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Heart s Vortex Intracardiac Blood Flow Phenomena 1st
Edition Ares Pasipoularides Digital Instant Download
Author(s): Ares Pasipoularides
ISBN(s): 9781607950332, 1607950332
Edition: 1
File Details: PDF, 23.11 MB
Year: 2009
Language: english
Heart’s Vortex
Intracardiac Blood Flow
Phenomena
Ares Pasipoularides, MD, PhD, FACC

Consulting Professor of Surgery
Duke University School of Medicine
Durham, North Carolina, U.S.A.
Formerly, Director of Cardiac Function of the Duke/NSF Research Center

for Emerging Cardiovascular Technologies, Duke University
Formerly, Director of Cardiovascular Research at Brooke Army Medical Center

Fort Sam Houston, San Antonio, Texas
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Notice: The authors and publisher have made every effort to ensure that the patient care recommended
herein, including choice of drugs and drug dosages, is in accord with the accepted standard and practice
at the time of publication. However, since research and regulation constantly change clinical standards,
the reader is urged to check the product information sheet included in the package of each drug, which
includes recommended doses, warnings, and contraindications. This is particularly important with new
or infrequently used drugs. Any treatment regimen, particularly one involving medication, involves in-
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not intended as, and should not be employed as, a substitute for individual diagnosis and treatment.
The image is more than an idea.
It is a vortex or cluster of fused ideas
and is endowed with energy.
—Ezra Pound
For, verily, art is embedded in nature;

whoever can draw her out, has her.
—Albrecht Dürer
To my wife, Jane Wright Pasipoularides,
who is the foundation of joy
for all I do.
Contents
Foreword Danny O. Jacobs, MD, MPH xvii
Prologue xx
Acknowledgments xxv
I Fundamentals of Intracardiac Flows and Their Measurement 1

1 Introduction 2
1.1 Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.2 The black-box approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.3 The glass-box approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.4 Intracardiac flow phenomena . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.5 Dissipative structures and flow patterns . . . . . . . . . . . . . . . . . . . . . 10
1.5.1 Dissipative structures . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.5.2 Flow patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.6 The continuum assumption . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
1.7 Properties of fluid media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
1.8 What is fluid flow? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
1.9 Flow-mediated interactions of form and function . . . . . . . . . . . . . . . . 20
1.9.1 Murray’s law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
1.10 The morphogenetic role of endothelial fluid shear . . . . . . . . . . . . . . . 23
1.11 Optimal use of medical imaging and flow visualization data . . . . . . . . . 26
References and further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
2 Handy Mathematical Instruments of Thought 35

2.1 Ensemble averages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
2.2 Vectors and scalars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
2.2.1 Adding and subtracting vectors . . . . . . . . . . . . . . . . . . . . . 41
2.2.2 Dot product and cross product . . . . . . . . . . . . . . . . . . . . . . 42
2.2.3 The triple scalar product . . . . . . . . . . . . . . . . . . . . . . . . . . 43
v
vi Contents
2.3 Kinematics of circular motion and rotation . . . . . . . . . . . . . . . . . . . 43

2.4 Phasors and complex numbers . . . . . . . . . . . . . . . . . . . . . . . . . . 45
2.4.1 Complex quantities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
2.5 Fields and field lines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
2.5.1 Contour maps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
2.5.2 Measurement of kinematic characteristics of velocity vector fields . . 52
2.6 The divergence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
2.6.1 Flux and divergence of a vector . . . . . . . . . . . . . . . . . . . . . . 55
2.7 The gradient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
2.7.1 Pressure gradient force . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
2.8 Circular motion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
2.9 Forced vortex motion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
2.10 The curl and vorticity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
2.11 The Laplacian . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
2.12 Average and instantaneous derivatives . . . . . . . . . . . . . . . . . . . . . . 63
2.13 Total and partial time derivatives . . . . . . . . . . . . . . . . . . . . . . . . . 65
2.14 Integration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
2.14.1 Antiderivatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
2.14.2 The area under a curve . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
2.14.3 Simpson’s rule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
2.14.4 Accumulated change . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
2.15 Line and surface integrals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
2.16 The binary number system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
2.16.1 Bits, bytes, and words . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
2.17 Analog vs. digital signals and analog-to-digital conversion . . . . . . . . . . 72
2.17.1 The decibel scale and signal-conditioning filters . . . . . . . . . . . . 77
2.17.2 A/D conversion for images . . . . . . . . . . . . . . . . . . . . . . . . 79
2.18 Fourier transform and Fourier series . . . . . . . . . . . . . . . . . . . . . . . 82
2.18.1 Fourier series for any interval . . . . . . . . . . . . . . . . . . . . . . . 86
2.19 Fourier analysis in image processing . . . . . . . . . . . . . . . . . . . . . . . 88
2.20 Fourier analysis with computers . . . . . . . . . . . . . . . . . . . . . . . . . 91
2.20.1 Qualitative insight into the Fourier transform algorithm . . . . . . . 92
2.20.2 Frequency response of systems . . . . . . . . . . . . . . . . . . . . . . 94
2.20.3 Discrete (DFT) and Fast (FFT) Fourier transform . . . . . . . . . . . . 94
2.21 Auto-correlation and cross-correlation . . . . . . . . . . . . . . . . . . . . . . 95
2.22 Differential equations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
2.22.1 Navier–Stokes equations . . . . . . . . . . . . . . . . . . . . . . . . . . 101
2.22.2 Solution of the Navier–Stokes equations . . . . . . . . . . . . . . . . . 101
Contents vii
2.23 Feedback mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

2.23.1 Feedback loop . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
2.24 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
3 Some Notable Pioneers 115

3.1 Euclid, Ptolemy, and the origins of perspective and projective geometry . . 116
3.2 Aristotle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
3.3 Leonardo da Vinci and Albrecht Dürer . . . . . . . . . . . . . . . . . . . . . . 119
3.4 William Harvey, Marcellus Malpighi, and Giovanni Alphonso Borelli . . . . 127
3.5 Leonhard Euler and Daniel Bernoulli . . . . . . . . . . . . . . . . . . . . . . . 131
3.6 Hermann von Helmholtz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
3.7 Étienne-Jules Marey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
3.8 Claude Bernard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
3.9 Otto Frank, Ernest H. Starling, and Maurice B. Visscher . . . . . . . . . . . . 143
3.10 Werner Forssmann, André Cournand, and Dickinson Richards . . . . . . . . 144
3.11 Modern instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
3.11.1 Computer assisted tomography . . . . . . . . . . . . . . . . . . . . . 149
3.11.2 Digital angiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
3.11.3 Real-time 3-D echocardiography . . . . . . . . . . . . . . . . . . . . . 152
3.11.4 Magnetic resonance imaging . . . . . . . . . . . . . . . . . . . . . . . 152
3.12 CFD and scientific visualization: merging numbers and images . . . . . . . 154
4 Fluid Dynamics of Unsteady Flow 165

4.1 Inertial, viscous, and pressure gradient forces . . . . . . . . . . . . . . . . . . 166
4.2 Fields . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
4.2.1 Impulse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
4.2.2 The streamfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
4.3 Volume and surface forces: gravitational force and pressure gradient . . . . 173
4.4 The flow-field equations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
4.4.1 Introducing the conservation equations . . . . . . . . . . . . . . . . . 174
4.4.2 Equation of continuity . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
4.4.3 Equation of motion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
4.4.4 Convective acceleration effects . . . . . . . . . . . . . . . . . . . . . . 179
4.4.5 Boundary conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
4.4.6 Bernoulli’s theorem for steady flow . . . . . . . . . . . . . . . . . . . 182
4.4.7 Vena contracta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
4.5 A recapitulation: the unsteady Bernoulli equation . . . . . . . . . . . . . . . 187
viii Contents
4.6 Viscosity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190

4.7 Viscous flow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
4.7.1 Brief remark on irreversibility . . . . . . . . . . . . . . . . . . . . . . . 193
4.8 Dimensions and units . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
4.9 Boundary layer and flow separation . . . . . . . . . . . . . . . . . . . . . . . 197
4.9.1 Unsteadiness and entrance length effects . . . . . . . . . . . . . . . . 200
4.10 Impulsive flows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
4.11 Reynolds number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
4.11.1 The role of the Reynolds criterion . . . . . . . . . . . . . . . . . . . . 206
4.11.2 The limit of zero viscosity . . . . . . . . . . . . . . . . . . . . . . . . . 207
4.12 Laminar and turbulent boundary layers . . . . . . . . . . . . . . . . . . . . . 208
4.12.1 Favorable and adverse gradient effects on the boundary layer . . . . 209
4.13 Mechanisms of mixing in fluid flow . . . . . . . . . . . . . . . . . . . . . . . 210
4.14 Flow instabilities and turbulence . . . . . . . . . . . . . . . . . . . . . . . . . 212
4.14.1 Mechanisms of instability . . . . . . . . . . . . . . . . . . . . . . . . . 213
4.14.2 Turbulent eddies and mean flow . . . . . . . . . . . . . . . . . . . . . 215
4.14.3 Turbulence energy: sources and sinks . . . . . . . . . . . . . . . . . . 216
4.14.4 Turbulence cascade . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
4.14.5 Pseudosound generation by turbulent flow . . . . . . . . . . . . . . . 221
4.14.6 Turbulent mixing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
5 Micromanometric, Velocimetric, Angio- and Echocardiographic Measurements 234

5.1 Hemodynamic data aquisition at catheterization . . . . . . . . . . . . . . . . 235
5.1.1 Hemodynamic data acquisition systems . . . . . . . . . . . . . . . . . 236
5.1.2 Nyquist theorem and aliasing . . . . . . . . . . . . . . . . . . . . . . . 239
5.1.3 Circular discontinuity and windowing . . . . . . . . . . . . . . . . . 240
5.2 Hemodynamic measurements . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
5.3 Micromanometric and velocimetric calibrations . . . . . . . . . . . . . . . . 247
5.3.1 Micromanometric calibrations . . . . . . . . . . . . . . . . . . . . . . 248
5.3.2 Velocimetric calibrations . . . . . . . . . . . . . . . . . . . . . . . . . . 250
5.4 Angiocardiography and digital subtraction angiography . . . . . . . . . . . 250
5.4.1 X-ray contrast media . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
5.5 Echocardiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
5.5.1 2-D echocardiography . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
5.5.2 Contrast echocardiography . . . . . . . . . . . . . . . . . . . . . . . . 266
5.6 Detection of endocardial borders . . . . . . . . . . . . . . . . . . . . . . . . . 268
5.6.1 Harmonic imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Contents ix
5.6.2 Spatial resolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271

5.6.3 Temporal resolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
5.7 Resolving heart motion with 2-D echocardiography . . . . . . . . . . . . . . 275
5.7.1 3-D echo imaging in the study of intracardiac blood flows . . . . . . 277
5.8 M-mode display . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
5.9 Doppler echocardiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
5.9.1 Doppler modalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
5.9.2 Continuous wave and pulsed wave Doppler . . . . . . . . . . . . . . 282
5.9.3 Doppler signal processing for spectral Doppler modalities . . . . . . 282
5.9.4 Pulse repetition frequency, aliasing and low velocity rejection . . . . 287
5.9.5 Color Doppler signal processing . . . . . . . . . . . . . . . . . . . . . 288
5.9.6 Time-domain systems . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
5.9.7 Fusion of hemodynamic multimodality measurements . . . . . . . . 291
6 Cardiac Morphology and Flow Patterns: Structural–Functional Correlations 298

6.1 The heart is a helix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
6.2 Ventricular myoarchitecture is intertwined with intraventricular blood flow 301
6.3 Ventricular myoarchitecture engenders compound motion patterns . . . . . 305
6.4 Ventricular myoarchitecture and shear strain minimization . . . . . . . . . . 308
6.5 The intraventricular blood as a myocardial “hemoskeleton” . . . . . . . . . . 309
6.6 Torrent-Guasp’s “flattened rope” or muscle band . . . . . . . . . . . . . . . . . 311
6.7 Implications of the Torrent-Guasp model . . . . . . . . . . . . . . . . . . . . 315
7 Cardiac Cycle and Central Pressure, Flow, and Volume Pulses 323
7.1 Low- vs. high-pressure operation: the disparate needs of diastole
and systole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
7.2 Central pulsatile pressure-flow relations . . . . . . . . . . . . . . . . . . . . . 326
7.2.1 Central velocity profiles . . . . . . . . . . . . . . . . . . . . . . . . . . 327
7.3 Notable factors affecting central pulse magnitudes and waveforms . . . . . 329
7.4 Factors affecting heart filling . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
7.5 Hemodynamic events of the normal cardiac cycle . . . . . . . . . . . . . . . 337
7.5.1 Semilunar valve closure and phase of isovolumic relaxation . . . . . 337
7.5.2 Atrioventricular valve opening and rapid ventricular filling phase . 339
7.5.3 Phase of slow ventricular filling . . . . . . . . . . . . . . . . . . . . . 341
7.5.4 Phase of atrial systole . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
7.5.5 Atrioventricular valve closure and onset of ventricular contraction . 346
7.5.6 Phase of isovolumic contraction and semilunar valve opening . . . . 347
x Contents
7.5.7 LV isovolumic contraction period vanishes during intense exercise . 348

