnelle,
pour la gentillesse quÕil a manifestŽe ˆ mon Žgard tout au long de mon parcours de thŽsard, pour la confiance quÕil mÕa accordŽe au dŽmarrage de ce projet,
quÕil re•oive ici lÕexpression de ma profonde gratitude.
A Madame le Docteur Jean-Lise Samuel,
qui mÕa dŽjˆ questionnŽ sur Ç mon È sujet dans le cadre des journŽes de la SociŽtŽ Fran•aise dÕHypertension et qui aujourdÕhui a bien voulu acceptŽ dÕ•tre rapporteur de ce travail de th•se,
quÕelle trouve ici lÕexpression de ma reconnaissance et de ma sinc•re gratitude.
A Monsieur le Professeur Xavier Monnet,
pour avoir acceptŽ, sans me connaitre, ma collaboration de jeune interne lors de mon arrivŽe en France,
pour avoir manifestŽ envers moi son estime personnelle et professionnelle au fil du temps, pour avoir acceptŽ dÕ•tre rapporteur de ce travail
quÕil trouve ici lÕexpression de ma sinc•re et amicale gratitude.
A Monsieur le Professeur Jean Jacques Mercadier
qui a suivi mon parcours scientifique d•s le dŽbut, Žtant responsable pŽdagogique du Master 2, pour avoir acceptŽ de faire partie de ce jury,
qu'il trouve ici l'expression de ma reconnaissance et de ma sinc•re gratitude.
A Monsieur le Professeur Bernard Cholley,
pour avoir acceptŽ de me rencontrer et me permettant ainsi dÕŽcrire une Ç autre page È de ma vie professionnelle,
pour avoir acceptŽ de faire partie de ce jury,
qu'il trouve ici l'expression de ma reconnaissance et de ma sinc•re gratitude.
A Monsieur le Professeur Bijan Ghaleh-Marzban,
pour avoir menŽ le bateau dans des Ç eaux pŽrilleuses È et acceptŽ ouvertement la confrontation avec moi, pas toujours dŽtendue,
pour les nombreuses discussions, non seulement scientifiques, qui ont caractŽrisŽ les sŽances dÕŽcriture des papiers et du prŽsent manuscrit,
pour le lien dÕamitiŽ qui sÕest progressivement installŽ entre nous, je souhaite lui exprimer ma profonde reconnaissance et mon attachement.
A mes amis de Ç lÕŽquipe porc È Alain BizŽ, Lucien Sambin, Jonathan Melka, Dyonissis Pongas et Hon Lai Chan : sans leur collaboration et soutien rien de tout cela aurait ŽtŽ possible.
A mes amis de Ç lÕŽquipe lapin È Fanny Lidouren, Mourad Chenoune, Nicolas Couvreur, Lys Darbera, Mathias Kohlhauer, Renaud Tissier pour leur soutien et ouverture dÕesprit.
A tous les autres membres de lÕEquipe 03 Sandrine Pons, StŽphanie Michineau, Roland Zini, JinBo Su, Hubert Dabire, Camille Bouissou-Schrtz, Alexandra dÕAnglemont de Tassigny, Bela•d Bouhemad, Mathieu Jozwiak, Saadia Karim, Sandrine Bonizec, StŽphanie Paradis, ValŽrie Martin, Rana Assaly, Lolita Portal, Romain Long, Didier Morin, Sophie Nunez, Corinne Deschenes, Lydie Laure, Luca Zilberstein, Valerie Chetboul, Vassiliki Gouni, Roberto Motterlini, Roberta Foresti, Philippe Lecorvoisier, Luc Hittinger pour leur gentillesse et accueil chaleureux.
En ce tournant de ma vie je tiens tout particuli•rement ˆ exprimer ma profonde affection et ma reconnaissance ˆ ceux que je consid•re mon trŽsor humain:
mes amis dÕenfance avec qui jÕai grandi et muri ;
mes amis et coll•gues avec qui jÕai eu lÕhonneur et le plaisir de partager ma vie : merci pour mÕavoir appuyŽ et soutenu quand les nuages ont occupŽ lÕhorizon ;
les figures socratiques qui ont pointillŽ ma vie et ont fa•onnŽ par leur dŽmarche mon esprit; Sylvie, Claude, Antoine, Armelle, Charlotte, CŽline et Charlotte qui mÕont accueilli.
! "!
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&00!1!american college of cardiology!
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)#0!1!european society of cardiology!
.%?8!1!IG=A5C;A>!E5A5BJ5CBJ=:>!878H;MG>!
NO<?)O!1!heart failure with preserved ejection fraction!
NO<9)O!1!heart failure with reduced ejection fraction!
'0<O)B!1!;ACGPP;C=A8>!8=93;=MG>!Q!P9=8:;5A!3R4S>8:;5A!B94C>9@4>! '0<O)9!1!;ACGPP;C=A8>!8=93;=MG>!Q!P9=8:;5A!3R4S>8:;5A!943G;:>! ')0!1!;AJ;T;:>G9!3>!HR>AU7E>!3>!85A@>9C;5A!3>!HR=AI;5:>AC;A>! '(%!1!;E=I>9;>!B=9!94C5A=A8>!E=IA4:;MG>! %N0!1!E75C;A!J>=@7!8J=;A! %%?C!1!%4:=HH5B95:4;A=C>C!
VN/W'!1!National Heart, Lung and Blood Institute!
