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A key component in developing atrial digital twins (ADT) - virtual representations of patients' atria - is the accurate prescription of myocardial fibers which are essential for the tissue characterization. Due to the difficulty of reconstructing atrial fibers from medical imaging, a widely used strategy for fiber generation in ADT relies on mathematical models. Existing methodologies utilze semi-automatic approaches, are tailored to specific morphologies, and lack rigorous validation against imaging fiber data. In this study, we introduce a novel atrial Laplace-Dirichlet-Rule-Based Method (LDRBM) for prescribing highly detailed myofiber orientations and providing robust regional annotation in bi-atrial morphologies of any complexity. The robustness of our approach is verified in eight extremely detailed bi-atrial geometries, derived from a sub-millimiter Diffusion-Tensor-Magnetic-Resonance Imaging (DTMRI) human atrial fiber dataset. We validate the LDRBM by quantitatively recreating each of the DTMRI fiber architectures: a comprehensive comparison with DTMRI ground truth data is conducted, investigating differences between electrophysiology (EP) simulations provided by either LDRBM and DTMRI fibers. Finally, we demonstrate that the novel LDRBM outperforms current state-of-the-art fiber models, confirming the exceptional accuracy of our methodology and the critical importance of incorporating detailed fiber orientations in EP simulations. Ultimately, this work represents a fundamental step toward the development of physics-based digital twins of the human atria, establishing a new standard for prescribing fibers in ADT.

Cardiocirculatory mathematical models serve as valuable tools for investigating physiological and pathological conditions of the circulatory system. To investigate the clinical condition of an individual, cardiocirculatory models need to be personalized by means of calibration methods. In this study we propose a new calibration method for a lumped-parameter cardiocirculatory model. This calibration method utilizes the correlation matrix between parameters and model outputs to calibrate the latter according to data. We test this calibration method and its combination with L-BFGS-B (Limited memory Broyden - Fletcher - Goldfarb - Shanno with Bound constraints) comparing them with the performances of L-BFGS-B alone. We show that the correlation matrix calibration method and the combined one effectively reduce the loss function of the associated optimization problem. In the case of in silico generated data, we show that the two new calibration methods are robust with respect to the initial guess of parameters and to the presence of noise in the data. Notably, the correlation matrix calibration method achieves the best results in estimating the parameters in the case of noisy data and it is faster than the combined calibration method and L-BFGS-B. Finally, we present real test case where the two new calibration methods yield results comparable to those obtained using L-BFGS-B in terms of minimizing the loss function and estimating the clinical data. This highlights the effectiveness of the new calibration methods for clinical applications., Comment: 33 pages, 7 figures, submitted to International Journal for Numerical Methods for Engineering

Multiphysics simulations frequently require transferring solution fields between subproblems with non-matching spatial discretizations, typically using interpolation techniques. Standard methods are usually based on measuring the closeness between points by means of the Euclidean distance, which does not account for curvature, cuts, cavities or other non-trivial geometrical or topological features of the domain. This may lead to spurious oscillations in the interpolant in proximity to these features. To overcome this issue, we propose a modification to rescaled localized radial basis function (RL-RBF) interpolation to account for the geometry of the interpolation domain, by yielding conformity and fidelity to geometrical and topological features. The proposed method, referred to as RL-RBF-G, relies on measuring the geodesic distance between data points. RL-RBF-G removes spurious oscillations appearing in the RL-RBF interpolant, resulting in increased accuracy in domains with complex geometries. We demonstrate the effectiveness of RL-RBF-G interpolation through a convergence study in an idealized setting. Furthermore, we discuss the algorithmic aspects and the implementation of RL-RBF-G interpolation in a distributed-memory parallel framework, and present the results of a strong scalability test yielding nearly ideal results. Finally, we show the effectiveness of RL-RBF-G interpolation in multiphysics simulations by considering an application to a whole-heart cardiac electromecanics model., Comment: 23 pages, 9 figures

Finite element-based high-order solvers of conservation laws offer large accuracy but face challenges near discontinuities due to the Gibbs phenomenon. Artificial viscosity is a popular and effective solution to this problem based on physical insight. In this work, we present a physics-informed machine learning algorithm to automate the discovery of artificial viscosity models in a non-supervised paradigm. The algorithm is inspired by reinforcement learning and trains a neural network acting cell-by-cell (the viscosity model) by minimizing a loss defined as the difference with respect to a reference solution thanks to automatic differentiation. This enables a dataset-free training procedure. We prove that the algorithm is effective by integrating it into a state-of-the-art Runge-Kutta discontinuous Galerkin solver. We showcase several numerical tests on scalar and vectorial problems, such as Burgers' and Euler's equations in one and two dimensions. Results demonstrate that the proposed approach trains a model that is able to outperform classical viscosity models. Moreover, we show that the learnt artificial viscosity model is able to generalize across different problems and parameters.