7.5.8 Phase of ventricular ejection . . . . . . . . . . . . . . . . . . . . . . . . 350
7.6 Systolic descent and upward diastolic recoil of the atrioventricular anulus
plane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358
7.6.1 Atrial stiffness and ventricular systolic load . . . . . . . . . . . . . . . 364
7.7 Coronary vessel effects restoring diastolic heart shape . . . . . . . . . . . . . 365
7.8 Systolic wall thickening and mural cyclic volume shifts . . . . . . . . . . . . 367
7.9 Complementarity and competitiveness of intrinsic and extrinsic ejection
load components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
7.10 Asynchronism between right- and left-sided events . . . . . . . . . . . . . . 373
7.11 Indices of myocardial contractility from central pressure and flow tracings 375
7.11.1 Ventricular outflow acceleration . . . . . . . . . . . . . . . . . . . . . 378
7.12 Clinically important patterns of altered cardiac cycle phase durations . . . . 380
7.13 Fluid dynamics of cardiac valve operation . . . . . . . . . . . . . . . . . . . . 382
7.13.1 Aortic valve opening . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
7.13.2 Aortic valve closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
7.13.3 Mitral valve operation . . . . . . . . . . . . . . . . . . . . . . . . . . . 388
7.14 Reciprocal transformations of mitral and aortic rings . . . . . . . . . . . . . 391
7.15 Pathophysiology and fluid dynamics of cardiac valves . . . . . . . . . . . . 393
7.15.1 Functional mitral insufficiency . . . . . . . . . . . . . . . . . . . . . . 393
7.15.2 Functional coronary insufficiency . . . . . . . . . . . . . . . . . . . . 394
7.15.3 Fatigue of semilunar cusps . . . . . . . . . . . . . . . . . . . . . . . . 394
7.15.4 Arteriosclerosis and aortic root stiffening . . . . . . . . . . . . . . . . 394
8 Addendum to Chapters 4, 5, & 7: A Gallery of Multisensor

Catheter Cardiodynamics 408
8.1 Signal distortion in standard catheterization systems . . . . . . . . . . . . . 409
8.2 Preamble to high-fidelity cardiodynamic tracings . . . . . . . . . . . . . . . . 410
8.3 High-fidelity hemodynamic/fluid dynamic tracings . . . . . . . . . . . . . . 419
9 Vortex Formation in Fluid Flow 442

9.1 Symmetry and the breaking of symmetry . . . . . . . . . . . . . . . . . . . . 443
9.2 Flow regime bifurcations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 444
9.2.1 Flow-associated structures and pattern formation . . . . . . . . . . . 445
9.2.2 Sensitive dependence on initial conditions . . . . . . . . . . . . . . . 447
9.3 Vorticity and circulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 448
9.3.1 Vortex or eddy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454
Contents xi
9.4 Vortex dynamics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454

9.5 Interesting vortical patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . 457
9.5.1 The Helmholtz–Kelvin instability . . . . . . . . . . . . . . . . . . . . 457
9.5.2 Flow past a cylinder . . . . . . . . . . . . . . . . . . . . . . . . . . . . 458
9.5.3 A note on flow disturbances and instabilities . . . . . . . . . . . . . . 462
9.5.4 Taylor–Couette flow . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463
9.5.5 Secondary flows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 469
9.5.6 Flow in curved vessels . . . . . . . . . . . . . . . . . . . . . . . . . . . 470
9.6 Vortex formation mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . 473
II Visualization of Intracardiac Blood Flows: Methodologies,

Frameworks, and Insights 481
10 Cardiac Computed Tomography, Magnetic Resonance, and Real-Time 3-D

Echocardiography 482
10.1 Computed tomography—CT . . . . . . . . . . . . . . . . . . . . . . . . . . . 484
10.1.1 DSR – the dynamic spatial reconstructor . . . . . . . . . . . . . . . . 488
10.1.2 How imaging projections yield topographic information . . . . . . . 489
10.1.3 What is measured in CT? . . . . . . . . . . . . . . . . . . . . . . . . . 490
10.1.4 The backprojection operation . . . . . . . . . . . . . . . . . . . . . . . 496
10.1.5 Spiral/helical, electron beam, and multislice spiral cardiac CT . . . . 498
10.1.6 Recent advances in cardiac CT and dynamic ventriculography . . . . 504
10.2 Magnetic resonance imaging—MRI . . . . . . . . . . . . . . . . . . . . . . . . 505
10.2.1 MRI in a nutshell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505
10.2.2 Spins and the MR phenomenon . . . . . . . . . . . . . . . . . . . . . . 508
10.2.3 MRI slice selection and signal localization . . . . . . . . . . . . . . . . 510
10.2.4 Slice selection, phase and frequency encoding in MRI sequences . . . 513
10.2.5 Gradient echo and spin echo MRI sequences . . . . . . . . . . . . . . 514
10.2.6 Sources of contrast between tissues in MR images . . . . . . . . . . . 517
10.2.7 Contrast techniques for high resolution anatomical cardiovascular
images . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521
10.2.8 MRI raw data acquisition methods and k-space . . . . . . . . . . . . 523
10.2.9 Cardiac (ECG) triggering . . . . . . . . . . . . . . . . . . . . . . . . . 526
10.3 Cardiac MRI techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531
10.3.1 Time-of-flight methods . . . . . . . . . . . . . . . . . . . . . . . . . . . 532
10.3.2 Phase-contrast velocity mapping . . . . . . . . . . . . . . . . . . . . . 534
10.3.3 Superimposition of an MRI velocity image on an anatomic image . . 538
xii Contents
10.3.4 Cine-MRI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 543

10.3.5 Evolution of 4-D (spatiotemporal) scanning technologies . . . . . . . 545
10.4 Real-time and live 3-D echocardiography . . . . . . . . . . . . . . . . . . . . 547
10.4.1 3-D reconstructions from 2-D images . . . . . . . . . . . . . . . . . . 547
10.4.2 Real-time 3-D echocardiography . . . . . . . . . . . . . . . . . . . . . 549
10.4.3 Live 3-D echocardiography . . . . . . . . . . . . . . . . . . . . . . . . 558
10.4.4 3-D Doppler echocardiography . . . . . . . . . . . . . . . . . . . . . . 562
10.5 Functional Imaging of unsteady, 3-D intracardiac flow patterns . . . . . . . 566
11 Postprocessing Exploration Techniques and Display of Tomographic Data 582

11.1 Plato’s cave and modern 3-D imaging modalities . . . . . . . . . . . . . . . . 583
11.2 Volume visualization in a nutshell . . . . . . . . . . . . . . . . . . . . . . . . 585
11.3 Visualizing 3-D on a monitor screen . . . . . . . . . . . . . . . . . . . . . . . 587
11.4 Translating 3-D into 2-D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 589
11.4.1 Z-buffering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 593
11.5 Postprocessing techniques for tomographic data . . . . . . . . . . . . . . . . 594
11.5.1 Multiplanar reformation . . . . . . . . . . . . . . . . . . . . . . . . . . 595
11.5.2 Maximum intensity projection . . . . . . . . . . . . . . . . . . . . . . 596
11.5.3 Shaded surface display . . . . . . . . . . . . . . . . . . . . . . . . . . 598
11.5.4 Volume rendering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 601
11.5.5 Shading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 606
11.6 Image processing and meshing . . . . . . . . . . . . . . . . . . . . . . . . . . 608
11.6.1 Delaunay tessellation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610
11.6.2 Plastering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611
11.7 Dynamic mesh deformation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613
11.7.1 Data compression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614
11.8 3-D display challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 616
11.8.1 Multimodality imaging data integration . . . . . . . . . . . . . . . . . 617
12 Computational Fluid Dynamics, or “CFD” 623

12.1 Burgeoning computing power for CFD . . . . . . . . . . . . . . . . . . . . . . 626
12.2 Basic ideas in CFD analysis of flow fields . . . . . . . . . . . . . . . . . . . . 629
12.3 Practical implementation of CFD to intracardiac flows . . . . . . . . . . . . . 633
12.4 Solving intracardiac flow problems with computers . . . . . . . . . . . . . . 637
12.5 Dynamic intracardiac flow-field geometry . . . . . . . . . . . . . . . . . . . . 638
12.5.1 Edge detection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 639
12.5.2 Image segmentation: the first step in CFD simulations . . . . . . . . 642
Contents xiii
12.6 Flow-field discretization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 646

12.6.1 Structured and unstructured grids . . . . . . . . . . . . . . . . . . . . 648
12.6.2 The need for boundary-fitted coordinate systems . . . . . . . . . . . 652
12.6.3 Adaptive and moving grids . . . . . . . . . . . . . . . . . . . . . . . . 654
12.7 Iterative solution of the discretized flow-field equations . . . . . . . . . . . . 657
12.7.1 Convergence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 659
12.7.2 Consistency and stability . . . . . . . . . . . . . . . . . . . . . . . . . 662
12.7.3 Conservation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 662
12.8 Computational costs of realistic chamber geometries . . . . . . . . . . . . . . 663
12.8.1 Spatial and temporal resolution . . . . . . . . . . . . . . . . . . . . . . 664
12.8.2 Spatiotemporal accuracy constraints and the Courant condition . . . 665
12.9 Postprocessing and scientific visualization . . . . . . . . . . . . . . . . . . . . 667
12.9.1 Scientific visualization . . . . . . . . . . . . . . . . . . . . . . . . . . . 668
13 CFD of Ventricular Ejection 680

13.1 Brief historic survey of CFD approaches to intracardiac flow . . . . . . . . . 684
13.1.1 Immersed boundary method . . . . . . . . . . . . . . . . . . . . . . . 684
13.1.2 Predetermined boundary motion method . . . . . . . . . . . . . . . . 685
13.1.3 Hybrid correlative imaging–CFD method . . . . . . . . . . . . . . . . 687
13.2 Immersed Boundary (IB) method . . . . . . . . . . . . . . . . . . . . . . . . . 688
13.2.1 Whole heart pumping dynamics by IB method . . . . . . . . . . . . . 689
13.2.2 Limitations of the IB method in intracardiac flow simulations . . . . 692
13.3 Method of Predetermined Boundary Motion (PBM) . . . . . . . . . . . . . . 694
13.3.1 Numerical grid generation . . . . . . . . . . . . . . . . . . . . . . . . 695
13.3.2 Mathematical formulation of the flow field . . . . . . . . . . . . . . . 699
13.3.3 Numerical solution scheme . . . . . . . . . . . . . . . . . . . . . . . . 703
13.3.4 Left ventricular ejection flow-field computation . . . . . . . . . . . . 703
13.3.5 Pressure calculation in the unsteady intraventricular flow field . . . . 705
13.3.6 The effect of ventriculoannular disproportion on intraventricular
flow dynamics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 706
13.3.7 The effect of LV eccentricity on intraventricular flow dynamics . . . 708
13.4 PBM viscous flow simulation of LV ejection by FEM . . . . . . . . . . . . . . 710
13.4.1 Viscous flow simulation of the effects of ventriculoannular
disproportion and varying LV chamber eccentricity . . . . . . . . . . 714
13.5 Validation of PBM simulations . . . . . . . . . . . . . . . . . . . . . . . . . . 716
13.5.1 Validation against an analytical fluid dynamic model of LV ejection . 717
13.5.2 Catheterization results: normal ejection gradients . . . . . . . . . . . 718
13.5.3 Catheterization results: ejection gradients in aortic stenosis . . . . . 722
13.6 Clinical implications of ejection gradients . . . . . . . . . . . . . . . . . . . . 724
xiv Contents
14 CFD of Ventricular Filling: Heart’s Vortex 735

14.1 Myocardial diastolic function . . . . . . . . . . . . . . . . . . . . . . . . . . . 737
14.2 Fluid dynamic underpinnings of diastolic function changes with
chamber dilatation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 738
14.3 Disparate patterns of confluent and diffluent flows . . . . . . . . . . . . . . . 739
14.4 The role of high-pass filters . . . . . . . . . . . . . . . . . . . . . . . . . . . . 742
14.5 Overview of the CFD challenge . . . . . . . . . . . . . . . . . . . . . . . . . . 742
14.5.1 Validation of simulated velocity fields using MR measurements . . . 745
14.6 The Functional Imaging (FI) method in RV filling simulations . . . . . . . . 745
14.6.1 Experimental animals and procedures . . . . . . . . . . . . . . . . . . 746
14.6.2 Multisensor catheter measurements . . . . . . . . . . . . . . . . . . . 748
14.6.3 3-D real-time echocardiography and image segmentation . . . . . . . 748
14.6.4 Reconstruction of endocardial border points . . . . . . . . . . . . . . 751
14.6.5 Model of the tricuspid orifice . . . . . . . . . . . . . . . . . . . . . . . 751
14.6.6 Volumetric Prism Method . . . . . . . . . . . . . . . . . . . . . . . . . 752
14.6.7 Mesh generation and determination of boundary conditions . . . . . 758
14.6.8 Reynolds number, adaptive gridding and the Courant condition . . 759
14.6.9 Computer simulations and flow visualization . . . . . . . . . . . . . 761
14.6.10 Flow visualization and Functional Imaging . . . . . . . . . . . . . . . 764
14.7 Diastolic RV flow fields in individual animal hearts . . . . . . . . . . . . . . 765
14.7.1 Onset of E-wave upstroke . . . . . . . . . . . . . . . . . . . . . . . . . 765
14.7.2 Upstroke through the peak of the E-wave . . . . . . . . . . . . . . . . 769
14.7.3 Downstroke of the E-wave . . . . . . . . . . . . . . . . . . . . . . . . 771
14.8 Doppler echocardiographic implications . . . . . . . . . . . . . . . . . . . . . 773
14.9 Functional imaging vs. multisensor catheterization . . . . . . . . . . . . . . 774
14.10 The RV diastolic vortex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 776
14.11 The LV diastolic vortex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 777
14.12 Color M-mode Doppler echocardiograms and the intraventricular vortex . 780
14.13 Evolution of axial velocities and pressures throughout the E-wave . . . . . 782
14.13.1 Local and convective components of the diastolic pressure gradient 784
14.13.2 Interplay of convective with local acceleration effects . . . . . . . . . 787
14.14 Physiological significance of the filling vortex: to facilitate diastolic
filling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 789
14.15 Clinical impact of chamber size and wall motion patterns . . . . . . . . . . 791
14.15.1 Convective deceleration load and diastolic ventriculoannular
disproportion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 795
14.16 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 795
Contents xv
15 Fluid Dynamic Epigenetic Factors in Cardiogenesis and Remodeling 808

