EDITORIAL

What Is Pulsatile Flow?

Gordon Wright, Ph.D., and Anthony Furness, Ph.D.

The most surprising feature of the literature and the prolonged discussions on the subject of pulsatile and nonpulsatile blood flow is that pulsatile flow has not been
defined. It is anomalous that scientific investigations
and discussions can proceed with no clear demarcation
of the factors being compared. The most discerning authors pay only token acknowledgment to this problem
by referring to the pressure pulse amplitude measured
at some peripheral site by uncharacterized manometric
techniques, and to the pulse repetition frequency (pulse
rate). However, no evidence that pressure pulse amplitude or pulse rate has any physiological significance
has been presented.
The benefits of pulsatile flow are now well known and
are prominent in the cardiopulmonary bypass literature,
as reviewed by one of us [l]and Mavroudis [2]. In opposition, there is a growing population of authors reporting that they have been unable to detect any notable
differences between pulsatile and nonpulsatile flow [3].
One reason for this dichotomy (and there are others)
may be that different investigators have used different
types of pulsatile flow. As suggested by Philbin [3],
some types of pulsatile flow are more effective than nonpulsatile flow in preserving tissue function while others
are not. The one type of pulsatile flow we can be
confident about is the type produced in the aorta by the
normal left ventricle, and it has been suggested that this
might form the basis of a working definition [4].On the
other hand, it is clear that some benefits can be obtained
using pulsatile pumps that produce very bizarre arterial
pressure and flow waveforms compared with normal
(Fig 1) [51.
The urgent requirement for a descriptive technique
that is capable of distinguishing among different types
of pulsatile flow is apparent. In common usage, the flow
of blood from the heart to the aorta is described as a
time-history of events-an ejection phase and a recovery phase of ventricular action. We may extend this description by adding factors such as ejection phase duration, peak flow, and pressure pulse amplitude, but the
time domain description cannot provide a comprehensive definition of pulsatile flow because the morphology
of the waveform is not included.
A more complete description can be obtained by the
use of frequency domain techniques by which the complex pressure or flow waveform is transformed to a
mean level plus a series of sine waves of differing amplitude, frequency, and phase (harmonics) [6, 71. The
power of left ventricular ejection is then derived as the
product of left ventricular mean pressure and flow plus
From the Department of Biological Sciences, University of Keele, Keele,
Staffordshire ST5 5BG, England.

401

the products of pressure and flow at each harmonic

level. This gives us a clue to one of the principal advantages of pulsatile flow: for equal mean blood flow rates,
pulsatile flow contains more energy (power x time),
because nonpulsatile flow is completely represented by
the mean value, whereas it is necessary to add a series of
sine waves of different amplitude, frequency, and phase
to describe pulsatile flow. It is important to recognize
that this is not just a mathematical trick. It has real physiological significance and may be the most fundamental
benefit of pulsatile flow.
The dynamic properties of the vascular system are
similarly obtained as the quotient of mean pressure and
mean flow (peripheral vascular resistance) plus the quotients of the corresponding harmonics. Phase differences between pressure and flow for corresponding harmonics are caused by compliance and inertance in the
vascular system. The important consideration here is
that unlike a purely resistive system, a system with compliant and inertive components is capable of both temporary storage and lateral transmission of energy.
The transient storage of energy in the walls of the
major arteries has the effect of off-loading the heart, or
pump, from the high-resistance peripheral vascular
beds. The effect of this is that pulsatile flow meets a
lower impedance than nonpulsatile flow, because the
cardiovascular system is predominantly compliant. As
Figure 2 shows, aortic input impedance is dependent on
the frequency content (in terms of sine waves) of the
complex waveform.
Thus, pulsatile flow produced by the normal left ventricle gives us two important and fundamental advantages over nonpulsatile flow. First, at equal mean blood
flow rates, pulsatile flow contains more energy. Some of
this energy is transmitted downstream where it performs work, such as tissue perfusion and the promotion
of metabolic exchange, and some energy is directed radially where it encourages the movement of tissue fluids
and the formation and flow of lymph. Second, pulsatile
flow is more easily transmitted to the peripheral vascular
beds because the major arteries are compliant. These
two factors may be responsible for the plethora of physiological and pathological advantages that have been reported in controlled pump trials. Failures to detect advantages in some studies may be due to the fact that the
frequency content (in terms of sine waves) of the pump
output may not have been optimal for the patients on
whom it was used. It should be noted that the important
point is what occurs in the aorta, so that our concept of
"the pump" has to include the aortic line and cannula. A
compliant arterial line or a small-bore cannula can considerably modify the pulse. It should also be noted that
currently available pulsatile pumps can be operated in a