When generating in-silico clinical electrophysiological outputs, such as electrocardiograms (ECGs) and body surface potential maps (BSPMs), mathematical models have relied on single physics, i.e. of the cardiac electrophysiology (EP), neglecting the role of the heart motion. Since the heart is the most powerful source of electrical activity in the human body, its motion dynamically shifts the position of the principal electrical sources in the torso, influencing electrical potential distribution and potentially altering the EP outputs. In this work, we propose a computational model for the simulation of ECGs and BSPMs by coupling a cardiac electromechanical model with a model that simulates the propagation of the EP signal in the torso, thanks to a flexible numerical approach, that simulates the torso domain deformation induced by the myocardial displacement. Our model accounts for the major mechano-electrical feedbacks, along with unidirectional displacement and potential couplings from the heart to the surrounding body. For the numerical discretization, we employ a versatile intergrid transfer operator that allows for the use of different Finite Element spaces to be used in the cardiac and torso domains. Our numerical results are obtained on a realistic 3D biventricular-torso geometry, and cover both cases of sinus rhythm and ventricular tachycardia (VT), solving both the electromechanical-torso model in dynamical domains, and the classical electrophysiology-torso model in static domains. By comparing standard 12-lead ECG and BSPMs, we highlight the non-negligible effects of the myocardial contraction on the EP-outputs, especially in pathological conditions, such as the VT., Comment: 34 pages, 20 figures, 4 tables

Simulating the cardiac function requires the numerical solution of multi-physics and multi-scale mathematical models. This underscores the need for streamlined, accurate, and high-performance computational tools. Despite the dedicated endeavors of various research teams, comprehensive and user-friendly software programs for cardiac simulations are still in the process of achieving full maturity within the scientific community. This work introduces lifex-ep, a publicly available software for numerical simulations of the electrophysiology activity of the cardiac muscle, under both physiological and pathological conditions. lifex-ep employs the monodomain equation to model the heart's electrical activity. It incorporates both phenomenological and second-generation ionic models. These models are discretized using the Finite Element method on tetrahedral or hexahedral meshes. Additionally, lifex-ep integrates the generation of myocardial fibers based on Laplace-Dirichlet Rule-Based Methods, previously released in Africa et al., 2023, within lifex-fiber. This paper provides a concise overview of the mathematical models and numerical methods underlying lifex-ep, along with comprehensive implementation details and instructions for users. lifex-ep features exceptional parallel speedup, scaling efficiently when using up to thousands of cores, and its implementation has been verified against an established benchmark problem for computational electrophysiology. We showcase the key features of lifex-ep through various idealized and realistic simulations. lifex-ep offers a user-friendly and flexible interface. lifex-ep provides easy access to cardiac electrophysiology simulations for a wide user community. It offers a computational tool that integrates models and accurate methods for simulating cardiac electrophysiology within a high-performance framework, while maintaining a user-friendly interface.

Cardiac digital twins provide a physics and physiology informed framework to deliver predictive and personalized medicine. However, high-fidelity multi-scale cardiac models remain a barrier to adoption due to their extensive computational costs and the high number of model evaluations needed for patient-specific personalization. Artificial Intelligence-based methods can make the creation of fast and accurate whole-heart digital twins feasible. In this work, we use Latent Neural Ordinary Differential Equations (LNODEs) to learn the temporal pressure-volume dynamics of a heart failure patient. Our surrogate model based on LNODEs is trained from 400 3D-0D whole-heart closed-loop electromechanical simulations while accounting for 43 model parameters, describing single cell through to whole organ and cardiovascular hemodynamics. The trained LNODEs provides a compact and efficient representation of the 3D-0D model in a latent space by means of a feedforward fully-connected Artificial Neural Network that retains 3 hidden layers with 13 neurons per layer and allows for 300x real-time numerical simulations of the cardiac function on a single processor of a standard laptop. This surrogate model is employed to perform global sensitivity analysis and robust parameter estimation with uncertainty quantification in 3 hours of computations, still on a single processor. We match pressure and volume time traces unseen by the LNODEs during the training phase and we calibrate 4 to 11 model parameters while also providing their posterior distribution. This paper introduces the most advanced surrogate model of cardiac function available in the literature and opens new important venues for parameter calibration in cardiac digital twins.