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6
LISTE DES FIGURES ET DES TABLEAUX
Figure 1 : DiffŽrentes subdivisions et phases du cycle cardiaque 13
Figure 2 : Mod•le expŽrimental dÕErnest Starling 17
Figure 3 : Graphiques input-output de la performance cardiaque globale et plus
particuli•re-ment du ventricule gauche 18
Figure 4 : La fonction cardiaque reprŽsentŽe par les courbes pression-volume 19
Figure 5 : Courbes pression-volume et Žlastance 20
Figure 6 : ExpŽriences de Ôtwitch contractionÕ sur un muscle papillaire de chat : relations
longueur-temps (l/lmax) et force-temps (mN) 22
Figure 7 : Graphiques illustrant les effets dÕun clampage total de lÕaorte ˆ diffŽrents phases de
lÕŽjection (prŽcoce, intermŽdiaire, tardive) 24
Figure 8 : Division du cycle cardiaque en tant que pompe musculaire et courbe
pression-volume correspondante 27
Figure 9 : Relation entre la pression et le volume ventriculaires gauche 32
Figure 10 : Crit•res Žchocardiographiques Doppler pour la classification de la dysfonction
diastolique 35
Figure 11 : PrŽvalence de lÕinsuffisance cardiaque en fonction de lÕorigine gŽographique 46 Figure 12 : Droites dÕŽlastance tŽlŽ-systolique (Ees) 59
Figure 13 : Couplage des rigiditŽs ventriculaire et artŽrielle 59
Figure 14 : Paradigme temporel de la progression de lÕinsuffisance cardiaque chronique
64
Figure 15 : Instrumentation des animaux 84
Figure 16 : SchŽma illustrant le principe de la mesure de la contractilitŽ rŽgionale par la
technique de la sonomicromŽtrie 86
Figure 17 : Courbe dose-rŽponse ˆ lÕangiotensine II 91
Figure 18 : Protocole expŽrimental 92
Figure 19 : Evolution de la pression artŽrielle moyenne chez les animaux traitŽs par
angiotensine II 93
7
Figure 21 : Relation entre temps de relaxation isovolumique et frŽquence cardiaque 99
Figure 22 : LÕŽjection chez les animaux traitŽs par angiotensine-II 99
Figure 23 : Relation entre temps de contraction isovolumique et frŽquence cardiaque 101 Figure 24 : Relation entre le temps de contraction isovolumique et le triple produit [(Pression
VG)*FC*dP/dtmax] en rŽponse ˆ la perfusion de dobutamine 102
Figure 25 : Relation entre temps de contraction et relaxation isovolumiques 103
Figure 26 : Evaluation des temps dÕŽjection, de remplissage, de contraction isovolumique et
de relaxation isovolumique ˆ J0 et ˆ J28 109
Figure 27 : Evaluation des temps dÕŽjection, de remplissage, de contraction isovolumique et
de relaxation isovolumique ˆ J0 sans ivabradine et ˆ J28 avec ivabradine 110
Figure 28 : Evaluation des temps dÕŽjection, de remplissage, de contraction isovolumique et
de relaxation isovolumique pendant lÕadministration de dobutamine ˆ J0 sans ivabradine et ˆ
J28 avec ivabradine 110
Tableau 1 : Valeurs normales des indices Žvaluant la fonction diastolique par Doppler 34 Tableau 2 : PrŽvalence des sympt™mes et des signes dÕinsuffisance cardiaque dans lÕIC-FEr
(systolic HF) et dans lÕIC-FEp (diastolic HF) 42
Tableau 3 : Param•tres hŽmodynamiques des porcs perfusŽs par ATII 94
Tableau 4 : Param•tres hŽmodynamiques des porcs perfusŽs par sŽrum physiologique 94 Tableau 5 : Intervalles de temps chez les porcs traitŽs par angiotensine-II 98
! X!
INTRODUCTION
!
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! "Y!
PARTIE
!""!
CHAPITRE I : PHYSIOLOGIE DU CYCLE
CARDIAQUE
!"*!
'[!/)!0m0/)!0&(2'&nl)!
A. Historique
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B. Les diffŽrentes phases du cycle cardiaque
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!"+! ! ! ! 2RGA!B5;A:!3>!@G>!8H;A;MG>]!8>!C5A:!H>C!T9G;:C!3>!8oG9!MG;!97:JE>A:!H>!878H>!1!=;AC;!H=!C7C:5H>! >C:!H>!:>EBC!85EB9;C!>A:9>!H>!B9>E;>9!^W"_!>:!H>!3>G6;FE>!T9G;:!^W*_]!8\>C:!Q!3;9>!>A:9>!H=!P>9E>:G9>! 3>!H=!@=H@>!E;:9=H>!<!5G@>9:G9>!3>!H=!@=H@>!=59:;MG>!>:!H=!P>9E>:G9>!3>!H=!@=H@>!=59:;MG>!<!5G@>9:G9>! 3>!H=!@=H@>!E;:9=H>!c!H=!3;=C:5H>!C>!C;:G>]!Q!H\5BB5C4]!>A:9>!H>!3>G6;FE>!T9G;:!>:!H>!B9>E;>9!3G!878H>! CG;@=A:[!/>C!T9G;:C!3>!8oG9!C5A:!>AI>A394C!A5A!C>GH>E>A:!B=9!H>C!PHG6!:G9TGH>A:C!MG;!C>!B953G;C>A:!Q! !"#$ !##$ %#$ &#$ '#$ "#$ #$ ! "# $ $ % "# &' ( ( ) * +& ()*+,-$ ./0.1$ )2134$ 5,+*/0$ ./0.1$ -0)414$ 5,+*/0$ ./0.1$ )2134$ ()*+,-$./0.1$ -0)414$ 64).)078,-$ -)3+*/-+,)3$ 9:1-+,)3$ 64).)078,-$*10/;/+,)3$ </2,=$,3>0)?$ @,/4+/4,4$ (+*,/0$AB4+)01$ ()*+,-$C*1447*1$ (+*,/0$C*1447*1$ D13+*,-70/*$C*1447*1$
Figure 1. DiffŽrentes subdivisions et phases du cycle cardiaque. En A, la subdivision en systole et diastole selon Henderson, en B selon Wiggers, en C selon la dŽfinition utilisŽe en clinique humaine et en D selon la subdivision modifiŽe de Wiggers. La petite ligne verticale sur le tracŽ de la pression ventriculaire avant la fermeture de la valve aortique indique le dŽbut de lÕintervalle intermŽdiaire selon la subdivision de Wiggers. En E, le cÏur est considŽrŽ comme un syst•me muscle-pompe intŽgrŽ, o• la contraction et la relaxation constituent deux phases de la systole. Les traits verticaux au milieu de lÕŽjection indiquent que la transition de la contraction ˆ la relaxation ne peut •tre facilement identifiŽe. Ainsi, la relaxation iso-volumique et la succion font partie de la phase de relaxation de la pompe musculaire. (dÕapr•s Brutsaert, 1989)
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1- La contraction isovolumique
/=! 85A:9=8:;5A! ;C5@5HGE;MG>! 34TG:>! =@>8! H=! P>9E>:G9>! 3>! H=! @=H@>! E;:9=H>! >:! C\=8JF@>! =@>8! H\5G@>9:G9>! 3>! H=! @=H@>! =59:;MG>]! H>! @5HGE>! >C:! =H59C! 85AC:=A:[! &;AC;! :5G:>C! H>C! P598>C! 85A:9=8:;H>C! 8>A:9;BF:>C! =BBH;MG4>C! B=9! H>! E758=93>! =T5G:;CC>A:! Q! GA>! 4H4@=:;5A! 9=B;3>! 3>! H=! B9>CC;5A! @>A:9;8GH=;9>!I=G8J>[!