402 The Annals of Thoracic Surgery Voi 39 No 5 May 1985

Pressure

3001
-100

I*

Fig 1 . Pressure and flow waveforms generated in a model of the human vascular system by (A) a conventional roller pump (Sarns), (B)
a modijied roller pump (Stiickert), and (0a positive-displacement
pulsatile pump (Polystan). The modified roller pump can be operated
in nonpulsatile or pulsatile mode with a continuous range of adjustment between these extremes.

"01
.OOti

., -.--+-.
,.
-0

21

1s ,

quency-dependent corrections are necessary. Also, the

site of measurement is of great importance since the
pressure and flow pulses vary considerably between the
aorta and the peripheral arteries [6]. Finally, it will be
apparent from this discussion of impedance that measurements of peripheral vascular resistance are of little
consequence, because this value is derived from the
quotient of mean pressure and mean flow, and does not
include the considerable effects of compliance and inertance in pulsatile flow.
This brief and oversimplified discussion has not answered the original question, but it attempts to point the
way in a field of unnecessary confusion. The basic strategy in pulsatile flow studies is quite unreproachable.
The type of pulsatile flow we need is not the type produced by a pump with that mode labeled on it, but the
type that is ideally matched to the cardiovascular system. The only type of pulsatile flow we can be sure
about at present is that generated by the normal left
ventricle. Comparative studies in which the pump output fails to approach this ideal may have demonstrable
clinical benefits, but in our opinion, it is difficult to determine the relevance of these studies to the discussions
concerning the relative merits of pulsatile and nonpulsatile flow.

References

Radians
Phase

-2

Fig 2 . Impedance spectrum in pig aorta. The impedance modulus is

v e y high for nonpulsatileflow (zero frequency). Phase refers to the
delay of flow behind pressure. Positive values of phase indicate inertance, and negative values indicate compliance.

variety of modes (see Fig 1). Some modes of operation

may be better matched to the aortic input impedance
than others.
The importance of accurate measurements should be
stressed. Measuring pulsatile pump output from the
pump meter display is totally inadequate; even when an
electromagnetic flowmeter is employed, certain fre-

1. Wright G: Brain damage in dogs resulting from pulsatile and

non-pulsatile blood flows in extracorporeal circulation. University of Keele Ph.D. thesis, 1971
2. Mavroudis C: To pulse or not to pulse (collective review).
Ann Thorac Surg 25:259, 1978
3. Philbin DM. Should we pulse? J Thorac Cardiovasc Surg
M805, 1982
4. Sanderson JM, Morton PG, Tolloczko TS, et al: The MortonKeele pump: a hydraulically activated pulsatile pump for use
in extracorporeal circulation. Med Biol Eng, March 1973, p
182
5. Taylor KM, Bain WH, Davidson KG, et al: Comparative clinical study of pulsatile and non-pulsatile perfusion in 350 consecutive patients. Thorax 37:324, 1982
6. McDonald DA: Blood Flow in Arteries. Second edition. London, Arnold, 1974
7. Mdnor WR: Hemodynamics. Baltimore, Williams & Wilkins,
1982