15.1 The heart tube . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 809
15.2 Formation of heart chambers . . . . . . . . . . . . . . . . . . . . . . . . . . . 813
15.2.1 Right atrium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 814
15.2.2 Left atrium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 815
15.2.3 Interatrial septum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 815
15.2.4 Interventricular septum . . . . . . . . . . . . . . . . . . . . . . . . . . 816
15.2.5 Semilunar and atrioventricular valves . . . . . . . . . . . . . . . . . . 819
15.3 Fetal circulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 820
15.4 Intracardiac flow structures and shear as prenatal morphogenetic and
epigenetic factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 822
15.4.1 Dynamic balance of myogenic tone and endothelial dilatation . . . . 823
15.4.2 Cellular response to shear . . . . . . . . . . . . . . . . . . . . . . . . . 823
15.5 Prenatal interactions of blood and endocardium . . . . . . . . . . . . . . . . 825
15.5.1 Coordination of cardiac form and function . . . . . . . . . . . . . . . 827
15.5.2 Flow molding of the embryonic heart chambers . . . . . . . . . . . . 829
15.5.3 Mechanosensing endocardium and valvulogenesis . . . . . . . . . . 831
15.5.4 Endocardium influences mural histoarchitectonics . . . . . . . . . . . 833
15.6 Postnatal cardiomyocyte and endocardial mechanotransduction properties 835
15.6.1 Frank–Starling mechanism in cardiac muscle . . . . . . . . . . . . . . 836
15.6.2 Endocardial mechanotransduction in cardiac muscle . . . . . . . . . 837
16 A Recapitulation with Clinical and Basic Science Perspectives:

Directions of Future Research 851
16.1 Normal ventricular ejection pressure gradients . . . . . . . . . . . . . . . . . 854
16.1.1 Impulse and Bernoulli components . . . . . . . . . . . . . . . . . . . 855
16.1.2 Conditions with augmented nonobstructive ejection gradients . . . . 855
16.2 Abnormal transvalvular and intraventricular ejection gradients . . . . . . . 858
16.2.1 Transvalvular gradients in aortic stenosis . . . . . . . . . . . . . . . . 858
16.2.2 Pressure loss recovery in aortic stenosis . . . . . . . . . . . . . . . . . 860
16.2.3 Apparent “dynamic obstruction” of the outflow tract post-AVR . . . . 863
16.2.4 The pressure gradients of hypertrophic cardiomyopathy . . . . . . . 864
16.2.5 Ventriculoannular disproportion in the dilated ventricle . . . . . . . 864
16.3 Intrinsic and extrinsic components of ventricular load . . . . . . . . . . . . . 865
16.4 Implications for emerging research frontiers . . . . . . . . . . . . . . . . . . . 866
16.4.1 Ventricular ejection flow-field dynamics . . . . . . . . . . . . . . . . . 867
16.4.2 Quantitation of Rushmer and Bernoulli gradients with and
without outflow obstruction . . . . . . . . . . . . . . . . . . . . . . . . 867
xvi Contents
16.5 Diastolic filling dynamics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 868

16.5.1 Convective deceleration load and diastolic ventriculoannular
disproportion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 869
16.5.2 Implications for invasive and noninvasive diastolic gradients . . . . 871
16.5.3 Vortical motions facilitate diastolic filling by eliminating CDL . . . . 872
16.5.4 Further clinical correlations of large vortical motions . . . . . . . . . 873
16.6 Implications for emerging research frontiers . . . . . . . . . . . . . . . . . . . 874
16.7 Modeling anatomic details of the cardiac chambers . . . . . . . . . . . . . . 876
16.7.1 Valve leaflets and valve anulus orientation . . . . . . . . . . . . . . . 876
16.7.2 Ventricular chamber wall twisting and untwisting . . . . . . . . . . . 878
16.7.3 Incorporation of the correlate atrium and its inflow trunks . . . . . . 879
16.7.4 Papillary muscles and the trabeculae carneae . . . . . . . . . . . . . . . 879
16.8 Patient-specific predictive cardiology and surgery . . . . . . . . . . . . . . . 880
17 Epilogue 889
III Appendix 891
Functional Imaging as Numerical Flow Field Visualization, and Its Verification

and Validation 892
A.1 Functional Imaging is a numerical flow-field visualization . . . . . . . . . . 893
A.2 Error and uncertainty in Functional Imaging and verification and
validation assessment activities . . . . . . . . . . . . . . . . . . . . . . . . . . 894
A.3 Verification assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 896
A.4 Validation assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 898
A.5 Concluding remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 900
Index 904
Foreword
Concern for man and his fate must always form the chief interest of all
technical endeavors. Never forget this in the midst of your diagrams and
equations, and
Most of the fundamental ideas of science are essentially simple, and may, as
a rule, be expressed in a language comprehensible to everyone.
——Albert Einstein
Perfection is achieved, not when there is nothing more to add, but when there
is nothing left to take away.
——Antoine de Saint-Exupéry
We are what we repeatedly do; excellence, then, is not an act but a habit.
——Aristotle
here are challenges in academic medicine that are especially noteworthy. Dr.
T Donald Kennedy, President Emeritus of Stanford University, references these chal-

lenges in some of his writings where he describes the responsibilities of academicians
as including teaching and mentoring, discovery and publication, among other obliga-
tions.1 When I assumed the chair of surgery at Duke University’s School of Medicine
and Hospital several years ago, I was, of course, aware of the department’s long and
distinguished history in thoracic surgery, as well as its prowess in associated scientific in-
vestigation. Indeed, as a “card-carrying” surgeon-scientist with an abiding interest in and
commitment to clinical and academic excellence, these characteristics of the department
were major attractions for me to move to Durham, North Carolina.
Nevertheless, there is nothing quite like having the opportunity to meet, face-to-
face, with some of the individuals responsible for Duke’s historical successes. Dr. Ares
Pasipoularides, one of our emeritus research professors, is one of those individuals. Within
minutes of meeting him, the depth and breadth of his intellect and dedication to science
are palpable. His desire to educate and to inform becomes apparent only a short while
later. After only brief study, it becomes obvious that he does these things very well.
1
Kennedy, D. Academic Duty. Cambridge, MA: Harvard University Press, 1997.
xvii
xviii Foreword
Cardiovascular disease remains a major cause of death for many of the world’s peo-
ple. Simultaneously, our ability to assess the heart, and the methods that can be used for
this purpose, continue to expand and improve rapidly. High resolution digital imaging
and associated computational assessments of flow and physiological function are now
commonly available to clinicians and scientists. Whether directly caring for patients or
researching the mechanisms of disease, one must be able to understand and assimilate
the data obtained from measurements of changes in intracardiac blood flow induced by
or associated with particular diseases because these are the final macroscopic biologi-
cal correlates or “read-outs” of the underlying cellular or subcellular events that govern
the heart’s raison d’être. However, understanding these flow phenomena and their rela-
tionships is a fundamentally difficult task since the scientific and physiological under-
pinnings are quite complex and require an appropriate understanding of mathematics,
fluid dynamics, computer modeling and simulation in the context of their relationship to
the biological sciences. Explaining and teaching this information is at least an order of
magnitude more difficult than understanding it, and the ability to do so is a rare talent,
in my view.
When I had the opportunity to see a draft of what Ares and I affectionately describe
as his “opus magnum,” I first remembered the expectations that were enumerated by Dr.
Kennedy. It was clear to me that Dr. Pasipoularides’ book, Heart’s Vortex: Intracardiac Blood
Flow Phenomena, would be much more than just an encyclopedic source of information. It
would be equally valuable as an illustration of a lifelong commitment to learning, insight,
the joys inherent to scientific investigation and discovery, and a dedication to teaching
and other experiences that could be shared with and enjoyed by students of the cardio-
vascular sciences of all ages, regardless of their backgrounds, preparation, or knowledge
bases. As one begins to digest its contents, which are organized around well-referenced
fundamentals of intracardiac flows as well as their visualization and measurement, one
truly has the sense that an expert teacher is there with you, looking over your shoulder as
you learn about cardiac hemodynamics—including its developmental history, theoretical
frameworks, and practical applications. The loving attention to detail and the care taken
in constructing the book is evident; it is a tangible projection of Dr. Kennedy’s concepts
of academic duty.
As I further studied the contents of Dr. Pasipoularides’ book, I was reminded of another
literary masterpiece, The Visual Display of Quantitative Information by Edward Tufte, which
is another of my favorite books. One of Dr. Tufte’s goals was to illustrate how complex
ideas, concepts and data can be best presented visually – although this is not an easy task
and certainly may not be straightforward! Indeed, in my opinion, his studies suggest
that knowledge can often be most efficiently and effectively exchanged when crisp and
clearly written, parsimonious text is complemented by informative figures, graphs, or
other displays. Therein lies another strength of Heart’s Vortex. Dr. Pasipoularides has
provided the correct number of carefully designed figures to illustrate important principles
that significantly increase the accessibility of the material that is presented. To my eye,
they all, perhaps intuitively, reflect Dr. Tufte’s highest principles.
Foreword xix
I am honored to have been invited to write this Foreword to what I think will be an
important contribution to the world’s scientific literature. I believe it will be found to be
a masterwork by a mastermind.
Danny O. Jacobs, M.D., M.P.H.

David C. Sabiston, Jr. Professor
Chair, Department of Surgery
Duke University School of Medicine
Duke University Hospital
Durham, North Carolina, U.S.A.
Prologue
Whosoever loveth instruction loveth knowledge

——Prov. xii 1
I do not intend to avoid digressions and episodes; that is part of every

conversation; indeed of life itself.
——Alexander Herzen
Herzen, A. and D. Macdonald (1973). My past and thoughts: the memoirs of
Alexander Herzen. New York, Knopf.
The men of experiment are like the ant, they only collect and use; the
reasoners resemble spiders, who make cobwebs out of their own substance.
But the bee takes a middle course: it gathers its material from the flowers of
the garden and of the field, but transforms and digests it by a power of its own.
Not unlike this is the true business of [natural] philosophy; for it neither relies
solely or chiefly on the powers of the mind, nor does it take the matter which it
gathers from natural history and mechanical experiments and lay it up in the
memory whole, as it finds it, but lays it up in the understanding altered and
digested. Therefore from a closer and purer league between these two
faculties, the experimental and the rational (such as has never yet been
made), much may be hoped.
——Sir Francis Bacon (1561–1626)
Novum Organum (1620), Book I, Aphorism XCV. From the translation of
James Spedding, Robert Leslie Ellis, and Douglas Denon Heath in The Works
(Vol. VIII), published in Boston by Taggard and Thompson, 1863.
oday, measurements of 3-D cardiac chamber contours and flow patterns in hu-
T mans and experimental animals can be routinely acquired non-invasively. High