2- L'Žjection ventriculaire
2FC!MG>!H=!B9>CC;5A!@>A:9;8GH=;9>!I=G8J>!34B=CC>!H=!B9>CC;5A!=59:;MG>]!H\;A@>9C;5A!3G!I9=3;>A:! 3>! B9>CC;5A! 5G@9>! H=! @=H@>! =59:;MG>[! 0>HH><8;! E=9MG>! H=! P;A! 3>! H=! 85A:9=8:;5A! ;C5@5HGE;MG>! >:! H>! 34TG:! 3>! H\4S>8:;5A[! /=! 85A:9=8:;5A! 3G! E758=93>! >C:! E=;A:>A=A:! =G65:5A;MG>]! H>C! 8=93;5E7587:>C! 8J=AI>=A:! H>G9! H5AIG>G9! >:! H=! P598>! 34@>H5BB4>!c! H=! B=95;! E758=93;MG>! C\4B=;CC;:! >:! C>! 9=885G98;:[! 0>C! E5G@>E>A:C! 943G;C>A:! H>! @5HGE>! 3>! H=! 8=@;:4! @>A:9;8GH=;9>! I=G8J>! >:! 4S>8:>A:! H>! C=AI! @>9C! H\=59:>!>:!H=!8;98GH=:;5A!B49;BJ49;MG>[!/>!I9=3;>A:!3>!B9>CC;5A!3>!B=9:!>:!3\=G:9>!3>!H=!@=H@>!=;AC;!MG>! H\4H=C:;8;:4!3>!H\=59:>!>:!3>C!=9:F9>C!B49;BJ49;MG>C!34:>9E;A>A:!H=!@;:>CC>!3\4S>8:;5A!3G!C=AI[!
3- Le ralentissement de l'Žjection et le dŽbut de la relaxation
&B9FC! =@5;9! =::>;A:! GA>! @=H>G9! E=6;E=H>! H59C! 3>! H\4S>8:;5A! 9=B;3>]! H=! B9>CC;5A! @>A:9;8GH=;9>! 34895Z:[!/>!8=H8;GE!87:5C5H;MG>!>C:!B95I9>CC;@>E>A:!B5EB4!B=9!H>!94:;8GHGE!C=985BH=CE;MG>!>:!H>C! E75P;T9;HH>C! >A:9>A:! >A! 9>H=6=:;5A[! /=! @;:>CC>! 3\4B=;CC;CC>E>A:! 3G! E758=93>! 3;E;AG>[! ?=9! 85AC4MG>A:]! H=! @;:>CC>! 3\4S>8:;5A! 3;E;AG>! E=;C! H\4S>8:;5A! >C:! E=;A:>AG>! >A! B=9:;>! I9v8>! Q! H=! 3;C:>AC;T;H;:4!3>!H\=59:>]!E48=A;CE>!Q!H=!T=C>!3>!H\>PP>:!p;A3w>CC>H!^W>HU!"jj-_[!2FC!MG>!H=!B9>CC;5A! @>A:9;8GH=;9>!34895Z:!=G<3>CC5GC!3>!H=!B9>CC;5A!=59:;MG>]!H\;A@>9C;5A!3G!I9=3;>A:!3>!B9>CC;5A!P>9E>!H=! @=H@>!=59:;MG>]!I4A49=A:!H>!B9>E;>9!85EB5C=A:!&*!3G!3>G6;FE>!T9G;:!3G!8oG9!^W*_[!
!"-!
4- La relaxation isovolumique
&B9FC!H=!P>9E>:G9>!3>!H=!@=H@>!=59:;MG>]!>:!B>A3=A:!H>!85G9:!;AC:=A:!MG;!B948F3>!H\5G@>9:G9>!3>! H=!@=H@>!E;:9=H>]!H>!@>A:9;8GH>!C>!9>H=6>!C=AC!8J=AI>9!3>!@5HGE>!1!8\>C:!H=!9>H=6=:;5A!;C5@5HGE;MG>[! 2FC! MG>! H=! B9>CC;5A! @>A:9;8GH=;9>! 3>C8>A3! =G<3>CC5GC! 3>! H=! B9>CC;5A! =G9;8GH=;9>! I=G8J>]! H=! @=H@>! E;:9=H>!C\5G@9>!>:!H>!9>EBH;CC=I>!@>A:9;8GH=;9>!34TG:>[!
5- Le remplissage prŽcoce (succion)
/=! BJ=C>! 3>! 9>EBH;CC=I>! CG9@>A=A:! SGC:>! =B9FC! H\5G@>9:G9>! 3>! H=! @=H@>! E;:9=H>! =CCG9>! H=! BHGC! I9=A3>! B=9:;>! 3G! 9>EBH;CC=I>!c! >HH>! >C:! B=9:;8GH;F9>E>A:! >PP;8=8>! I9v8>! Q! H=! 9>H=6=:;5A! =8:;@>! 3G! @>A:9;8GH>! MG;! B95@5MG>! GA>! `CG88;5A! @>A:9;8GH=;9>`[! /=! B9>CC;5A! @>A:9;8GH=;9>! I=G8J>! 9>3>C8>A3! T9GCMG>E>A:! >A! 3>CC5GC! 3>! H=! B9>CC;5A! =G9;8GH=;9>! I=G8J>! >:! H>! C=AI! B4AF:9>!T9GCMG>E>A:! 3=AC! H>! @>A:9;8GH>[! /=! 85ET;A=;C5A! 3>! H=! 9>H=6=:;5A! =8:;@>! 3G! E758=93>! >:! H=! B9>CC;5A! 3>! H\=PPHG6! C=AIG;A! 3;C:>A3>A:! H>C! B=95;C! 3G! @>A:9;8GH>! 1! H>! E758=93>! C\=E;A8;:]! C\4H=9I;:! >:! C\=HH5AI>[! />! 9>EBH;CC=I>! @>A:9;8GH=;9>! 9=B;3>! B>G:! =H59C! r:9>! Q! H\59;I;A>! 3\GA! :95;C;FE>! T9G;:! 3G! 8oG9! W+]! BHGC! B=9:;8GH;F9>E>A:!=G3;TH>!Q!H\>6>98;8>!5G!H59C!3\GA>!:=8J78=93;>!C;AGC=H>[!