The accurate robust and efficient transfer of the deformation gradient tensor between meshes of different resolution is crucial in cardiac electromechanics simulations. We present a novel method that combines rescaled localized Radial Basis Function (RBF) interpolation with Singular Value Decomposition (SVD) to preserve the positivity of the determinant of the deformation gradient tensor. The method involves decomposing the evaluations of the tensor at the quadrature nodes of the source mesh into rotation matrices and diagonal matrices of singular values; computing the RBF interpolation of the quaternion representation of rotation matrices and the singular value logarithms; reassembling the deformation gradient tensors at quadrature nodes of the destination mesh, to be used in the assembly of the electrophysiology model equations. The proposed method overcomes limitations of existing interpolation methods, including nested intergrid interpolation and RBF interpolation of the displacement field, that may lead to the loss of physical meaningfulness of the mathematical formulation and then to solver failures at the algebraic level, due to negative determinant values. The proposed method enables the transfer of solution variables between finite element spaces of different degrees and shapes and without stringent conformity requirements between different meshes, enhancing the flexibility and accuracy of electromechanical simulations. Numerical results confirm that the proposed method enables the transfer of the deformation gradient tensor, allowing to successfully run simulations in cases where existing methods fail. This work provides an efficient and robust method for the intergrid transfer of the deformation gradient tensor, enabling independent tailoring of mesh discretizations to the particular characteristics of the physical components concurring to the of the multiphysics model., Comment: 24 pages; 11 figures

Impaired cardiac function has been described as a frequent complication of COVID-19-related pneumonia. To investigate possible underlying mechanisms, we represented the cardiovascular system by means of a lumped-parameter 0D mathematical model. The model was calibrated using clinical data, recorded in 58 patients hospitalized for COVID-19-related pneumonia, to make it patient-specific and to compute model outputs of clinical interest related to the cardiocirculatory system. We assessed, for each patient with a successful calibration, the statistical reliability of model outputs estimating the uncertainty intervals. Then, we performed a statistical analysis to compare healthy ranges and mean values (over patients) of reliable model outputs to determine which were significantly altered in COVID-19-related pneumonia. Our results showed significant increases in right ventricular systolic pressure, diastolic and mean pulmonary arterial pressure, and capillary wedge pressure. Instead, physical quantities related to the systemic circulation were not significantly altered. Remarkably, statistical analyses made on raw clinical data, without the support of a mathematical model, were unable to detect the effects of COVID-19-related pneumonia, thus suggesting that the use of a calibrated 0D mathematical model to describe the cardiocirculatory system is an effective tool to investigate the impairments of the cardiocirculatory system associated with COVID-19.

Predicting the evolution of systems that exhibit spatio-temporal dynamics in response to external stimuli is a key enabling technology fostering scientific innovation. Traditional equations-based approaches leverage first principles to yield predictions through the numerical approximation of high-dimensional systems of differential equations, thus calling for large-scale parallel computing platforms and requiring large computational costs. Data-driven approaches, instead, enable the description of systems evolution in low-dimensional latent spaces, by leveraging dimensionality reduction and deep learning algorithms. We propose a novel architecture, named Latent Dynamics Network (LDNet), which is able to discover low-dimensional intrinsic dynamics of possibly non-Markovian dynamical systems, thus predicting the time evolution of space-dependent fields in response to external inputs. Unlike popular approaches, in which the latent representation of the solution manifold is learned by means of auto-encoders that map a high-dimensional discretization of the system state into itself, LDNets automatically discover a low-dimensional manifold while learning the latent dynamics, without ever operating in the high-dimensional space. Furthermore, LDNets are meshless algorithms that do not reconstruct the output on a predetermined grid of points, but rather at any point of the domain, thus enabling weight-sharing across query-points. These features make LDNets lightweight and easy-to-train, with excellent accuracy and generalization properties, even in time-extrapolation regimes. We validate our method on several test cases and we show that, for a challenging highly-nonlinear problem, LDNets outperform state-of-the-art methods in terms of accuracy (normalized error 5 times smaller), by employing a dramatically smaller number of trainable parameters (more than 10 times fewer).