resolution digital imaging modalities, e.g., 3-D echo, Doppler, spiral CT and MRI,
advances in computing, numerical simulations and scientific visualization, and sophisti-
cated experimental flow models have expanded rapidly the information becoming avail-
able to cardiologists and researchers. The growing availability of such data adds a new
dimension to the assessment of cardiac disease. The observable patterns can be looked
xx
Prologue xxi
upon as letters of an alphabet. To understand their meaning, the observer needs the ability
to “read the script.”
This book addresses this urgent need for proper understanding of the physiologic and
clinical relevance of intracardiac flow patterns and flow-related variables, associated with
cardiac pumping under normal and disease conditions. It will be useful in elucidating the
generation and the (patho-) physiologic implications of flow effects that are noted in vivo,
and will guide improved therapeutic interventions.
To help make sense of even the most difficult concepts, this book introduces physical
and physiological ideas in a singular way: it is illustrated profusely with insightful, multi-
panel drawings and schematics by the author, in addition to reproductions of high-fidelity
fluid dynamic recordings at cardiac catheterization, and computer-generated intracardiac
flow maps and flow variable plots. The primary emphasis is on using basic principles and
approaches of fluid dynamics to better understand intracardiac blood flow phenomena,
in both the normal and the abnormal (diseased) human heart.
To this end, results have been used not only from clinical and animal multisensor
catheterization and angiography studies but also from a novel Functional imaging (FI)
method. This FI method has been developed by the author and his co-workers at the
Cardiac Surgical Research Lab at Duke University and the Duke/NSF Research Center for
Emerging Cardiovascular Technologies. It evolved from our method of predetermined
boundary motion (PBM) for the investigation of intracardiac blood flows by computa-
tional fluid dynamics (CFD) methodology. In both of these methods, the movement of the
endocardial chamber boundary is determined independently of the flow, which is gener-
ated by and depends on it. Only the resulting flow field of the intraventricular blood must
be computed, by incorporating the uncoupled wall motion into the CFD.
The FI method reveals detailed blood flow patterns in the hearts of individual exper-
imental animals and human subjects. It uses information derived from digital imaging
modalities that can provide dynamic 3-D cardiac chamber contours with high spatiotem-
poral resolution. The method combines geometric modeling of the cardiac chambers
throughout the cardiac cycle with computational fluid dynamics. Instantaneous cham-
ber geometry is derived directly from dynamic endocardial 3-D contours, which permits
ventricular blood flow simulations on individual experimental animals or patients with
normal or abnormal regional wall motion patterns.
Insight into a physical process can be improved if a pattern produced by or related to
it is accessible to visual inspection. FI can extend our understanding of the ventricular
ejection and filling processes and of dynamic patterns of intracardiac flows in previously
unattainable ways. Global vortical flow patterns that are beautifully visualized by FI can
be identified as the main flow feature associated with ventricular filling, and, as the title
suggests, figure prominently in the book.
Through several decades, I have been engaged in clinical multisensor catheterization
and noninvasive imaging research, in (patho-) physiologic and bioengineering animal
and bench experiments, and in mathematical modeling and computational simulation
studies of cardiac fluid dynamics and function. I have invested the years of firsthand
research and teaching needed in order to develop a truly integrative and effective approach
xxii Prologue
to communicating knowledge and difficult concepts to others, including undergraduate,

graduate and medical students, postdoctoral fellows, residents and medical and surgical
specialists.
An underlying theme of the book is to share with the reader the pleasures that come
with successfully completing difficult research programs on intracardiac fluid dynamics
and with constructing a number of new clinically relevant theories on cardiac function.
Digital imaging and visualization as well as computational fluid dynamics are difficult
subjects, regrettably beyond the reach of many interested people who are afraid of being
inundated with equations. Nevertheless, these rapidly evolving tools have allowed fasci-
nating discoveries that intrigue, interest strongly, and can be understood by the average
clinician or investigator.
The book is not a mere compilation of the most up-to-date scientific data and relevant
concepts. Rather, it is an integrated educational means to developing pluridisciplinary
background, knowledge, and understanding. Such understanding allows an apprecia-
tion of the crucial, albeit heretofore generally unappreciated, importance of intracardiac
blood flow phenomena in a host of multifaceted functional and morphogenetic2 cardiac
adaptations. These adaptations are physiologically and clinically relevant, since they can
potentially bring about transitions to maladaptive disease states.
The book concentrates on cardiological and (patho-)physiological fluid dynamic con-
cepts, many developed by the author, and is profusely illustrated with over 400 Figures
and multipanel Diagrams, forming a vital part of the pedagogy and explaining the con-
cepts. All these illustrations were prepared by the author, using Adobe CS [versions 1–4]TM
and other graphic design software suites. I endorse heartily Ezra Pound’s view that
The image is more than an idea.

It is a vortex or cluster of fused ideas
and is endowed with energy.
The book is organized in two parts. Part I provides comprehensive pedagogic back-
ground from many disciplines that are necessary for a deep and broad understanding
and appreciation of intracardiac blood flow phenomena. Such indispensable background
spans several chapters and covers necessary mathematics, a brief history of the evolution
of ideas and methodological approaches that are relevant to cardiac fluid dynamics and
imaging, a qualitative introduction to fluid dynamic stability theory, chapters on physics
and fluid dynamics of unsteady blood flows and an intuitive introduction to various kinds
of relevant vortical fluid motions.
An extensive and intensive grounding is provided in high-fidelity multisensor
catheterization, and in angiocardiographic and conventional echocardiographic imaging
modalities. An entire chapter is devoted to functional cardiac anatomy and myofiber
histoarchitectonics and to their interactions with intracardiac blood flow. A unique and
comprehensive presentation of the cardiac cycle in depth, both in health and in disease,
2
Morphogenetic = giving rise to form; Gk μoρϕη (morphe), form; γνητ ικoν (genetikon), giving rise to,
bearing.
Prologue xxiii
is then developed, along with the fluid dynamics of heart valve operation. Powerful new
pathophysiological concepts that have, on the basis of fluid dynamic reasoning applied
to physiological and clinical problems, been developed and published by the author in
influential cardiology journals, are thoroughly explained and discussed. They include
complementarity and competitiveness of the intrinsic and extrinsic components of the systolic
ventricular load, the convective deceleration component of the diastolic ventricular load, the im-
portant facilitative role of the normal diastolic ventricular vortex for filling, systolic, and
diastolic ventriculoannular disproportion, and more.
A gallery of human high-fidelity multisensor-catheter hemodynamics and fluid dy-
namics covering a variety of important normal and abnormal cardiac states follows. I
look upon this gallery as a veritable National Treasure. I acquired the high-fidelity mul-
tisensor catheterization datasets that I utilized in its creation mostly during my tenure as
Director of Cardiology Research at Brooke Army Medical Center, in San Antonio, TX. At
the time, the Cardiac Catheterization Laboratories at BAMC were by far the most out-
standing diagnostic and investigative catheterization labs in the world, performing over
1200 (!) high-fidelity multisensor catheterizations per year.
Part II. is devoted to pluridisciplinary approaches to the visualization of intracardiac
blood flows. It begins with a Chapter on 3-D real-time and “live 3-D” echocardiography
and Doppler echocardiography, CT tomographic scanning modalities, including multi-
detector spiral and helical dataset acquisitions, MRI and cardiac MRA, including phase-
contrast velocity mapping (PCVM), etc. An entire chapter is then devoted to the under-
standing of postprocessing exploration techniques and the display of tomographic data,
including “slice-and-dice” 3-D techniques and cine-MRI.
The course encompasses an intuitive introduction to CFD as it pertains to intracar-
diac blood flow simulations. This is followed—in separate chapters—by conceptually
rich treatments of the CFD of ejection and of diastolic filling, presenting at some length
the method of “PBM,” developed at Duke University by the author and his collabora-
tors. An entire chapter is devoted to fluid dynamic epigenetic factors in cardiogen-
esis and pre- and postnatal cardiac remodeling, and the book closes with Chapter 16,
on Clinical and Basic Science Perspectives, and their implications for emerging research
frontiers.
I am exceedingly gratified to have created this work as a single author, with a uni-
fied, single-person point of view, communicating with each grouping of my pluridis-
ciplinary readers as “one of them,” notwithstanding their diverse backgrounds! There
are about 1,500 pluridisciplinary bibliographic references cited in the text. The audience
will encompass undergraduate and graduate/post-graduate levels of training in medical
and related biomedical science and technology fields of study. It will include cardiol-
ogists, cardiovascular surgeons, and radiologists; medical physicists, fluid dynamicists,
and biomedical engineers; physiologists and other medical scientists—including embry-
ologists and geneticists interested in the role of flow-related forces in phenotypic expres-
sion; and zoologists and comparative physiologists.
Throughout the many years of writing and illustrating this book, I have felt like being
there, over-the-shoulder of my readers, sparing no effort whatsoever to render their task of
xxiv Prologue
comprehending sometimes quite difficult concepts, and their implications, as tractable as

humanly possible. In part as a consequence of this fact, the text is punctuated with many
informative and explanatory footnotes, as well as numerous in-text referrals to insight-
promoting figures and previous or subsequent book sections containing necessary back-
ground material, relevant explanations, or interesting clinical correlations.
The recognition of the unity of scientific inquiry is largely due to patient studies and
research in diverse disciplines. Throughout my career, I have been struck by how the
fertilization of one field by another makes new and important problems apparent; it also
makes simpler solutions of old problems possible. Yet, very few biomedical scientists are
adequately trained in mathematics and mechanics, and many others trained in quantita-
tive methods have inadequate grounding in physiological and biomedical science theory.
The book will serve a variety of audiences encompassing these extremes. The primary
one is medical students and doctors seeking understanding and knowledge about clini-
cally important intracardiac fluid flow phenomena. The range of medical professionals
includes cardiologists, imaging specialists, cardiac surgeons and physiologists, at all lev-
els of training and career development.
The book is certainly well-suited as both a supporting text and a reference book for
university courses in biomedical engineering and physiological fluid dynamics, cardiac
imaging, cardiovascular physiology, cardiology, physiology and biophysics, and fluid
mechanics with an eye to pluridisciplinary applications. It also aims at the needs of
biomedical engineers and technologists who are interested in learning about what people
involved in clinically motivated studies of cardiovascular fluid mechanics have been up to.
A.P.
Durham and Asheville, North Carolina
Acknowledgments
Thanks to Jason Malley, Executive Editor, PMPH-USA, for his great insight and intuition
and for his continued support and guidance, and to the tireless and expert Joanne Jay
and her coworkers at Newgen North America’s New York and India teams who did their
utmost to support my quest for the highest possible quality of both the written and visual
presentations.
To those who have contributed to this book indirectly, you will find acknowledgments
and due thanks woven throughout the text. I employed this method purposely, hoping
it would make your reading of the book more enjoyable and provocative, and my thanks
and gratitude more profound and meaningful.
The resources and helpful, expert librarians at the Duke University and Medical Center
Libraries, the North Carolina State University Libraries, the University of North Carolina
Asheville Library, the University of Texas and Health Sciences Center at San Antonio
Libraries, the Brooke Army Medical Center at San Antonio Library, the Trinity University
at San Antonio Library, the Harvard University and School of Medicine (Countway)
Libraries, the New England Primate Research Center Library, the Massachusetts Gen-
eral Hospital Library, the Barker Engineering Library at M.I.T., and the Brown University
Libraries have proven invaluable, as have those of the Library of Congress and the National
Library of Medicine of the U.S.A.
xxv
Part I
I
Fundamentals of Intracardiac Flows and
Their Measurement
Chapter 1
Introduction
A man is not a dog to smell out each individual track, he is a man to see, and seeing, to
analyze. He is a sight tracker with each of the other senses in adjunctive roles. Further, man is
a scanner, not a mere looker. A single point has little meaning unless taken with other points
and many points at different times are little better. He needs the whole field, the wide view.
——Professor F. M. N. Brown of the University of Notre Dame [9].
The real voyage of discovery consists not in seeking new landscapes, but in having new eyes.
——Marcel Proust (1871–1922), French novelist, in his autobiography [62].
1.1 Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.2 The black-box approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.3 The glass-box approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.4 Intracardiac flow phenomena . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.5 Dissipative structures and flow patterns . . . . . . . . . . . . . . . . . . . 10
1.5.1 Dissipative structures . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.5.2 Flow patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.6 The continuum assumption . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
1.7 Properties of fluid media . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
1.8 What is fluid flow? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
1.9 Flow-mediated interactions of form and function . . . . . . . . . . . . . . 20
1.9.1 Murray’s law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
1.10 The morphogenetic role of endothelial fluid shear . . . . . . . . . . . . . 23
2
Chapter 1. Introduction 3
1.11 Optimal use of medical imaging and flow visualization data . . . . . . . 26

References and further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
erhaps because of our past as hunters and gatherers, our visual perception
P is excellent at detecting and recognizing spatial patterns. We also very spontaneously

compare them to one another. This is why, in the common language, we speak of
“ripples” on water as well as on sand or we describe cortical cell “dendrites” (Gk. dendron
= tree) as tree-like structures. Observation and interpretation of intricate spatiotemporal
patterns are fundamental to many areas of medicine, yet in hemodynamics and ventric-
ular dynamics, our historic interest has been more related to temporal patterns and in
particular those of pulsatile waveform analyses. The fact that spatial patterns are every-
where in cardiovascular flows hardly needs amplification. From the rich color Doppler
images of intracardiac blood flow, to the intriguing pictures from cardiac MRI studies
illustrating intraventricular diastolic vortical motions, there is a wide range of spatial
arrangements present. Nevertheless, because of an interest in nominal1 “left ventricu-
lar,” “right atrial,” “aortic,” and so on, pulses of pressure, flow, and volume, we have
until recently managed to more often than not avoid confronting the challenges of spatial
heterogeneity in intracardiac blood flow.
The last few decades however have heralded an explosion of interest in cardiac fluid
dynamics, particularly in spatiotemporal patterns of intracardiac flow, which we will
address in proper detail in Chapters 12–16. Two important areas of work are arguably
the catalyst that brought the questions of intracardiac flow patterns to the forefront of
the minds of clinicians, biomedical engineers, physiologists, cellular biologists, and em-
bryologists. The first is the ready availability of high spatiotemporal resolution digital
imaging modalities and the attendant analysis that is possible with these data, made all
the easier by the ever decreasing cost of computing power and the availability of “off-the-
shelf,” low-cost simulation, and scientific visualization software. The second is the rise
in awareness of the broader impact of normal and abnormal intracardiac flow patterns
on, e.g., shear forces, which modulate important cellular processes, including morpho-
genesis, hyperplasia and myocardial remodeling, as well as factors involved in clotting
activation and thrombosis.
Digital cardiac imaging is providing enormous amounts of spatiotemporal data to
complement the temporal data traditionally measured, and we are eagerly looking to use
this for predictive modeling of myocardial responses. In principle, we have the tools
available to undertake this work and, already, impressive intracardiac blood flow models
and color graphics are being generated. However, in many cases, the scientific under-
standing of these measurements is questionable. We need better ways to develop and
assess spatiotemporal patterns of intracardiac flow, as well as to exploit properly and
fully the information that is becoming available from new measurement methods, which
often provide us with very different information to that which we are using today.
In the analysis of cardiac hemodynamic performance, two major viewpoints are possi-
ble; the first is derived from the traditional temporal approach, while the second encom-
passes detailed spatiotemporal phenomena and processes:
1
Nominal values are those that we can obtain by ordinary means, such as a fluid-filled catheter con-
nected to an external strain gauge for pressure measurements.
4 Chapter 1. Introduction
• a “black-box” approach—the overall relationships between input and output are