6- La diastase
&! H\;CCG>! 3>! H=! BJ=C>! 9=B;3>! 3G! 9>EBH;CC=I>]! H>C! B9>CC;5AC! @>A:9;8GH=;9>C! >:! =G9;8GH=;9>C! C5A:! MG=C;E>A:! 4I=H>C[! />! @>A:9;8GH>! A>! C>! 9>EBH;:! MG=C;E>A:! BHGC! >:! H=! @=H@>! E;:9=H>! C>! P>9E>! B=9:;>HH>E>A:[!/>!@5HGE>!3>!H=!8=@;:4!@>A:9;8GH=;9>!A>!8J=AI>!BHGC[!0>::>!BJ=C>!3>!9>EBH;CC=I>!H>A:! @5;9>!AGH!>C:!34A5EE4>!3;=C:=C>[!
7- La contraction atriale
&!H\;CCG>!3>!H=!3;=C:=C>]!=H59C!MG>!H>!9>EBH;CC=I>!@>A:9;8GH=;9>!>C:!MG=C;E>A:!:>9E;A4]!CG9@;>A:! H=!85A:9=8:;5A!=:9;=H>[!)HH>!B95@5MG>!GA>!=GIE>A:=:;5A!3>!H=!B9>CC;5A!=:9;=H>]!9>C:=G9=A:!GA!I9=3;>A:! 3>!B9>CC;5A!>A:9>!H\=:9;GE!>:!H>!@>A:9;8GH>[!/=!@=H@>!E;:9=H>!C\5G@9>!>:!H>!9>EBH;CC=I>!9>B9>A3[!&!8>! E5E>A:]!H=!@;:>CC>!3G!PHG6!C=AIG;A!Q!:9=@>9C!H=!@=H@>!E;:9=H>!=GIE>A:>[''[!/&!O$V0K'$V!2)!?$%?)!!
2>BG;C! H>C! B9>E;F9>C! 3>C89;B:;5AC! 3>! N=9@>7]! H>! 8oG9! >:! H>! C7C:FE>! @=C8GH=;9>! 5A:! 4:4! =CC;E;H4C!Q!GA!8;98G;:!J739=GH;MG>!P>9E4!=@>8!GA>!B5EB>!=G!E;H;>G!3>C:;A4>!Q!>AI>A39>9!GA!I9=3;>A:! 3>!B9>CC;5A!>A:9>!H>!C>8:>G9!3\=E5A:!>:!8>HG;!>A!=@=H[!2R4A59E>C!>PP59:C!85A8>B:G>HC!5A:!4:4!B953G;:C! B5G9! P59EGH>9! 3>C! E53FH>C! E=:J4E=:;MG>C! 8=B=TH>C! 3>! 9>B953G;9>! H>C! 8=9=8:49;C:;MG>C! 3G! C7C:FE>! 8=93;5@=C8GH=;9>[!
!"g! lA>!B5EB>!8599>CB5A3!Q!GA!E48=A;CE>!8=B=TH>!3>!:9=ACP49>9!GA!PHG;3>!3\GA!B5;A:!Q!GA!=G:9>! 3>! H\>CB=8>[! 0>! :9=ACP>9:! B>G:! C\=885EB=IA>9! 3\GA>! =GIE>A:=:;5A! 3>! B9>CC;5A! =G! B5;A:! P;A=H! 3>! 34BH=8>E>A:]!3\GA>!4H4@=:;5A!I9=@;E4:9;MG>!3>!H=!E=CC>!34BH=84>!5G!3\GA!E5G@>E>A:!@>9C!GA!C;:>!Q! 3;C:=A8>! 85AC;349=TH>! B=9! 9=BB59:! =G! B5;A:! ;A;:;=H[! />! 34BH=8>E>A:! 3\GA! PHG;3>! 85A:9>! H=! I9=@;:4! ;EB5C>! Q! H=! B5EB>! 3>! :9=ACP49>9! 3>! H\4A>9I;>! @>9C! H=! E=CC>! >A! E5G@>E>A:[! #=AC! 8>::>! 4A>9I;>]! H=! E=CC>! 3>! H;MG;3>! A>! B5G99=! =::>;A39>! H>! A5G@>=G! A;@>=G! I9=@;E4:9;MG>[! 2>! ErE>]! H>! 34BH=8>E>A:! 3\GA! PHG;3>! =G! :9=@>9C! 3\GA! :G7=G! 3>E=A3>! 3>! H\4A>9I;>! B5G9! @=;A89>! H>C! 94C;C:=A8>C! 3G>C! Q! H=! P9;8:;5A!>A:9>!H>!H;MG;3>!>:!H>C!B=95;C!3G!:G7=G[! />!E53>!3>!:9=ACP>9:!3>!H\4A>9I;>!B9;C!>A!85EB:>!B>9E>:!3>!3;C:;AIG>9!H>C!`B5EB>C!8;A4:;MG>C`! >:!H>C!`B5EB>C!Q!34BH=8>E>A:!B5C;:;P`!1!3=AC!H>!B9>E;>9!8=C]!>HH>C!:9=ACPF9>A:!H\4A>9I;>!3>!E=A;F9>! 85A:;AG>]!3=AC!H>!3>G6;FE>!3>!P=q5A!B49;53;MG>[!/>C!B5EB>C!Q!34BH=8>E>A:!B5C;:;P!=BBH;MG>A:!GA>! P598>!Q!H=!CG9P=8>!3\GA!@5HGE>!3>!PHG;3>!P>9E4]!34:>9E;A=A:!GA>!=GIE>A:=:;5A!3>!B9>CC;5A!BG;C!GA! E5G@>E>A:!@;=!3>C!@=H@>C!5G!3>C!B59:>C[!0>C!C5A:!8>C!B5EB>C!Q!34BH=8>E>A:!B5C;:;P!MG;!3489;@>A:! H>!E;>G6!H>!8oG9!3>C!E=EE;PF9>C[! !