Computational fluid dynamics (CFD) is an important tool for the simulation of the cardiovascular function and dysfunction. Due to the complexity of the anatomy, the transitional regime of blood flow in the heart, and the strong mutual influence between the flow and the physical processes involved in the heart function, the development of accurate and efficient CFD solvers for cardiovascular flows is still a challenging task. In this paper we present lifex-cfd, an open-source CFD solver for cardiovascular simulations based on the lifex finite element library, written in modern C++ and exploiting distributed memory parallelism. We model blood flow in both physiological and pathological conditions via the incompressible Navier-Stokes equations, accounting for moving cardiac valves, moving domains, and transition-to-turbulence regimes. In this paper, we provide an overview of the underlying mathematical formulation, numerical discretization, implementation details and examples on how to use lifex-cfd. We verify the code through rigorous convergence analyses, and we show its almost ideal parallel speedup. We demonstrate the accuracy and reliability of the numerical methods implemented through a series of idealized and patient-specific vascular and cardiac simulations, in different physiological flow regimes. The lifex-cfd source code is available under the LGPLv3 license, to ensure its accessibility and transparency to the scientific community, and to facilitate collaboration and further developments.

Algebraic multigrid (AMG) methods are among the most efficient solvers for linear systems of equations and they are widely used for the solution of problems stemming from the discretization of Partial Differential Equations (PDEs). The most severe limitation of AMG methods is the dependence on parameters that require to be fine-tuned. In particular, the strong threshold parameter is the most relevant since it stands at the basis of the construction of successively coarser grids needed by the AMG methods. We introduce a novel Deep Learning algorithm that minimizes the computational cost of the AMG method when used as a finite element solver. We show that our algorithm requires minimal changes to any existing code. The proposed Artificial Neural Network (ANN) tunes the value of the strong threshold parameter by interpreting the sparse matrix of the linear system as a black-and-white image and exploiting a pooling operator to transform it into a small multi-channel image. We experimentally prove that the pooling successfully reduces the computational cost of processing a large sparse matrix and preserves the features needed for the regression task at hand. We train the proposed algorithm on a large dataset containing problems with a highly heterogeneous diffusion coefficient defined in different three-dimensional geometries and discretized with unstructured grids and linear elasticity problems with a highly heterogeneous Young's modulus. When tested on problems with coefficients or geometries not present in the training dataset, our approach reduces the computational time by up to 30%.

We present a novel mathematical model that simulates myocardial blood perfusion by embedding multiscale and multiphysics features. Our model incorporates cardiac electrophysiology, active and passive mechanics, hemodynamics, reduced valve modeling, and a multicompartment Darcy model of perfusion. We consider a fully coupled electromechanical model of the left heart that provides input for a fully coupled Navier-Stokes - Darcy Model for myocardial perfusion. The fluid dynamics problem is modeled in a left heart geometry that includes large epicardial coronaries, while the multicompartment Darcy model is set in a biventricular domain. Using a realistic and detailed cardiac geometry, our simulations demonstrate the accuracy of our model in describing cardiac perfusion, including myocardial blood flow maps. Additionally, we investigate the impact of a regurgitant aortic valve on myocardial perfusion, and our results indicate a reduction in myocardial perfusion due to blood flow taken away by the left ventricle during diastole. To the best of our knowledge, our work represents the first instance where electromechanics, hemodynamics, and perfusion are integrated into a single computational framework.

This spreading of prion proteins is at the basis of brain neurodegeneration. This paper deals with the numerical modelling of the misfolding process of $\alpha$-synuclein in Parkinson's disease. We introduce and analyze a discontinuous Galerkin method for the semi-discrete approximation of the Fisher-Kolmogorov (FK) equation that can be employed to model the process. We employ a discontinuous Galerkin method on polygonal and polyhedral grids (PolyDG) for space discretization, to accurately simulate the wavefronts typically observed in the prionic spreading and we prove stability and a priori error estimates. Next, we use a Crank-Nicolson scheme to advance in time. For the numerical verification of our numerical model, we first consider a manufactured solution, and then we consider a case with wavefront propagation in two-dimensional polygonal grids. Next, we carry out a simulation of $\alpha$-synuclein spreading in a two-dimensional brain slice in the sagittal plane with a polygonal agglomerated grid that takes full advantage of the flexibility of PolyDG approximation. Finally, we present a simulation in a three-dimensional geometry reconstructed from magnetic resonance images of a patient's brain., Comment: arXiv admin note: text overlap with arXiv:2210.02272