examined to varying degrees of mechanistic resolution; and,
• a “glass-box,” or “clear-box” approach—the spatiotemporal details of intracardiac

blood flow phenomena are evaluated.
The vastly different levels of the spatial capabilities of these two limiting approaches must
be considered when deciding how best to study specific aspects of cardiac function. This
is a question of “horses for courses”—of choosing the appropriate tool for the job.
1.1 Processes
In approaching blood flow phenomena, it is usually advantageous to take processes rather
than events as basic entities. I shall not attempt any rigorous definition of a process; rather
I shall allude to examples and make some very informal remarks. The main difference
between events and processes is that events are relatively localized in space and time,
while processes have much greater temporal duration, and in many cases, much greater
spatial extent. In space–time diagrams, events are represented by points, whereas processes
are represented by lines. A ball colliding with a tree would count as an event; the ball,
traveling from the kicker’s foot to the tree, would constitute a process. The activation of
an x-ray detector by an x-ray would be an event; the x-ray beam, traveling from its source
through the body and emerging modified to activate the detector would be a process.
Complex processes involve a large number of changing interacting variables. The basic
problem in understanding complex systems [35] is that, as the number of interactions
between variables increases, the complexity of the system increases exponentially and such
complex systems become exceedingly difficult, or even impossible, to solve.
A complex process may include a large number of variables, as long as there are few
interconnections between the variables [36]; when the number of interconnections (k) be-
comes large, k > 5, the system becomes unstable over time and is usually insoluble [78].
Complex multiple interactions can be reduced through the creation of higher-order the-
oretical concepts [43]. A higher-order concept (C) takes account of the effects of subor-
dinate variables, but reduces the group to just one variable. In effect, the original inter-
actions have been disposed of and the newly fashioned concept C can interact with new
variables as a single variable.
Proceeding to an interesting example, a well-known example of a physical process is
the Brownian movement or motion, the ceaseless, erratic, zigzag movement exhibited by
minute particles of matter when suspended in a fluid.2 The molecules of the liquid itself
are similarly subjected to a movement of this kind, but it is not directly observable by
microscope. This movement is due to the ceaseless “bombardment” of the solid particles
by the molecules of the liquid, moving because of thermal agitation. The existence of
2
It was first observed with a microscope by Robert Brown in 1827, on particles of a size of the order of
the micrometer, i.e., sufficiently small to be pushed around to a substantial extent by the water molecules,
but sufficiently large to be observable with his microscope.
1.1. Processes 5
the Brownian movement is thus closely related to and is a mark of the discontinuous
(molecular, atomic) nature of matter. Einstein’s approach [21] to Brownian movement is
instructive: he identified the mean-square displacements of suspended particles, rather
than their velocities, as suitable observable quantities. Previous investigators had tried to
determine the “mean velocity of agitation” by following as nearly as possible the path
of individual particles. Values so obtained were always a few microns per second for
particles of the order of a micron.
But the particle trajectories are confused and complicated so often and so rapidly that
it is impossible to follow them. Similarly, because of the large number of interconnec-
tions between the variables (i.e., the molecular velocities of the suspending medium) the
apparent mean speed of a suspended particle during a given time varies in the wildest
way in magnitude and direction, and does not tend to a limit as the time taken for an ob-
servation decreases. Neglecting, therefore, the true velocity, which cannot be measured,
and disregarding the extremely intricate path followed by a particle during a given time,
Einstein chose, as the magnitude characteristic of the process, the mean-square displace-
ments of suspended particles; this displacement will clearly be longer, the more active the
agitation. Thus, by neglecting the intricate path of suspended particles—reflecting the
large number of interconnections between the molecular velocities of the liquid—and by
introducing another concept, far more easily extracted by observation, Einstein opened
a new promising way to study the complex system, and proved that the mean square of
the horizontal displacement during time t increases in proportion to that time.
Physical processes can be investigated analytically, experimentally, via computer sim-
ulations, and by combined methods of attack. An example is provided by the direct
modeling by random steps of the diffusive phenomena, which comprise the spontaneous
movement and scattering of particles (atoms and molecules) of liquids, gases, and solids.
Imagine placing a small drop of ink in a perfectly motionless—macroscopically—glass of
water. Even without stirring, the particles of ink will be gradually spread out in the water.
While being spread out, the drop of ink remains centered on its starting point. This phys-
ical process is what is called diffusion. It can be shown, by applying the random-walk3
model to the process, that the average distance reached by the particles increases propor-
tionally with the square root of time, in line with the analysis of Brownian movement that
was outlined above.
An example of a process from molecular science relates to the theory of the size of
polymer macromolecules, obtained by the sequencing of a great number, N, of small iden-
tical monomers, connected together by covalent chemical bonds (a macromolecular poly-
mer chain can be visualized as a pearl necklace). It is notable that the geometry of such
macromolecules is not linear; the chain can fold up in many ways to form a kind of ball.
Naturally then the question arises of the polymer size, which depends in some way on
the number N of monomers. Modeling the folding process as a simple random walk with
3
The random-walk process may be envisioned by considering the following process: A person takes a
step in a randomly chosen direction, then takes another step in a randomly chosen direction, and then takes
another step in a randomly chosen direction, and so on until a total of N successive steps have been taken.
This process is known as the random walk and it has been extremely useful to scientists in many fields who
study stochastic (probabilistic) processes.
Figure 1.1: The system or process investigated is inside the black-box (BB) but all we are interested
in is the input and output. We do not have to know what is inside the system or how it works. We
can change the output by modifying either the input or the process itself.
3 dimensions, in which the successive monomers have random orientations completely

independent from each other, the size of the molecule can be shown to increase as the square
root of N. Taking account of steric constraints, it can be shown that the size of the molecule
increases in parallel with N raised to the power 0.59 approximately (and not 0.5, which is
not much different).
1.2 The black-box approach

The time-honored method of scientific inquiry is to treat the system or the process that
is being investigated as a black-box, as is depicted in Figure 1.1. Black-box models are
applied when there are plenty of data available regarding the performance of a system of
interest [7], but its functioning is unknown or very complex—there is not enough knowl-
edge to create a mathematical model, the system is very nonlinear and dependent on
operation point, or the analysis of the system is very time-consuming. The black-boxes
are data-driven models, which do not explicitly model the physics of the system, but
establish a mathematical relationship between a large number of input-output pairs mea-
sured from the system. Good quality data are essential for the approach. Input–output
black-box data mapping can be modeled in terms of a mathematical function (linear or
nonlinear model), which contains a number of parameters whose values are determined
with the help of the data. In most cases, it is not necessary or, in view of measurement
errors, meaningful to describe all the details of the measured data. The outputs will vary
slightly due to errors. Because the model outputs are part of the equations for the sta-
tistical parameter estimates, these parameters must also be subject to uncertainties, and
statistical methods are available to compute the variance of parameters.4 A smooth func-
4
For the regression model to be stable and statistically valid, the confidence intervals must be smaller
(preferably, much smaller) in absolute value than the respective parameter values [20,66]. An unstable model
1.2. The black-box approach 7
tion which describes the phenomenon reliably is of much more use in the estimation of
physiological performance characteristics than an “exact” representation of the data.
The mathematical input–output relationship is an empirical model, which is computed
statistically from clinical measurements or experimental time-series data. For systems
evolving in space, the output may also be pictures. This opens the vast field of image pro-
cessing, basically extending to two-dimensional (2-D) quasi-continuous arrays the view-
point of one-dimensional (1-D), discrete time-series. The internal characteristics of the
system are unknown but amenable to probing and analysis. One applies some appropri-
ately selected input stimulus to the black-box and determines the output response to the
specific stimulus. By varying the input and correlating with it the response, one deduces
information about the most probable behavior of the box for a given magnitude of stimu-
lus. One then speculates on models of the process that would reproduce, first qualitatively
and then quantitatively, such a spectrum of responses. Then one proceeds to design critical
tests for discriminating between the initially acceptable models. The classic experimental
development of the Frank–Starling law of the heart, discussed in Chapter 3, on pp. 143 ff.,
and in Chapter 15, on pp. 836 ff., is a prime instance of its application in physiology.
The black-box approach is focused on parameters that can be measured to gain insights
into normal and abnormal function from the observed input–output associations. For in-
stance, the continuous biorheologic process of ejection results in a single assessment of a
number, a measurable stroke volume (SV); this is merely a global concept that represents
the difference between the end-diastolic (EDV) and end-systolic (ESV) chamber volumes.
Both the SV and the ejection fraction (EF), derived immediately from it—EF = SV/EDV—
transcend completely possibly crucial “details” of the ejection process that influence SV.
One continuous act, the process of ejection, results in a single assessment of SV that de-
pends on two instants in the cycle. However, the imposition of discrete steps on the overall
act may reveal a wealth of additional descriptive detail. Having ejected an incremental
volume element represented by ΔV in a certain time increment Δt, the effective volumet-
ric ejection velocity, or rate of change of chamber volume, is simply the ratio ΔV /Δt—but
the ratio taken is of this incremental volume to this time in the course of ejection. There
are now as many assessments of speed as there are intervals Δt of time; and of these, there
are, in principle, arbitrarily many.5 An overall average value, the mean ejection flow rate,
is obtained as the ratio of SV to ejection time.
Since the ventricle’s function is to set the blood in motion, to evaluate its functional
characteristics, one needs knowledge of stroke volume but also of the velocities and ac-
celerations in the course of ejection. Looked at from this viewpoint, a single ejection time
index of ventricular function is almost inconceivable; any single index will give evidence
of only one aspect of function related to either blood displacement, velocity, or accelera-
tion. Which of these aspects is most important will depend on the problem at hand and
on how subtle the changes evaluated are. The hemodynamic situation is best explained
may yield very inaccurate derivative values and absurd results for even a small range of extrapolation. For
an unstable model, a small change in the data (e.g., by adding or removing just one data point) may lead to
large changes in the parameter values.
5
Similar considerations apply for the rate of change of ejection velocity, or volumetric acceleration of
outflow.
by an analogy. Suppose that one cylinder of an automobile engine is dead and the prob-
lem is to discover the resulting performance defect. Clearly, the information given by the
odometer would be useless for this problem, since the car could still be driven over a long
distance. Input from the speedometer would probably not reveal the weakness, since the
car might still cruise at 65 mph on the freeway. However, knowledge of acceleration will
detect the weakness readily, because with one cylinder out, the pickup will certainly be
impaired. From these simple considerations, we can expect that ventricular dysfunction
(or hyperfunction) will best be revealed by estimates of acceleration during ejection. Since
the simple “black-box” approach can readily provide such estimates, it is a useful tactic.
1.3 The glass-box approach

For the glass-box approach [22,63], the differential equations which describe the evolution
and spatiotemporal characteristics of the intracardiac flow field are analyzed, using as
inputs measurements obtained by emerging sophisticated imaging modalities. Medical
imaging had conventionally been viewed as a way of viewing anatomical structures of
the body. However, cardiac imaging has seen truly exciting advances in recent years.
New imaging methods can now display cardiac anatomy and dynamic flow phenomena,
and we can envision emerging important applications to a wide range of diagnostic and
therapeutic procedures.
Not only can growing technological advances create new and better ways to extract
dynamic information about intracardiac flows, but they also offer the promise of making
some existing imaging tools more convenient and economical, thus increasing their clinical
and research use. However, while exponential improvements in computing power have
contributed to the development of today’s biomedical imaging capabilities, they alone do
not provide a sufficient springboard to enable the development of truly novel concepts
of cardiac physiology and its derangements. That development will require continued
training and research in fluid dynamic aspects of cardiac function and associated areas.
Afterall, the optimal use of medical imaging and visualization obviously depends on
what the user wants to see! Especially in the case of visualization, the questions of users
often vary in a significant way. In turn, that depends on their appreciation of the flow
phenomena that are there to recognize, understand, and incorporate in an integrated
framework of cardiac function. New ideas in the field may well replace other already
existing methods; in any event, they enrich the assortment of possible views of patient or
experimental animal derived imaging data.
The imaging and numerical investigation of intracardiac flows in the glass-box ap-
proach is still at an early stage. However, the physiological, embryological, and clinical
importance of this class of flows is not in question. This book has evolved over many
years in order to introduce, develop, and integrate concepts and methods from several
fields, which underlie a pluridisciplinary approach to intracardiac flow phenomena. It
is aimed at context-setting for what the reader will encounter in the literature of intrac-
ardiac blood flow; i.e., on providing a mental structure in which to place findings in the
biomedical engineering, physiological, and medical literature, as well as his or her own
1.4. Intracardiac flow phenomena 9
relevant clinical or experimental observations. Most models describing the flow within
the human heart are derived from empirical observations in animals and also in human
subjects undergoing diagnostic evaluation and follow-up studies. The available mea-
surement techniques are, therefore, important and they have evolved in parallel with an
increased understanding of intracardiac flow phenomena. With rapid developments in
measurement methods and tools for analyses, we should have all the ingredients to give
us new insights into interactive aspects of cardiac function.
Even so, just how do we go about it? Are the paradigms we develop able to use all
or most of the information we have available? Needless to say, between the black- and
glass-box views, as we defined them here, there exists in actual practice a continuum that
admits different levels of exposure of any given system’s detailed mechanisms and of the
equations that govern its dynamic behavior, under any set of operating conditions.
1.4 Intracardiac flow phenomena