A. Le cÏur comme pompe hydraulique
&! H=! P;A! 3G! u'uFE>! C;F8H>]! 4B5MG>! 85AA=;CC=A:! GA! >CC59! ;EB59:=A:! 3>! H=! BJ7C;MG>! >:! 3>C! E=:J4E=:;MG>C]! GA! 3>C! 5TS>8:;PC! B9;A8;B=G6! 3>C! BJ7C;5H5I;C:>C! 8=93;5@=C8GH=;9>C! 4:=;:! 3\>6BH59>9! H\=BBH;8=T;H;:4! 3>C! H5;C! BJ7C;MG>C! 85EE>! 8>HH>C! 3>! ?5;C>G;HH>]!3>! W>9A5GHH;! 5G! 3>! O;8w! =G! C7C:FE>! 8=93;5@=C8GH=;9>[! )A! G:;H;C=A:! H>! 8oG9! >A:;>9! ;C5H4! >:! 9=885934! Q! GA! 8;98G;:! C>E;<P>9E4! ^O;I[! *=_]! )9A>C:! #:=9H;AI! ^?=::>9C5A! "j",_! 85A8>@=;:! H\=A=H7C>! >:! H=! MG=A:;P;8=:;5A! 3>! H=! B>9P59E=A8>! 8=93;=MG>! 3=AC! H>! 8=39>! 3RGA! C7C:FE>! J739=GH;MG>!1! H=! `B5EB>`! 9>q5;:! GA>! 8>9:=;A>! MG=A:;:4! 3>! H;MG;3>! MG\>HH>! 35;:! B5GCC>9! 3=AC! GA! C>8:>G9! Q! J=G:>! B9>CC;5A! c! H\>A:94>! 3>! H=! B5EB>! ^`B948J=9I>`_! 85A3;:;5AA>]!3=AC!8>9:=;A>C!H;E;:>C]!C=!C59:;>!^34T;:_!^O;I[!*T_[!
nG>HMG>C! 348>AA;>C! BHGC! :=93]! &9:JG9! .G7:5A! =! :9=ACB5C4! 8>C! 85A8>B:C! =G! 8oG9! in situ! >:! =! 4H=T594! H>C! I9=BJ;MG>C! >A:94><C59:;>! 3489;@=A:! H=! B>9P59E=A8>! 8=93;=MG>! >A! 85A3;:;5AC! A59E=H>C! >:! B=:J5H5I;MG>C! ^O;I[! +=_! ^.G7:5A! "j--_[! 'H! =! E;C! >A! 9>H=:;5A! H=! B9>CC;5A! Q! H\>A:94>! 3>! H=! B5EB>! ^H=! B9>CC;5A! =:9;=H>! 395;:>_! =@>8! H>! 34T;:! Q! C=! C59:;>! ^B953G;:! 3G! @5HGE>! 3\4S>8:;5A! >:! 3>! H=! P94MG>A8>! 8=93;=MG>_[! 2>! E=A;F9>! C;E;H=;9>]! #=9A5PP! >:! %;:8J>HH! ^#=9A5PP! =A3! %;:8J>HH! "jg"_! 5A:! 85994H4! H=! B9>CC;5A!=:9;=H>!I=G8J>!=@>8!H>!34T;:!5G!H>!:9=@=;H!@>A:9;8GH=;9>!I=G8J>!^O;I[!+T_[!!
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Figure 2. Mod•le expŽrimental dÕErnest Starling.
a) la partie gauche illustre le dispositif expŽrimental, la partie droite montre une transposition moderne du concept de pompe hydraulique avec le rŽservoir (bleu), la pompe (jaune) et la post-charge (rouge).
b) la partie gauche reproduit les tracŽs originaux de lÕexpŽrience de Starling: les dimensions ventriculaires (C), la pression artŽrielle (BP) et la pression du rŽservoir atrial (VP). Avec la montŽe de VP, les dimensions ventriculaires C et la pression artŽrielle augmentent. La partie droite illustre la relation entre augmentation de la pression atriale droite et le dŽbit cardiaque aortique (dÕapr•s Patterson, 1914).
a b P re ss ion a tri al e droi te (m m H2 O )
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a
b
Fig3. Graphiques input-output de la performance cardiaque globale (a) et plus particuli•rement du ventricule gauche (b). En (a) partie haute ˆ gauche, la relation entre pression atriale droite et dŽbit cardiaque, en conditions normale, dÕactivation adrŽnergique et pathologique. En (a) partie haute ˆ droite, la relation entre pression atriale droite et retour veineux pour diffŽrents niveaux de pression moyenne systŽmique (qui sert de moteur pour le retour veineux). En (a) partie gauche en bas, lÕintŽgration des deux graphiques (dÕapr•s Guyton, 1955).
En b, la relation entre pression atriale gauche et travail ventriculaire gauche en sortie de la pompe (travail nŽcessaire pour lÕŽjection ventriculaire) (dÕapr•s Sarnoff, 1961).
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B. Le cÏur comme pompe hŽmodynamique
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Figure 4. La fonction cardiaque reprŽsentŽe par les courbes pression-volume.!x!I=G8J>!H\>6B49;>A8>!3>!O9=Aw!!CG9!
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8=93;=MG>C! "]! *]! +! >:! ,! C>! 3495GH>A:! =@>8! 3>C! @5HGE>C! :4H4<3;=C:5H;MG>C! 895;CC=A:C[! yGCMG\=G! +>! 878H>]! H=! B9>CC;5A!
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3;=I9=EE>!B9>CC;5A<@5HGE>!^3\=B9FC!O9=A8w]!"Xj-_[! ! " # $ ! % & $ ' ' ( & $ ! % & $ ' ' ( & $ ! ) * + ( # $ ! ! " # $ % & $ ' ' ( & $ % & $ ' ' ( & $ ) * + ( # $ !