We introduce a multiphysics and geometric multiscale computational model, suitable to describe the hemodynamics of the whole human heart, driven by a four-chamber electromechanical model. We first present a study on the calibration of the biophysically detailed RDQ20 activation model (Regazzoni et al., 2020) that is able to reproduce the physiological range of hemodynamic biomarkers. Then, we demonstrate that the ability of the force generation model to reproduce certain microscale mechanisms, such as the dependence of force on fiber shortening velocity, is crucial to capture the overall physiological mechanical and fluid dynamics macroscale behavior. This motivates the need for using multiscale models with high biophysical fidelity, even when the outputs of interest are relative to the macroscale. We show that the use of a high-fidelity electromechanical model, combined with a detailed calibration process, allows us to achieve remarkable biophysical fidelity in terms of both mechanical and hemodynamic quantities. Indeed, our electromechanical-driven CFD simulations - carried out on an anatomically accurate geometry of the whole heart - provide results that match the cardiac physiology both qualitatively (in terms of flow patterns) and quantitatively (when comparing in silico results with biomarkers acquired in vivo). We consider the pathological case of left bundle branch block, and we investigate the consequences that an electrical abnormality has on cardiac hemodynamics thanks to our multiphysics integrated model. The computational model that we propose can faithfully predict a delay and an increasing wall shear stress in the left ventricle in the pathological condition. The interaction of different physical processes in an integrated framework allows us to faithfully describe and model this pathology, by capturing and reproducing the intrinsic multiphysics nature of the human heart.

In the context of SARS-CoV-2 pandemic, mathematical modelling has played a fundamental role for making forecasts, simulating scenarios and evaluating the impact of preventive political, social and pharmaceutical measures. Optimal control theory can be a useful tool based on solid mathematical bases to plan the vaccination campaign in the direction of eradicating the pandemic as fast as possible. The aim of this work is to explore the optimal prioritisation order for planning vaccination campaigns able to achieve specific goals, as the reduction of the amount of infected, deceased and hospitalized in a fixed time frame, among age classes. For this purpose, we introduce an age stratified SIR-like epidemic compartmental model settled in an abstract framework for modelling two-doses vaccination campaigns and conceived with the description of COVID19 disease. Overall, we formalize an optimal control framework adopting the model as state problem by acting on the administrations of vaccine-doses. An extensive campaign of numerical tests, featured in the Italian scenario and calibrated on available data from Dipartimento di Protezione Civile Italiana, shows that the presented framework can be a valuable tool to support the planning of vaccination campaigns minimizing specific goals.

Parameter estimation and uncertainty quantification are crucial in computational cardiology, as they enable the construction of digital twins that faithfully replicate the behavior of physical patients. Robust and efficient mathematical methods must be designed to fit many model parameters starting from a few, possibly non-invasive, noisy observations. Moreover, the effective clinical translation requires short execution times and a small amount of computational resources. In the framework of Bayesian statistics, we combine Maximum a Posteriori estimation and Hamiltonian Monte Carlo to find an approximation of model parameters and their posterior distributions. To reduce the computational effort, we employ an accurate Artificial Neural Network surrogate of 3D cardiac electromechanics model coupled with a 0D cardiocirculatory model. Fast simulations and minimal memory requirements are achieved by using matrix-free methods, automatic differentiation and automatic vectorization. Furthermore, we account for the surrogate modeling error and measurement error. We perform three different in silico test cases, ranging from the ventricular function to the entire cardiovascular system, involving whole-heart mechanics, arterial and venous circulation. The proposed method is robust when high levels of signal-to-noise ratio are present in the quantities of interest in combination with a random initialization of the model parameters in suitable intervals. As a matter of fact, by employing a single central processing unit on a standard laptop and a few hours of computations, we attain small relative errors for all model parameters and we estimate posterior distributions that contain the true values inside the 90% credibility regions. With these benefits, our approach meets the requirements for clinical exploitation, while being compliant with Green Computing practices.