The term phenomenon6 denotes an observable event. Phenomena make up the raw data of
science in general and fluid dynamics and physiology in particular. One of the more serious
hurdles in analyzing the flow of fluids is the bewildering range of phenomena which
may occur in seemingly simple flow situations; and how, at times, very small changes in
flow parameters produce drastic changes in flow patterns. Thus, when we open a water
faucet, water comes out initially in a smooth “transparent” stream and remains so as the
flow rate is increased. Then, suddenly, when a critical flow rate is exceeded, the smooth
stream breaks up into an irregular one. Clearly, the mathematical models describing the
behavior of the water stream in the two cases have to be quite different.
Many flow phenomena can be exploited by technology and medicine. Intracardiac flow
phenomena refer to flow events and spatiotemporal flow patterns occurring according to
biorheological laws, in both health and disease, within the cardiac chambers and the ad-
joining trunks of the great vessels. They have physiologic, clinical, embryological, and
pathological interest, and are susceptible to scientific description and explanation. Their
recognition and enhanced understanding, as a result of recent advances in imaging, are
conducive to better evaluation of ventricular performance and adaptations, and to im-
proved diagnosis and management of functional abnormalities and failure.
There are degrees to which we can observe and explain flow phenomena and their
functional consequences, due to limitations in our knowledge of processes and/or our
measurement and modeling methods. It is important to realize that the scale at which
we take our measurements will also affect the extent to which we are able to observe and
describe spatiotemporal patterns of intracardiac flow phenomena [24, 26, 27, 52, 55]. If
we have only a few data points, we are unlikely to identify a meaningful pattern. With
just a few measurements, we might he tempted to treat a distribution of intraventricular
blood velocities as a random field. We must be confident that the measurements we are
interpreting are capturing the nature of the underlying phenomena, and are not simply
6
Exact transliteration from the Gk.
a function of our sampling extent or density (cf. Fig. 12.23 and the associated discussion
on pp. 672 f.). Because we may not be able to sample densely enough to fully define the
underlying patterns, we must exploit our understanding of large scale “coherent” (i.e.,
spatiotemporally correlated) motions and dominant processes and of their manifestations
at different scales.
We generally formulate our understanding of processes in the form of models [53,
56, 57], which in turn need measurements for proper testing, and so we have a theme
of observations, understanding and modeling linked in an iterative loop. Our models
ought to seek enlightenment [52–54, 69], rather than imitation. We might then look for
the essence of the intracardiac flow system under study, disregarding all aspects and
processes that we think are not absolutely essential. The resulting set of essential processes
will then define our model. The object is to reproduce the consequences of what we
think are the essentials, and the only thing that can prevent us from achieving this is an
inaccurate specification of the physics. What we can hope to get right is the interactions
between processes. In the simulation model, this can sometimes get lost in the process
of adjusting parameters to make the answer better—a process known as fine-tuning. In
the enlightenment model one would aim to get the physics right in a parsimonious way,
perhaps at the expense of a somewhat lower accuracy.
1.5 Dissipative structures and flow patterns

Nature presents us with countless events and objects that exhibit a high degree of order.
They often organize themselves out of disorder and once formed they manifest varying
degrees of stability against external and internal disturbances [10, 11]. Self-organizing
phenomena are not limited to physiological systems; seasonal weather patterns, fluid
flow systems, artistic work, etc., also display comparable characteristics. Physiological
science strives to explain how Nature matches form to function at all levels of organiza-
tion, from subcellular to intact organ-systems, and at the level of the organism as a whole.
Any effort to understand such self-organizing phenomena in a system must begin
with understanding that the underlying processes do not happen in a static or quasistatic
fashion. Rather, they occur under conditions that keep the system away from equilib-
rium, and they exhibit a stable order—either temporal, or spatial—instead of proceeding
toward an equilibrium state.
In 1952, Alan Turing, a British mathematician and artificial intelligence pioneer, sug-
gested [74] that the competition of chemical reactions and diffusion can bring about a rich
variety of pattern forming instabilities (see Section 9.2.1, on p. 445 f.), which give rise to
Turing patterns [44], so called in his honor. Turing was apparently the first to point out
that if diffusion, autocatalysis, and autoinhibition are combined in a set of rate equations
for two morphogens, a sinusoidal disturbance with a particular wavelength grows out
of thermal noise, thus leading to the spontaneous appearance of an ordered spatial pat-
tern [74]. The outcome of the pattern-generating reaction-diffusion mechanism depends
on at least five parameters: initial synthesis rate of the activator, diffusion rates of the
1.5. Dissipative structures and flow patterns 11
activator and of the inhibitor, and degradation rates of the activator and of the inhibitor.
Apart from chemical systems, this mechanism is also relevant to pattern forming biolog-
ical systems, which were Turing’s main motivation, since he proposed these phenomena
to explain the genesis of such biological patterns as a zebra’s stripes. He demonstrated
that the characteristic dimensions of the resulting stationary patterns are independent of
the characteristic lengths in the system, a feature that is qualitatively different from the
case of many hydrodynamic instabilities, for which the characteristic dimensions of the
patterns are usually given by the geometry of the set-up. This is, for example, the case for
Rayleigh–Bénard convection (see below) and for Taylor vortex flow (see Section 9.5.4, on
pp. 463 ff.). Turing pattern-forming chemical reactions can, in turn, induce and interact
with fluid motions because of the fluid density dependent gravity effects that they induce,
via concentration or temperature gradients that they create. Technical obstacles placed
Turing structures virtually beyond experimental reach for nearly four decades following
his ground breaking 1952 Royal Society paper [74]. Eventually, experimental evidence for
the existence of Turing structures, in comparatively simple chemical systems, emerged
[14, 42, 45, 51].
The solutions obtained by means of various mathematical and computational tech-
niques will be described in Chapters 2, 4, 9, and 12–14, to many flow phenomena reveal
rich features, including self-regulatory and self-organizing processes. In our study of in-
tracardiac flow phenomena, particularly in Chapters 13–16, we will encounter flow events
and processes that undergo self-regulatory and self-organizing evolution driven by causal
organizing factors. We label such processes “patterns.” By closely studying the character-
istics of a pattern, we may arrive at a mathematical description of its dynamics.
1.5.1 Dissipative structures
A profound distinction between equilibrium and dissipative structures was introduced by

Glansdorff and Prigogine [25, 47]. Equilibrium structures may be formed and maintained
through reversible transformations, implying no appreciable deviation from equilibrium.
A crystal is a typical example of an equilibrium structure, and macroscopically its state
corresponds to a static equilibrium. Dissipative structures, on the other hand, are formed
and maintained through effects arising out of the exchange of energy [3], and possibly
matter, under nonequilibrium conditions. Dissipative structures are maintained far away
from thermodynamic equilibrium by fluxes of energy, and possibly matter. A critical
distance from equilibrium, i.e., a minimum level of dissipation, is needed to maintain them
[61], and in this situation “specific kinetic laws permit the construction and maintenance
of a functional and structural order” [25].
Heat transfer from a wall to the fluid has stability consequences due to changes in
buoyancy and, to a secondary extent, in viscosity. A recurring example of instability
and an ensuing dissipative structure is that of the Rayleigh–Bénard cells in a thin layer
of liquid, enclosed between two plates so that no free air gap forms, and heated slowly
from below [4, 6, 38]. For small temperature gradients, i.e., near thermodynamic equi-
librium, heat diffusion is sufficient to dissipate the thermal energy supplied, with the
Figure 1.2: a. Rayleigh–Bénard instability in a thin layer of fluid between two flat surfaces heated
from below, to produce a gradient of temperature and density (T1 > T2 ; ρ1 < ρ2 ). If some of the
warmer fluid in the lower portion of the layer is displaced toward the upper part, it enters a region
of greater density and is subjected to a buoyancy force, B, acting toward the top. B is opposed
by a viscous force, V, and by heat diffusion, D, which tends to revert the temperature, T + θ, of
the rising particle to the temperature, T, of its surrounding fluid. In the same way, fluid displaced
downward from the upper portion of the layer, is denser than the surrounding fluid and tends to
descend further toward the bottom. b. Convection begins when B exceeds the dissipative effects
of V and D; it gives rise to beautiful dissipative structures; first to the Rayleigh–Bénard rolls, shown
in panels b. and c., and then—at higher Rayleigh numbers—to hexagonal Rayleigh–Bénard cells,
and, eventually, turbulence.
liquid remaining macroscopically in a state of rest, albeit in a “top-heavy” arrangement

engendered by the “adverse” temperature gradient. The temperature gradient acts as a
controlling parameter of the dynamic behavior of the system. When the flow of energy
into the liquid is raised, and with it the temperature gradient, the liquid—still below the
boiling point—moves away from thermodynamic equilibrium. It becomes increasingly
difficult for heat diffusion, by itself, to ensure the dissipation of the thermal energy sup-
plied. Unexpectedly, another channel opens, in competition with the diffusive channel,
through which the energy supplied may be dissipated: and abruptly, at the so-called
Rayleigh–Bénard instability, a macroscopic collective motion is triggered.
A flow produced by such effects is called buoyant convection. The hottest parts of the
liquid, those closest to the heat source, expand, and because of Archimedes’s buoyancy
tend to float, moving upward. Here they are cooled down, thus falling again toward
the bottom. Thus, a process of heat transport by convection is established by a collective
motion of liquid particles that is produced through the kinetic energy developed by the
work of the buoyancy forces generated by the gradient. The circulatory movement is
slowed down by two stabilizing processes: by heat diffusion, which aims at ironing out
the temperature gradient, thus tending to cancel out the density gradient, and by the
viscosity of the liquid, which causes any induced buoyant velocities to naturally tend
to decay. The liquid layer stays at rest as long as dissipation dominates but convection
develops when the destabilization is sufficient. The relative importance of the mutually
opposed forces is assessed by the Rayleigh number. Convection begins when the buoyancy
force exceeds the dissipative effects of viscous resistance and thermal diffusion, namely,
when the Rayleigh number exceeds a critical level. Convection aims at restoring a stable
density stratification, with heavy fluid at the bottom. Steady, stable roll-like Rayleigh–
Bénard vortices are illustrated in Figure 1.2. With further increase of the Rayleigh number
the rolls become unstable, and 3-D convection flows come into being. Best-known among
the steady, 3-D flow configurations are hexagonal vortex cells—Bénard cells—that give the
impression of honey combs when viewed from above in the presence of an appropriate
marker, such as aluminum flakes. At still higher Rayleigh numbers, the flow regime
becomes turbulent.
1.5.2 Flow patterns

We recognize any self-organizing flow event or phenomenon as a process involving dy-
namic interaction. The interaction embodies two mutually opposed actions: ordering
and disordering effects. We can place the concept of “pattern” in a proper perspective by
classifying such self-organizing flow events and observations in terms of the underlying
ordering/disordering effects. The nature of interaction depends on the characteristics of
the flow process, and energy exchanges and transformations among fluid particles are
extremely important in dictating the nature of the evolving pattern. Depending on the
relative importance (or strength) of the antagonistic influences, a flow system may—on
the basis of a black-box approach (see Fig. 1.3)—be classified into the following three main
classes:
(i) Ordering effect Disordering effect: The flow system eventually ends up in com-
plete randomness, as is exemplified by established homogeneous isotropic, or nearly
isotropic, turbulence, because the overall appearance of the flow seems not to change
(in a statistical sense) under translations and rotations.7 Fluid turbulence is a good
example of a homogeneous phenomenon. There are many scales of motion present
7
The compound term homogeneous isotropic turbulence was introduced by Lord Kelvin (1824–1907), in
1887 [23, 37]—see also discussion and pertinent footnote on p. 125.
Figure 1.3: Tank black-box model of the generation of a dynamic coherent flow pattern. The tank
level is determined by the applying rates of input and output, which correspond to ordering and
disordering effects. This may be expressed in terms of a difference between “gain” and “loss”;
that is, between an external destabilizing action and the system’s dissipative reaction that tends
to maintain it in the status quo. When the destabilizing action wins out, the critical fluctuation
associated with one of the system’s collective variables, instead of regressing, emerges as the or-
der parameter, and the system organizes itself, quite abruptly, into a pattern according to a new
structure.
at the same time and in the same region of space: the small scales of motion are em-
bedded in the larger-scale eddies. On the other hand, a flow is inhomogeneous and
exhibits discernible features and patterns if the different phenomena of interest are
widely separated in space, or time.
(ii) Ordering effect ≈ Disordering effect: Order and disorder coexist heterogeneously, as
exemplified by intermittent turbulence. Intermittency is a situation in which flow,
usually considered turbulent globally, manifests several identifiably different and
distinct states. Each of the states has a statistical probability of existing in a particu-
lar region of the flow field, but there is no predictable time of recurrence. An exam-
ple of intermittency is an overall laminar flow with finite-sized turbulent “patches”
convected along with it. The existence of intermittency indicates the presence of
relatively narrow interfaces separating regions of fluid having distinctly different
properties. Usually the system displaying intermittent turbulence is very sensitive to
an additional disturbance—ordering or disordering. In some cases, a “disturbance”
may then drive the system to either uniform order (laminar flow) or uniform disor-
der (established turbulence).
(iii) Ordering effect Disordering effect: The flowing fluid particles are set in formation
by an ordering effect, as exemplified by large-scale coherent vortical motions. As a
Figure 1.4: The chemical compound H2 O can exhibit not merely quantitative property changes,
but also striking qualitatively different physical states as its temperature rises. This behavior displays
a wonderfully nonlinear character, shifting abruptly from a solid to a liquid, and shifting abruptly
again from a liquid to a gas.
result, the system exhibits a characteristic order, structurally and functionally, as a