!*Y! 9>PHF:>!H\4:=:!3>!85A:9=8:;H;:4!3G!8oG9!>:!>C:!85AC;3494>!85EE>!H>!B=9=EF:9>!3>!94P49>A8>!3489;@=A:! H\;A5:95B;CE>[! ! ! ! ! ! ! !
/>C! =G:9>C! ;A3>6>C! MG;! 3485GH>A:! 3>! 8>::>! 9>B94C>A:=:;5A! C5A:!H=! 85EBH;=A8>! :4H4<3;=C:5H;MG>! ^9=BB59:! 3>! H=! B9>CC;5A! >:! 3G! @5HGE>! :4H4<3;=C:5H;MG>C! @>A:9;8GH=;9>C_]! H=! P9=8:;5A! 3\4S>8:;5A]! H=! 9>H=:;5A! a!:9=@=;H! C7C:5H;MG>! z! @5HGE>! @>A:9;8GH=;9>! :4H4<3;=C:5H;MG>!b! ^preload recruitable stroke
work_!>:!H=!9>H=:;5A!a!B9>CC;5A!=9:49;>HH>!C7C:5H;MG>!z!3;=EF:9>!:4H4<C7C:5H;MG>!3G!L.!b[!
!
C. Limites des mod•les de pompes hydraulique et hŽmodynamique
?HGC;>G9C!85AC;349=:;5AC!85A8>B:G>HH>C!35;@>A:!r:9>!P59EGH4>C!MG=A3!5A!4@=HG>!H=!@=H;3;:4!3>C! E53FH>C!B94C>A:4C!B94843>EE>A:[
1- Cadre temporel
/=!A5:;5A!3>!:>EBC!A\>C:!B=C!B9;C>!>A!85EB:>!3=AC!H>C!=BB958J>C!3489;:>C!^O;I[,_!1!34@>H5BB>9! GA>!B9>CC;5A!35AA4>!BHGC!5G!E5;AC!9=B;3>E>A:!B>G:!r:9>!GA!C;IA>!3\>PP;8;>A8>!3>!H=!B5EB>!c!;H!>A!@=! 3>! ErE>! B5G9! H>! :9=@=;H! B953G;:! B=9! H=! 8J=ET9>! @>A:9;8GH=;9>! =;AC;! MG>! B5G9! H>C! E53;P;8=:;5AC! 3>C! 3;E>AC;5AC! 3G! @>A:9;8GH>! I=G8J>[! )A! >PP>:]! 8\>C:! 3=AC! H>! 85A:;AGGE! 3>! H\>CB=8><:>EBC! MG>! H>C! E5G@>E>A:C! 8=93;=MG>C! C\;AC89;@>A:! >:! 35A8! H>! :>EBC! 3>@9=;:! P=;9>! B=9:;>! 3>! :5G:>! =A=H7C>! 3>! H=! B>9P59E=A8>!8=93;=MG>[!&;AC;]!3>BG;C!H>C!=AA4>C!"j-Y]!8>9:=;AC!BJ7C;5H5I;C:>C!5A:!=::;94!H\=::>A:;5A! CG9! 8>:! =CB>8:! >A! C5G:>A=A:! MG>! B5G9! B953G;9>! GA>! P5A8:;5A! 3>! B5EB=I>! >PP;8;>A:>]! H=! E=CC>! E758=93;MG>]!3=AC!C=!85EBH>6;:4]!35;:!C>!85A:9=8:>9!BHGC!5G!E5;AC!C;EGH:=A4E>A:!^(GCJE>9!"jg,_[!
! !
!
Figure 5. Courbes pression-volume et Žlastance.! (>H=:;5AC!
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C>9@5<85A:9kH4! ^3\=B9FC! #GI=<
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2- Concepts issus des Žtudes menŽes sur les fibres musculaires
/>C! :9=@=G6! CG9! H>C! P;T9>C! EGC8GH=;9>C! 8=93;=MG>C! ;C5H4>C! 5A:! E5A:94! MG>! H>C! 9>H=:;5AC! >A:9>! 85A:9=8:;5A!>:!9>H=6=:;5A!C5A:!BHGC!4:95;:>C!3>!8>!MG\5A!B5G@=;:!;E=I;A>9!1!3\GA>!B=9:]!H>C!@=9;=:;5AC! 3>C! 85A3;:;5AC! 3>! 8J=9I>! B>A3=A:! H=! BJ=C>! 3>! 85A:9=8:;5A! ;APHG>A8>A:! H>! 3495GH>E>A:! 3>! H=! 9>H=6=:;5A!c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
a) Modulation de la relaxation par la charge.
&G! 85G9C! 3>C! 85A:9=8:;5AC! ;C5:5A;MG>C! CG9! 3>C! P;T9>C! EGC8GH=;9>C! 8=93;=MG>C! ;C5H4>C! 3>! E=EE;PF9>C!^W9G:C=>9:]!3>!0H>98w!>:!=H[!"jdX_]!H\=GIE>A:=:;5A!I9=3G>HH>!3>!H=!B5C:<8J=9I>!>AI>A39>! GA>! 943G8:;5A! 3>! H=! @;:>CC>! 3>! 9=885G98;CC>E>A:! >:! GA! 9>:=93! 3G! 34TG:! 3>! H=! 9>H=6=:;5A! c! 3>! BHGC]! H\=HH5AI>E>A:!;C5:5A;MG>!=G!85G9C!3>!H=!9>H=6=:;5A]!ErE>!=G6!8J=9I>C!BHGC!P=;TH>C]!>C:!85AC:=EE>A:! CG;@;!B=9!GA>!8JG:>!=T9GB:>!3>!H=!P598>!;C5E4:9;MG>!^P;I[!g=_[!!