We introduce and analyze a discontinuous Galerkin method for the numerical modelling of the equations of Multiple-Network Poroelastic Theory (MPET) in the dynamic formulation. The MPET model can comprehensively describe functional changes in the brain considering multiple scales of fluids. Concerning the spatial discretization, we employ a high-order discontinuous Galerkin method on polygonal and polyhedral grids and we derive stability and a priori error estimates. The temporal discretization is based on a coupling between a Newmark $\beta$-method for the momentum equation and a $\theta$-method for the pressure equations. After the presentation of some verification numerical tests, we perform a convergence analysis using an agglomerated mesh of a geometry of a brain slice. Finally we present a simulation in a three dimensional patient-specific brain reconstructed from magnetic resonance images. The model presented in this paper can be regarded as a preliminary attempt to model the perfusion in the brain.

A major challenge in the computational fluid dynamics modeling of the heart function is the simulation of isovolumetric phases when the hemodynamics problem is driven by a prescribed boundary displacement. During such phases, both atrioventricular and semilunar valves are closed: consequently, the ventricular pressure may not be uniquely defined, and spurious oscillations may arise in numerical simulations. In this paper, we propose a suitable modification of the Resistive Immersed Implicit Surface (RIIS) method (Fedele et al., 2017) by introducing a reaction term to correctly capture the pressure transients during isovolumetric phases. The method, that we call Augmented RIIS (ARIIS) method, extends the previously proposed ARIS method (This et al., 2020) to the case of a mesh which is not body-fitted to the valves. We test the proposed method on two different benchmark problems, including a new simplified problem that retains all the characteristics of a heart cycle. We apply the ARIIS method to a fluid dynamics simulation of a realistic left heart geometry, and we show that ARIIS allows to correctly simulate isovolumetric phases, differently from standard RIIS method., Comment: 34 pages, 16 figures

We propose a mathematical and numerical model for the simulation of the heart function that couples cardiac electrophysiology, active and passive mechanics and hemodynamics, and includes reduced models for cardiac valves and the circulatory system. Our model accounts for the major feedback effects among the different processes that characterize the heart function, including electro-mechanical and mechano-electrical feedback as well as force-strain and force-velocity relationships. Moreover, it provides a three-dimensional representation of both the cardiac muscle and the hemodynamics, coupled in a fluid-structure interaction (FSI) model. By leveraging the multiphysics nature of the problem, we discretize it in time with a segregated electrophysiology-force generation-FSI approach, allowing for efficiency and flexibility in the numerical solution. We employ a monolithic approach for the numerical discretization of the FSI problem. We use finite elements for the spatial discretization of those partial differential equations that contribute to the model. We carry out a numerical simulation on a realistic human left heart model, obtaining results that are qualitatively and quantitatively in agreement with physiological ranges and medical images.

While ventricular electromechanics is extensively studied, four-chamber heart models have only been addressed recently; most of these works however neglect atrial contraction. Indeed, as atria are characterized by a complex physiology influenced by the ventricular function, developing computational models able to capture the physiological atrial function and atrioventricular interaction is very challenging. In this paper, we propose a biophysically detailed electromechanical model of the whole human heart that considers both atrial and ventricular contraction. Our model includes: i) an anatomically accurate whole-heart geometry; ii) a comprehensive myocardial fiber architecture; iii) a biophysically detailed microscale model for the active force generation; iv) a 0D closed-loop model of the circulatory system; v) the fundamental interactions among the different core models; vi) specific constitutive laws and model parameters for each cardiac region. Concerning the numerical discretization, we propose an efficient segregated-intergrid-staggered scheme and we employ recently developed stabilization techniques that are crucial to obtain a stable formulation in a four-chamber scenario. We are able to reproduce the healthy cardiac function for all the heart chambers, in terms of pressure-volume loops, time evolution of pressures, volumes and fluxes, and three-dimensional cardiac deformation, with unprecedented matching (to the best of our knowledge) with the expected physiology. We also show the importance of considering atrial contraction, fibers-stretch-rate feedback and suitable stabilization techniques, by comparing the results obtained with and without these features in the model. The proposed model represents the state-of-the-art electromechanical model of the iHEART ERC project and is a fundamental step toward the building of physics-based digital twins of the human heart.