collective feature of the flow field. Such collective features can be very stable against
disturbances, as long as the disturbances are not very strong. We characterize them
as “flow patterns.”8
It should be especially noted that the appearance and evolution of flow patterns are
usually neither gradual nor continuous; rather, they come about abruptly once certain
threshold values of flow-regime governing parameters are attained, or exceeded. A famil-
iar example of this sort of nonlinear, abrupt, and striking transition patterns is found in
the behavior of H2 O as a function of temperature (see Fig. 1.4).
At low temperatures, H2 O exhibits properties9 of a crystallized solid, ice. Up to a
point, increasing temperature has very little effect on this crystalline physical state. H2 O
remains crystallized and solid. As temperature continues to rise, however, there is an
abrupt and unexpected dramatic qualitative change. Ice becomes a liquid. This change is
nonlinear. If the temperature is below the melting point, ice remains ice. If the temperature
is held at the melting point, however, all the ice becomes water—not instantaneously, but
without any further rise in temperature. Continuing to increase the temperature changes
the behavior of this liquid very little, for another extensive range on the temperature
8
In specific flow situations that we will examine in subsequent chapters, we have made an attempt at
extracting laws that govern the characteristic behavior and the dynamics of such patterns.
9
A property of a substance or a system is any observable characteristic of the substance or system. The
properties of a substance or system characterize its state.
dimension. The water molecules move around more as they absorb heat, but the hot
water remains a liquid up to another critical temperature. When H2 O reaches its boil-
ing point, it changes character again, to a gas. Again the transition between physical
states is quite abrupt and qualitative, rather than merely quantitative.
Commonly, transitions into different successive flow patterns are accompanied by se-
quential breaking of geometric flow-field symmetries—see Sections 9.5.4 and 9.6, on pp.
463 ff. and 473 f., respectively. Convection systems, such as the Rayleigh–Bénard model
considered above, develop patterns by steps when progressively driven away from equi-
librium upon increasing the temperature gradient. The physical problem is clearly ruled
by a mechanical cause, buoyancy-induced advection10 , counteracted by thermodynamic
dissipation processes, i.e., viscous friction and thermal diffusion. When dealing with
pressure gradient driven flows, one could thus try to stay within the same framework
and start with the no-flow equilibrium situation, then consider weakly out-of-equilibrium
laminar regimes mostly controlled by viscous dissipation, and further increase the pres-
sure gradient to observe the transition to turbulence after some cascade of instabilities.
This approach can indeed be followed in some cases [44] but, in most strong pressure
gradient flows, mechanical evolution largely preempts the relaxation trends of thermo-
dynamic origin.
1.6 The continuum assumption

People have tried to understand space, time, motion, and the notion of “continuum” for
thousands of years. This pursuit lead the Pythagoreans to the discovery of irrational
numbers, to Zeno’s paradoxes, to infinitesimal calculus, and many more intriguing ideas.
What do we mean when we say “continuum?” Here is a description that was given by
Albert Einstein [39]: “The surface of a marble table is spread out in front of me. I can get
from any one point on this table to any other point by passing continuously from one point
to a ‘neighboring’ one, and repeating this process a (large) number of times, or, in other
words, by going from point to point without executing ‘jumps.’ I am sure the reader will
appreciate with sufficient clearness what I mean here by ‘neighbouring’ and by ‘jumps’ (if
he is not too pedantic). We express this property of the surface by describing the latter as
a continuum.”
The flow-governing equations arise in describing the flow characteristics of an in-
finitesimal fluid element using such a continuum assumption [15]. Imagine that we take
a fluid sample volume large enough to include a sufficient number of constituents of a
fluid medium so that it accurately represents the macroscopic density of the fluid within
a flow region of interest. We call this sample volume a fluid parcel. The parcel must
contain enough constituents of the fluid medium at hand to represent the average char-
acteristics of the fluid at the center point of the parcel; at the same time, it must be small
enough so that a parcel taken contiguous to it will have properties differing by only a
small amount from the other parcel. Therefore, when modeling a fluid as a continuum,
10
We use the terms advection/convection interchangeably to denote the macroscopic transport (or move-
ment) of a fluid and its properties by the fluid’s organized velocity field.
1.7. Properties of fluid media 17
the averaging parcel size should be much smaller than the smallest length scales in which
we are interested, so that we can consider the averaging parcel to be a “point.”
If we consider the smallest parcel of a fluid having the gross properties of the fluid
to be a material point, the properties of interest vary gradually from point to point in
the fluid, as though the fluid were a continuum. Material lines, surfaces, and volumes
are composed of material points. The preceding formulation is the continuum concept.
Treating a fluid, including blood in intracardiac flow studies, as a continuum allows the
use of very powerful tools, and it is therefore a very important concept. Once we assume
that the fluid itself is continuous in its properties, we may describe these properties with
continuous functions and apply differential equations in the analysis of flow processes.
This allows us to utilize the rather considerable stock of mathematical tools involving
continuous mathematical functions in its entirety in both the description and solution of
fluids problems.
In particular, the continuum assumption of the Navier–Stokes equations, which govern
flow of viscous fluids, is valid provided that the mean free path of the molecules is negli-
gible compared to the characteristic dimensions of the problem, i.e., of the flow region in
which the fluid is contained—a condition which requires a very high frequency of molec-
ular collisions with the wall. If this condition is not sufficiently met, the fluid will not be
under local thermodynamic equilibrium and the linear relationship between shear stress
and rate of shear strain (Newton’s law of viscosity, see Section 4.6, on pp. 190 f.) cannot
be applied. Velocity profiles, boundary wall shear stresses, mass flow rates and pressure
differences will then be influenced by noncontinuum effects, such as those applying in the
study of rarefied gas dynamics [5].11 Moreover, the conventional “no-slip” boundary con-
dition imposed at a solid–fluid interface will begin to break down even before the linear
stress-rate of shear strain relationship becomes invalid.
1.7 Properties of fluid media

We distinguish fluid media from solids based on their response to an applied static shear
force [6]. If, e.g., we subject a solid bar to a torque, it twists. The restoring elastic stresses
within a solid (below the yield limit) are proportional to the strains, and therefore, when
subjected to the shear force of a torque, a solid distorts through a specific angle (equi-
librium distortion) such that it develops internal stresses that just balance the applied
torque. The magnitude of the distortion angle generally depends on the applied torque
as well as on the elastic properties of the solid. When the torque is removed, the solid
regains its prior configuration.
If, on the other hand, the torque is applied to a fluid, the behavior is entirely different.
The fluid does not acquire an equilibrium distortion but continues to deform for as long
as the torque acts [6]. We make use of this behavior to define a fluid. Thus, a fluid is a
11
There are microscopic (molecular) models that recognize the particulate structure of the rarefied gas
as a myriad of discrete molecules and provide information for the position, velocity, and state of every
molecule at any instant.
medium that cannot be in equilibrium under the action of any shear force, no matter how
small. Although a fluid does not resist a shear force by acquiring an equilibrium defor-
mation, nonetheless it exhibits an equilibrium velocity. This equilibrium value increases
with the applied shear force. This suggests that a fluid does resist a shear force, not by
acquiring an equilibrium deformation but by acquiring an equilibrium rate of deforma-
tion. Thus, a fluid deforms continuously under the action of a shear force, but at a finite
rate determined by the applied shear force and the fluid properties. When the torque is
removed, the velocity of the fluid medium drops back to zero but it does not regain its
prior configuration.
Clearly, the constitutive equations for fluids are markedly different from those for
solids. There are substances, so-called “elastico-viscous fluids” or “visco-elastic solids,”
such as recently coagulated blood and mucous, which display behaviors intermediate
between those characterizing solid and fluid media.
1.8 What is fluid flow?

In this Section, we define more precisely what we mean by “fluid flow,” a phrase that
we have been using and will be using repeatedly, and we consider how a fluid flow is
like and unlike solid particle dynamics. In fact, the dynamics of fluid flows that we will
consider in the succeeding chapters are straightforward applications of classical physics,
built upon the familiar conservation laws [28, 52]—conservation of mass, linear and an-
gular momentum, and energy, which will be developed in Chapters 2, 4 and 9. In
this regard, the physics of fluid flow are no different from the physics of solid particle
mechanics.
Consider a collection of an arbitrarily large number of solid particles as “point masses”
moving under the influence of internal and external forces. We could conceive such point
masses to make up an extended fluid medium. However, there are important differences.
A fluid particle is in a literal sense pushed and pulled around by its surroundings (other
fluid particles, or the flow-field boundaries) in a way that solid particles may not be. At
the same time, a fluid particle may be quite dramatically stretched and strained and may
become so intermingled with its fluid surroundings as to effectively lose its identity. It
is this complete and intimate interaction between a fluid particle and its surroundings
that characterizes fluid flows and that distinguishes fluid dynamics from solid particle
dynamics. Thus, in a fluid mechanics problem, we have to solve for the fluid motion of
the entire fluid domain at once; we generally cannot understand or predict the motion
of one fluid parcel without understanding the overall fluid motion, i.e., obtaining the
solution, over the entire flow domain.
For even the simplest problems, this often will be a huge task that can be approached
in full only with the aid of a powerful computer, which is carefully programmed to fol-
low the laws governing fluid motion. The systems of equations governing the evolution
of intracardiac flow are nonlinear and are solved using numerical methods, which re-
flect the spatiotemporal scale of the underlying flow phenomena. The rapid upstrokes in
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PEACE" ***
“LET US HAVE PEACE!”
REMARKS
OF
LOGAN H. ROOTS,
ON THE
Assassination of Hon. James Hinds,
DELIVERED IN THE
HOUSE OF REPRESENTATIVES,
WASHINGTON, D. C.,
On Friday, January 22, 1869.
WASHINGTON:
1869.
REMARKS
BY
HON. LOGAN H. ROOTS.
Mr. Speaker—
The sad subject occupying the attention of this honorable body is
one that bears upon my mind with peculiar force. I was personally
acquainted with James Hinds during a busy portion of his eventful life,
and it was in the district that I have the honor to represent in which
he met his terrible death by political assassination.
His life, though short, was long enough for many hundreds to have
become so endeared as to have wished it longer. His life, though
short, was long enough to afford a wonderfully instructive lesson of
encouragement to all those in this crowded world struggling against
the barriers of poverty. Its history is an account of the child of
poverty, developed into the honored man by its own exertions. Its
history recounts what mighty results may be accomplished on no
other capital than a clear intellect under the impetus of an
indomitable will. Generally, when one falls so young the exclamation
is, “Oh! what might have been.” In this instance imagination might
feast itself on such a theme ad libitum; but that is not necessary, it
is grand enough to say, “See what was!”
Only twenty years ago James Hinds was a fatherless, penniless lad.
But so determined was he to acquire knowledge that he attended
school when he only did so by hiring a room, doing his own
housekeeping, and working enough beside outside of school hours
to earn the means of paying for his school expenses and daily living.
Such earnest perseverance created success even under the most
lowering clouds of adversity.
Traveling by such rugged steps he did not come upon the stage of
manhood a mere hot-house production of opulence, but an earnest,
laborious youth, gradually developed into a self-made, self-reliant
man. Experience taught him to never wait for the coming of success
or friends, but first make success, and then friends would come. His
nature and training alike rendered it equally impossible for him to
play sycophant to the rich or oppressor to the poor. His warm
sympathy with the oppressed and downtrodden touched a
responsive chord in men’s hearts that returned him in a remarkable
degree the affection of the masses. The humblest and most
friendless loved him without fear of being repulsed, and learned to
regard him as their especial champion.
When the great struggle came between human oppression and the
nation’s life, he was at once found positively on the side of his
country, and he went forth to do battle upon the side of loyalty, of
freedom, and justice to humanity.
It is now, though, nearly four years since the happy moment arrived
when he considered the struggle ended. We all proudly felt that
henceforth free speech and free men were to be as universal south
of Mason and Dixon’s line as they long had been north. It was at
that happy period that Mr. Hinds was allured by the genial clime and
inviting features of the Southwest to make his home in Arkansas,
and engaged in the practice of his profession with an assiduity that
received merited success.
Alas! it was not long until the fact was developed that the fierce fires
built on human oppression to destroy and keep destroyed the
relations of the State to the nation were not extinguished, but only
smoldering; compressed and changed, but not abated. When this
fact was developed, and the question arose as to whether or not
Arkansas should make an effort to regain her lost sisterhood in the
great family of States, notwithstanding the odium and dangers with
which those who had severed the State from her proper relations
cast about such a course, James Hinds became an earnest advocate of
her return to the loyal household. Elected to the Constitutional
Convention by one of the largest majorities in the State, he soon
became recognized as one of the prominent leaders, and to him the
humble, toiling citizen of that State owes a debt of gratitude he can
never repay; for in the construction of the fundamental law of the
State he was most active in the introduction and riveting of those
points which are barriers of protection for the many weak against
the few strong, and for the securing to the humblest all the rights of
citizenship granted to the proudest.
After the adjournment of the convention and the submittal of its
work to the people, he was elected by a remarkably large vote to a
seat in this body, and even in the brief period of his presence here
he exhibited a lively interest in the welfare of the State and
indefatigable efforts to promote her good without failing to strive for
the greatest weal of the whole nation.
Immediately upon the closing of the summer session he went to his
home and entered vigorously into the canvass for freedom, peace,
and prosperity against caste, oppression, revolution, and murder. I
know, sirs, many of you may think that the party which Mr. Hinds
opposed was equally anxious for peace with the party whose
principles he espoused. That might have been the case in other
places, but in Arkansas, at least, their acts showed that the
Republican party advocated peace with a desire that the beloved
white-winged spirit of peace might settle and abide in the land. But
when the Democracy did for a moment advocate peace, their desire
seemed to be for pieces of Radical skulls. To advocate real peace
was not entering upon a holiday pleasure excursion, but was to
brave death and tread on the very verge of eternity. All this James
Hinds knew, yet faltered not. A few days before his death he wrote
to a friend:
“We must win the election, stand a fight, or leave the State, and
it is sad to think that many of our number, perhaps myself
included, must be murdered before seeing the ides of
November, to know whether we win, fight, or leave.”
On the day of his murder he was in a county which he considered