/\=8895;CC>E>A:! 3>! H=! 8J=9I>! 3G9=A:! H=! 85A:9=8:;5A! ;C5:5A;MG>! E53;P;>! H>! 3485G9C! 3>! H=! 85A:9=8:;5A!ErE>!>:!3>!H=!9>H=6=:;5A!MG;!C\>A!CG;:!1!C;!8>::>!8J=9I>!>C:!;EB5C4>!B>A3=A:!H=!B9>E;F9>! E5;:;4! 3>! H=! BJ=C>! 3>! 9=885G98;CC>E>A:]! H=! BJ=C>! 3>! 9>H=6=:;5A! ;C5:5A;MG>! >C:! :9FC! H4IF9>E>A:! E53;P;4>!c! C;! >HH>! >C:! ;EB5C4>! B>A3=A:! H=! 3>G6;FE>! B=9:;>! >:! CG9:5G:! H>! :;>9C! P;A=H! 3>! H=! BJ=C>! 3>! 9=885G98;CC>E>A:]!8>::>!3>9A;F9>!>C:!=T94I4>!>:!H=!BJ=C>!3\=HH5AI>E>A:!MG;!CG;:!>C:!9>H=:;@>E>A:!BHGC! H>A:>! ^O;I[! gT_[! &! 85A:9=9;5]! H=! C5GC:9=8:;5A! 3>! H=! 8J=9I>! Q! 8>! E5E>A:! E53;P;>! H>! 3485G9C! 3>! H=! 85A:9=8:;5A! >:! 3>! H=! 9>H=6=:;5A! 3=AC! H>! C>AC! ;A@>9C>! ^O;I[! g8_[! )AP;A]! H\=8895;CC>E>A:! 3>! H=! 8J=9I>! B>A3=A:!H=!BJ=C>!3\=HH5AI>E>A:!;C5:5A;MG>!3>!H=!9>H=6=:;5A!H\=T9FI>!3>!P=q5A!;EB59:=A:>!^W9G:C=>9:]! (=3>E=w>9C!>:!=H[!"jX,_[!!
)A!94CGE4]!H>C!>PP>:C!CG9!H=!9>H=6=:;5A!;A3G;:C!B=9!3>C!8J=9I>C!;EB5C4>C!3G9=A:!H>C!3>G6<:;>9C! ;A;:;=G6!3>!H=!85A:9=8:;5A!;C5:5A;MG>!C5A:!5BB5C4C!Q!8>G6!;A3G;:C!3=AC!H>C!ErE>C!85A3;:;5AC!3G9=A:! H\=HH5AI>E>A:! ;C5:5A;MG>[! />! B=CC=I>! >A:9>! 8>C! 3>G6! BJ=C>C! C>! C;:G>! =G! E5E>A:! 3>! H=! :9=AC;:;5A! >A:9>! H=! 85A:9=8:;5A! >:! H=! 9>H=6=:;5A! ^W9G:C=>9:]! (=3>E=w>9C! >:! =H[! "jX,_!1! 8>::>! U5A>! S5G>! GA! 9kH>! E=S>G9!3=AC!H>!85A:9kH>!3>!H=!B>9P59E=A8>!C7C:5H;MG>!3G!8oG9!>A:;>9[!
!**!
b) Modulation de la relaxation par lÕactivation-inactivation
/>C!85EB59:>E>A:C!3>!H=!P;T9>!EGC8GH=;9>!>:!C>C!94B5AC>C!Q!H=!C4MG>A8>!3>!8J=9I>!C5A:!4:95;:>E>A:! H;4C!=G6!E5G@>E>A:C!8=H8;MG>C[!0>8;!C\5TS>8:;@>!A5:=EE>A:!H59CMG>!3>C!8>HHGH>C!E758=93;MG>C!C5A:! B94:9=;:4>C! B=9! H>! 34:>9I>A:! W9;S<-X! MG;! 34:9G;:! H>! 94:;8GHGE! C=985BH=CE;MG>! >:! 87:5BH=CE;MG>! ^W9G:C=>9:]!3>!0H>98w!>:!=H[!"jdX_!5G!>A!8=C!3\J7B56;>!^0JG8w]!.5>:J=HC!>:!=H[!"jX"_[!2=AC!8>C!8=C]! H=! 9>H=6=:;5A! C>ETH>! r:9>! I5G@>9A4>! B=9! H>! B958>CCGC! 3\;A=8:;@=:;5A]! Q! C=@5;9]! H=! 3;CC58;=:;5A! 3>C! B5A:C!=8:;A><E75C;A>[!
!
!*+!
D. Le cÏur comme pompe musculaire
/\>AC>ETH>! 3>C! 35AA4>C! B94C>A:4>C! B94843>EE>A:! 94CGH:>! 3>! H\=T5G:;CC>E>A:! 3>C! 85A8>B:C! B95B5C4C! =G! 34TG:! 3>C! =AA4>C! C5;6=A:>! ^&TT5::! =A3! %5EE=>9:C! "j-jc! #5AA>ATH;8w! "jg*_! >:! MG;! ;AC;C:=;>A:!CG9!H>!B=9=HH4H;CE>!>A:9>!H>!85EB59:>E>A:!3G!8oG9!>A:;>9!>:!8>HG;!3>C!P;T9>C!EGC8GH=;9>C! 8=93;=MG>C!MG;!H>!85EB5C>A:[!&;AC;!H>!8oG9!3>@;>A:!GA>!B5EB>!EGC8GH=;9>[!05EE>!B5G9!H>C!P;T9>C! E758=93;MG>C]!H>!8oG9!>A:;>9!E53GH>!C=!85A:9=8:;5A!>:!C=!9>H=6=:;5A!B=9!H>C!@=9;=:;5AC!3>!8J=9I>!>:! H>C! BJ4A5EFA>C! 3\=8:;@=:;5A<;A=8:;@=:;5A[! 2>! BHGC]! H=! 85EBH>6;:4! 3>! H=! C:9G8:G9>! 3>! H=! B=95;! @>A:9;8GH=;9>! >:! H=! 3;C:9;TG:;5A! CB=:;5<:>EB59>HH>! 3>! H=! 34B5H=9;C=:;5A<94B5H=9;C=:;5A! 4H>8:9;MG>! ;EB5C>A:! 3>! :>A;9! 85EB:>! 3>! H=! A5A<GA;P59E;:4! @>A:9;8GH=;9>! 85EE>! =G:9>! 34:>9E;A=A:! 3>! H=! 85A:9=8:;5A<9>H=6=:;5A[!
1-Modulation par la charge.