We propose a matrix-free solver for the numerical solution of the cardiac electrophysiology model consisting of the monodomain nonlinear reaction-diffusion equation coupled with a system of ordinary differential equations for the ionic species. Our numerical approximation is based on the high-order Spectral Element Method (SEM) to achieve accurate numerical discretization while employing a much smaller number of Degrees of Freedom than first-order Finite Elements. We combine vectorization with sum-factorization, thus allowing for a very efficient use of high-order polynomials in a high performance computing framework. We validate the effectiveness of our matrix-free solver in a variety of applications and perform different electrophysiological simulations ranging from a simple slab of cardiac tissue to a realistic four-chamber heart geometry. We compare SEM to SEM with Numerical Integration (SEM-NI), showing that they provide comparable results in terms of accuracy and efficiency. In both cases, increasing the local polynomial degree $p$ leads to better numerical results and smaller computational times than reducing the mesh size $h$. We also implement a matrix-free Geometric Multigrid preconditioner that results in a comparable number of linear solver iterations with respect to a state-of-the-art matrix-based Algebraic Multigrid preconditioner. As a matter of fact, the matrix-free solver proposed here yields up to 45$\times$ speed-up with respect to a conventional matrix-based solver.

We analyze left atrium haemodynamics, highlighting differences among healthy individuals and patients affected by atrial fibrillation. The computational study is based on patient-specific geometries of the left atria to simulate blood flow dynamics. We devise a novel procedure aimed at recovering the boundary conditions for the 3D haemodynamics simulations, particularly useful in absence of specific ones provided by clinical measurements. With this aim, we introduce a parametric definition of the atria displacement, and we employ a closed-loop lumped parameter model of the whole cardiocirculatory system conveniently tuned on the basis of the patient characteristics. We evaluate a number of fluid dynamics indicators for the atrial haemodynamics, validating our numerical results in terms of several clinical measurements; we investigate the impact of geometrical and clinical features on the risk of thrombosis. To analyse the correlation of thrombus formation with atrial fibrillation, coherently with the medical evidence, we propose a novel indicator, which we call age stasis and that arises from the combination of Eulerian and Lagrangian quantities. This indicator identifies regions where the slow flow cannot rinse the chamber properly, accumulating stale blood particles and creating optimal conditions for clot formation.

Modeling the whole cardiac function involves the solution of several complex multi-physics and multi-scale models that are highly computationally demanding, which call for simpler yet accurate, high-performance computational tools. Despite the efforts made by several research groups, no software for whole-heart fully-coupled cardiac simulations in the scientific community has reached full maturity yet. In this work we present the first publicly released package of lifex, a high-performance Finite Element solver for multi-physics and multi-scale problems developed in the framework of the iHEART project. The goal of lifex is twofold. On the one side, it aims at making in silico experiments easily reproducible and accessible to a wide community of users, including those with a background in medicine or bio-engineering. On the other hand, as an academic research library lifex can be exploited by scientific computing experts to explore new mathematical models and numerical methods within a robust development framework. lifex has been developed with a modular structure and will be released bundled in different modules. The tool presented here proposes an innovative generator for myocardial fibers based on Laplace-Dirichlet Rule-Based Methods, which are the essential building blocks for modeling the electrophysiological, mechanical and electromechanical cardiac function, from single-chamber to whole-heart simulations. This report comes with an extensive technical and mathematical documentation to welcome new users to the core structure of a prototypical lifex application and to provide them with a possible approach to include the generated cardiac fibers into more sophisticated computational pipelines.

Several epidemiological models have been proposed to study the evolution of COVID-19 pandemic. In this paper, we propose an extension of the SUIHTER model, first introduced in [Parolini et al, Proc R. Soc. A., 2021] to analyse the COVID-19 spreading in Italy, which accounts for the vaccination campaign and the presence of new variants when they become dominant. In particular, the specific features of the variants (e.g. their increased transmission rate) and vaccines (e.g. their efficacy to prevent transmission, hospitalization and death) are modeled, based on clinical evidence. The new model is validated comparing its near-future forecast capabilities with other epidemiological models and exploring different scenario analyses., Comment: 34 pages, 10 figures, 3 tables

We present a novel deep learning-based algorithm to accelerate - through the use of Artificial Neural Networks (ANNs) - the convergence of Algebraic Multigrid (AMG) methods for the iterative solution of the linear systems of equations stemming from finite element discretizations of Partial Differential Equations (PDE). We show that ANNs can be successfully used to predict the strong connection parameter that enters in the construction of the sequence of increasingly smaller matrix problems standing at the basis of the AMG algorithm, so as to maximize the corresponding convergence factor of the AMG scheme. To demonstrate the practical capabilities of the proposed algorithm, which we call AMG-ANN, we consider the iterative solution of the algebraic system of equations stemming from finite element discretizations of two-dimensional model problems. First, we consider an elliptic equation with a highly heterogeneous diffusion coefficient and then a stationary Stokes problem. We train (off-line) our ANN with a rich dataset and present an in-depth analysis of the effects of tuning the strong threshold parameter on the convergence factor of the resulting AMG iterative scheme.