less dangerous than some through which he had traversed, and he
so expressed himself, but added:
“With men all over the country bound by terrible oaths to take
Radical lives, we do not know where there is any safety. Oh! it is
terrible. But it may be that it is all for the best, for they say the
‘blood of the martyr is the seed of the church,’ and it may be
that the loyal blood now drenching this land will arouse those
criminally timid men who had the power and withheld the grant
of arms to our State authorities, and arouse the patriotic masses
to realize it is the nation’s duty to protect the nation’s citizens.”
Oh! little did he think at that moment that ere the sunlight of that
beautiful October day should give way to the cold dew of night his
own soul would be driven from his body by the cold damp of death.
He was traveling with Hon. Joseph Brooks, another tried and valiant
soldier in the great cause of freedom and equal rights. They were to
speak that day about six miles from the village of Indian Bay. They
had been refused passage on a steamboat because they were
Radicals, and so were belated. Some hundreds of eager, expectant
Republicans were awaiting their arrival. To this meeting the officers
of the Democratic club had gone as advocates of the adoption of
“joint peace resolutions.” The Republicans said that several Radicals
had then recently been killed in the county and no Democrats; and
therefore they thought if the Democracy had suddenly acquired a
desire for peace no resolutions were necessary; but although some
of them thought it merely a cloak for Democratic villany, they were
willing to bind themselves in resolutions to do what they intended
doing anyhow, and they therefore unanimously adopted the
resolutions. One of the principle signers and most apparently earnest
advocates was George W. Clark, secretary of the Democratic club.
But as soon as he had signed them he returned to his home, arriving
there before Messrs Brooks and Hinds had reached that far, and
himself gave the fated ones direction as to the road. When they had
ridden on he got his gun, saddled his horse, and rode after them.
The intended victims were riding along with their greatest solicitude
at the moment, being anxious though to reach the waiting crowd.
The horses being differently gaited, Mr. Brooks was at the moment
some fifty yards ahead. The man with grayish suit on rode up near,
but a very little in the rear of Mr. Hinds, smiling as Judas may have
smiled when he kissed his Lord and Master, he engaged in pleasant
conversation. For a second the three thus rode on, the victims
wholly unsuspecting, and the smiling murderer, with cold-blooded
calculation, waiting for a better opportunity to make sure of both. An
illustration of the meaning of Democratic peace resolutions is about
to be made. The same hand which a few hours before signed peace
resolutions now grasps the assassin’s weapon, within a very few feet
of Mr. Hinds’ back, the gun is suddenly raised. Click, click, hear the
triggers! Oh! the terrible instant! bang, bang, goes the gun. Mr.
Brooks’s horse, stung with buck-shot, bounds ahead with a wounded
rider, while the second horse madly leaps forward riderless, and
James Hinds lies on the ground motionless, dying. Another order of
the Ku-Klux-Klan has been executed; smiling with a fiend’s smile
upon his features stands the Democratic assassin; the soul of
another martyr is sent unshriven before the arbitrator of eternity;
dying, shot in the back, lies the Radical Congressman. Would to God
the curtain of oblivion might drop over the scene forever!
James Hinds’ spirit has passed from earth, but his life, deeds, and
death will not soon pass from memory, so well he lived, so hard he
toiled, so young was he gathered into the unseen fold, that when we
think of him we cannot avoid to lament that:
“The hand of the reaper
Takes the ears that are hoary,
But the voice of the weeper
Wails manhood in glory.”
He had so many noble qualities and won so many strong friends we
can very easily drop the veil of charity over his faults, whatever they
may have been. Had he been faultless he could not have been
human. It is said a death-bed is a detector of human hearts. If so, it
is pleasing to know that in his expiring moments, lying with no more
friendly touch than the breast of mother earth, his few words were
not concerning his own death tortures, but were expressions of
solicitude for his wife and two sweet daughters whom he loved so
dearly. Could you, sirs, have seen the hundreds of compressed lips
and wet eyes which spoke in an eloquence and intensity of grief
words could not be framed to utter when his remains passed
through the City of Little Rock. You would have exclaimed, “Behold,
how they loved him,” and certainly he who has thus won the love of
man must have a strong claim on the mercy of God.
But ceremonies in honor of the dead can only be beneficial in so far
as they affect the actions of the living. Could the spirit of James Hinds
speak to us to-day it would not be with an effort to induce fulsome
eulogies upon those who are beyond mortal aid, but from the portals
of the dead he would say protect the living.
The nation has the power to obey such a request, and when the
people arose in their might and majesty on the 3d day of November,
it was to declare in unmistakable terms their heartfelt approbation of
the promise of him whom they felt had the power to execute the
promise that freedom and protection should be guarantied as well
on the warm gulf coast as on the cold lake shores. That was the key-
note of the entire canvass. The mighty leader of the loyal hosts was
a popular man, remarkably, deservedly popular for his glorious
services to his country. But he was most popular from the full
confidence that the people had in him that he had the will and the
power to speak into peace and tranquility the angry waves of
prejudice and passion that were raging in the South, crimsoned with
human gore. It was the embodiment of that will and power for
which the nation in such overwhelming numbers spoke its
preference, and the present is an auspicious moment to inaugurate
obedience to the people’s behests. Many good men who have always
wanted peace, but could not tear themselves loose from political
thraldom in the heat of political excitement, now express their
earnest, anxious longing for protection of life and the restoration of
peace to the country.
The very leaders of the political assassinations themselves seem now
to be partially revolting from the horrible atrocities of the execution
of their own schemes and orders, which feeling, added to the
wholesome belief they have that the authorities will be sustained,
lives will be protected, and peace will be maintained, is making even
them for the time converts to the great loyal heart’s desire for
restoration of peace and protection.
It is not indemnification for the past that is asked, it is only security
for the future. The murdered cannot be brought to life, but the
murderers can be made to spare the living. Honeyed words alone
cannot accomplish this, but men must be made to feel that
protection will prove more profitable than assassination; kind words
may do the work if it is positively known that the nation supports the
State authorities, so that there is a reserve of sterner power which
can be brought to the support of kindness on any instant of
emergency. Let party lines be obliterated in this desire for the
maintainance of peace and protection. Let partisans now be
absorbed in patriots, so that all men, Republicans and Democrats
alike, will feel an inspiration of such God-given patriotism as found
utterance from the steps of this building when nearly four years ago
he who spake as one with less in him of earth than heaven, said:
“With malice toward none, with charity for all, with firmness in the
right as God gives us to see the right, let us strive to do all which
may achieve and cherish a just and lasting peace.” His words fell
with magic effect, because, while he extended the olive-branch with
the left, in his right hand he wielded the great American Army, the
most potential power on the face of the earth. The olive-branch
should still be extended, but it will only be to loose the hand that
offers it unless it is demonstrated that the strong arm of power will
be used whenever necessary to overwhelm the crushing tyranny of
lawlessness and oppression.
Ages gone the great Omnipotent who snatched time from eternity
and spoke system from chaos, said “Let there be light,” and the
sacred chronicler informs us “there was light.” To-day the mighty
people who have saved the nation’s life in the sanguinary struggle
and declared freedom in the kingdom of slavery, have said “let us
have peace.” Shall not the historian who records the doings of this
year be allowed to say “there was peace!”
Oh, shall it not be so! The spirit of James Hinds unites with hundreds
(you know not how many) of other spirits of treacherously murdered
men in beseechingly asking the question. Their suffering widows and
orphans, without even the little comforting crumb of a Government
pension, are weepingly asking the question. The hundreds of
thousands of maimed and crippled loyal men who fought and
suffered beside comrades who, fighting, fell to establish peace and
protection, are earnestly asking the question. Thirty-eight million
inhabitants in these United States whose prosperity can only be
commensurate with the maintenance of peace and protection, all
join in prayerfully asking the question. The countless lovers of
freedom throughout the whole world with one accord are looking to
this nation and anxiously asking the question. And, sirs, remember
the Representatives of the people and the Government must be
responsible for the answer.
TRANSCRIBER’S NOTES:
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Archaic or alternate spelling has been retained from the original.
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Diagnostic Ultrasound Imaging and Blood Flow Measurements

Diagnostic Ultrasound Imaging and Blood Flow Measurements

Multiphase Flow Research 1st Edition S. Martin

Gasdynamic Aspects of Two Phase Flow Hyperbolicity Wave

Potential vortex 2nd Edition Meyl Konstantin

Introduction to Electrical Interfacial Phenomena 1st

Inflammatory Diseases of Blood Vessels 1st Edition Gary S.

Werewolves Mysteries Legends and Unexplained Phenomena 1st

Ares Pasipoularides, MD, PhD, FACC

Formerly, Director of Cardiac Function of the Duke/NSF Research Center

Formerly, Director of Cardiovascular Research at Brooke Army Medical Center

PEOPLE’S MEDICAL PUBLISHING HOUSE

Sales and Distribution

Canada Tel: 65-6863-1580

For, verily, art is embedded in nature;

Foreword Danny O. Jacobs, MD, MPH xvii

I Fundamentals of Intracardiac Flows and Their Measurement 1

2 Handy Mathematical Instruments of Thought 35

2.3 Kinematics of circular motion and rotation . . . . . . . . . . . . . . . . . . . 43

2.23 Feedback mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

3 Some Notable Pioneers 115

4 Fluid Dynamics of Unsteady Flow 165

4.6 Viscosity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190

5 Micromanometric, Velocimetric, Angio- and Echocardiographic Measurements 234

5.6.2 Spatial resolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271

6 Cardiac Morphology and Flow Patterns: Structural–Functional Correlations 298

7.5.7 LV isovolumic contraction period vanishes during intense exercise . 348

8 Addendum to Chapters 4, 5, & 7: A Gallery of Multisensor

9 Vortex Formation in Fluid Flow 442

9.4 Vortex dynamics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454

II Visualization of Intracardiac Blood Flows: Methodologies,

10 Cardiac Computed Tomography, Magnetic Resonance, and Real-Time 3-D

10.3.4 Cine-MRI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 543

11 Postprocessing Exploration Techniques and Display of Tomographic Data 582

12 Computational Fluid Dynamics, or “CFD” 623

12.6 Flow-ﬁeld discretization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 646

13 CFD of Ventricular Ejection 680

14 CFD of Ventricular Filling: Heart’s Vortex 735

15 Fluid Dynamic Epigenetic Factors in Cardiogenesis and Remodeling 808

16 A Recapitulation with Clinical and Basic Science Perspectives:

16.5 Diastolic ﬁlling dynamics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 868

III Appendix 891

Functional Imaging as Numerical Flow Field Visualization, and Its Veriﬁcation

T Donald Kennedy, President Emeritus of Stanford University, references these chal-

Danny O. Jacobs, M.D., M.P.H.

Whosoever loveth instruction loveth knowledge

I do not intend to avoid digressions and episodes; that is part of every

T mans and experimental animals can be routinely acquired non-invasively. High

to communicating knowledge and difﬁcult concepts to others, including undergraduate,

The image is more than an idea.

comprehending sometimes quite difﬁcult concepts, and their implications, as tractable as

1.11 Optimal use of medical imaging and ﬂow visualization data . . . . . . . 26

P is excellent at detecting and recognizing spatial patterns. We also very spontaneously

• a “black-box” approach—the overall relationships between input and output are

• a “glass-box,” or “clear-box” approach—the spatiotemporal details of intracardiac

3 dimensions, in which the successive monomers have random orientations completely

1.2 The black-box approach