/>C!B9;A8;B=G6!34:>9E;A=A:C!3>!H=!8J=9I>!3=AC!H>!8oG9!;A:=8:!C5A:!1!H=!34P59E=:;5A!3G9=A:!H=! 85A:9=8:;5A]! H>C! =H:49=:;5AC! 3>! H\;EB43=A8>! =9:49;>HH>! B>A3=A:! H=! BJ=C>! :=93;@>! 3>! H\4S>8:;5A]! H>! 9>EBH;CC=I>! 3G! 94C>9@5;9! 8595A=;9>! B>A3=A:! H=! 9>H=6=:;5A! ;C5<@5HGE;MG>]! H>C! @=9;=:;5AC! 3>! @5HGE>! =B9FC!H\5G@>9:G9>!3>!H=!@=H@>!E;:9=H>!^W9G:C=>9:]!N5GCE=AC!>:!=H[!"jXY_[!
05EE>! B5G9! H>C! P;T9>C! EGC8GH=;9>C! ;C5H4>C]! GA>! =GIE>A:=:;5A! 3>! H=! 8J=9I>! B>A3=A:! H>C! B9>E;>9C!3>G6<:;>9C!3>!H=!85A:9=8:;5A!9>:=93>!H>!34TG:!3>!H=!9>H=6=:;5A!>:!=884HF9>!H=!@;:>CC>!3>!8JG:>! 3>!H=!B9>CC;5A!;A:9=<@>A:9;8GH=;9>!^?=9EH>7!=A3!#5AA>ATH;8w!"jgj_[!#;!H\;EB5C;:;5A!3>!H=!8J=9I>!>C:! ;EB59:=A:>!5G!C;!>HH>!CG9@;>A:!B>A3=A:!H=!BJ=C>!:=93;@>!3>!H\4S>8:;5A]!;H!7!=G9=!GA!34TG:!B94E=:G94!>:! GA! 9=H>A:;CC>E>A:! 3>! H=! T=;CC>! 3>! B9>CC;5A! ;A:9=<@>A:9;8GH=;9>! ^%G9I5]! p>C:>9J5P! >:! =H[! "jXYc! .;HH>T>9:! =A3! />f! "jj"c! />;:><%59>;9=! =A3! .;HH>T>9:! "jj,c! />;:><%59>;9=]! 0599>;=<?;A:5! >:! =H[! "jjj_!^O;I!d_[!)A!B9=:;MG>]!;H!>6;C:>!GA>!BJ=C>!3>!H\4S>8:;5A!B>A3=A:!H=MG>HH>!H>!@>A:9;8GH>!;A:>9=I;:! =@>8! H>! C7C:FE>! =9:49;>H! >:! 8>8;! B>G:! E53GH>9! H=! B>9P59E=A8>! E48=A;MG>! 3G! @>A:9;8GH>! B>A3=A:! H=! 9>H=6=:;5A!^W9G:C=>9:]!(=3>E=w>9C!>:!=H[!"jX,_[!
2-Modulation par lÕactivation-inactivation
2=AC! H>! 8oG9! >A:;>9]! 85EE>! B5G9! H=! P;T9>! EGC8GH=;9>! ;C5H4>]! H\=8:;@=:;5A! 3>! H\=BB=9>;H! 85A:9=8:;H>! C>! 3;CC;B>! B95I9>CC;@>E>A:! I9v8>! Q! BHGC;>G9C! B958>CCGC! MG;! 85AC5EE>A:! 3>! H\4A>9I;>[! /59CMG>!H>!B958>CCGC!3\=8:;@=:;5A!>C:!85AC:=A:]!H=!9>H=6=:;5A!>C:!E53GH4>!BHG:k:!B=9!H>C!@=9;=:;5AC!3>! 8J=9I>C[!&!85A:9=9;5]!>A!B94C>A8>!3>!85A3;:;5AC!3>!8J=9I>!C:=TH>C]!H=!9>H=6=:;5A!>C:!E53GH4>!BHG:k:! B=9! H>C! @=9;=:;5AC! 3>C! BJ4A5EFA>C! 3\=8:;@=:;5A<;A=8:;@=:;5A[! />C! 85A3;:;5AC! ;A:>9E43;=;9>C! C5A:! 4@;3>EE>A:!GA!E4H=AI>!3>C!3>G6!E48=A;CE>C[!
!*,! H! P=G:! 4I=H>E>A:! C5GH;IA>9! MG>! H>! B958>CCGC! 3\=8:;@=:;5A<;A=8:;@=:;5A! >C:! 4I=H>E>A:! H;4! =G6! 85A3;:;5AC!E4:=T5H;MG>C!85EE>!H=!C;:G=:;5A!;C8J4E;MG>!MG;!>C:!Q!H\59;I;A>!3\GA!9=H>A:;CC>E>A:!3>!H=! 9>H=6=:;5A!^N>9E=A!=A3!.59H;A!"jgjc!K7T>9I]!?=9EH>7!>:!=H[!"jgjc!.95CCE=A!=A3!%8/=G9;A!"jdgc! #:! y5JA! #G::5A]! O97>! >:! =H[! "jdX_]! =G! 85A:9kH>! A>G95<J59E5A=H! >:! =G6! 4@>A:G>HH>C! E53GH=:;5AC! BJ=9E=85H5I;MG>C[!
!
3-Modulation par la non-uniformitŽ
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F. Implications physiologiques et physiopathologiques du concept de
pompe musculaire
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!*g!
CHAPITRE II : LA DYSFONCTION
DIASTOLIQUE
!*d!
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P
V
F
Ic ejection
Contraction
S
D
IR
Diasstasis Atrial
Contr
Compliance
1
1
2
2
3
4
4
t
3
P
Pump
D
V
4
3
2
1
Inappropriate rise
in diastolic P-V
Diastolic dysfunction
diastolic failure
Relaxation
RFPFigure 8. Division du cycle cardiaque en tant que pompe musculaire et courbe pression-volume correspondante.
IC: contraction isovolumique; IR: relaxation isovolumique; S: systole; D: diastole.
1: fermeture de la valve aortique; 2: ouverture de la valve mitrale; 3: fin de la succion; 4: fermeture de la valve mitrale. Diastasis
!*X!
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A. Manifestation
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