We propose using machine learning and artificial neural networks (ANNs) to enhance residual-based stabilization methods for advection-dominated differential problems. Specifically, in the context of the finite element method, we consider the streamline upwind Petrov-Galerkin (SUPG) stabilization method and we employ ANNs to optimally choose the stabilization parameter on which the method relies. We generate our dataset by solving optimization problems to find the optimal stabilization parameters that minimize the distances among the numerical and the exact solutions for different data of differential problem and the numerical settings of the finite element method, e.g., mesh size and polynomial degree. The dataset generated is used to train the ANN, and we used the latter ``online'' to predict the optimal stabilization parameter to be used in the SUPG method for any given numerical setting and problem data. We show, by means of 1D and 2D numerical tests for the advection-dominated differential problem, that our ANN approach yields more accurate solution than using the conventional stabilization parameter for the SUPG method.

Mechano-electric feedbacks (MEFs), which model how mechanical stimuli are transduced into electrical signals, have received sparse investigation by considering electromechanical simulations in simplified scenarios. In this paper, we study the effects of different MEFs modeling choices for myocardial deformation and nonselective stretch-activated channels (SACs) in the monodomain equation. We perform numerical simulations during ventricular tachycardia (VT) by employing a biophysically detailed and anatomically accurate 3D electromechanical model for the left ventricle (LV) coupled with a 0D closed-loop model of the cardiocirculatory system. We model the electromechanical substrate responsible for scar-related VT with a distribution of infarct and peri-infarct zones. Our mathematical framework takes into account the hemodynamic effects of VT due to myocardial impairment and allows for the classification of their hemodynamic nature, which can be either stable or unstable. By combining electrophysiological, mechanical and hemodynamic models, we observe that all MEFs may alter the propagation of the action potential and the morphology of the VT. In particular, we notice that the presence of myocardial deformation in the monodomain equation may change the VT basis cycle length and the conduction velocity but do not affect the hemodynamic nature of the VT. Finally, nonselective SACs may affect wavefront stability, by possibly turning a hemodynamically stable VT into a hemodynamically unstable one and vice versa.

We propose a machine learning-based method to build a system of differential equations that approximates the dynamics of 3D electromechanical models for the human heart, accounting for the dependence on a set of parameters. Specifically, our method permits to create a reduced-order model (ROM), written as a system of Ordinary Differential Equations (ODEs) wherein the forcing term, given by the right-hand side, consists of an Artificial Neural Network (ANN), that possibly depends on a set of parameters associated with the electromechanical model to be surrogated. This method is non-intrusive, as it only requires a collection of pressure and volume transients obtained from the full-order model (FOM) of cardiac electromechanics. Once trained, the ANN-based ROM can be coupled with hemodynamic models for the blood circulation external to the heart, in the same manner as the original electromechanical model, but at a dramatically lower computational cost. Indeed, our method allows for real-time numerical simulations of the cardiac function. We demonstrate the effectiveness of the proposed method on two relevant contexts in cardiac modeling. First, we employ the ANN-based ROM to perform a global sensitivity analysis on both the electromechanical and hemodynamic models. Second, we perform a Bayesian estimation of two parameters starting from noisy measurements of two scalar outputs. In both these cases, replacing the FOM of cardiac electromechanics with the ANN-based ROM makes it possible to perform in a few hours of computational time all the numerical simulations that would be otherwise unaffordable, because of their overwhelming computational cost, if carried out with the FOM. As a matter of fact, our ANN-based ROM is able to speedup the numerical simulations by more than three orders of magnitude.

We present a new computational model for the numerical simulation of blood flow in the human left heart. To this aim, we use the Navier-Stokes equations in an Arbitrary Lagrangian Eulerian formulation to account for the endocardium motion and we model the cardiac valves by means of the Resistive Immersed Implicit Surface method. To impose a physiological displacement of the domain boundary, we use a 3D cardiac electromechanical model of the left ventricle coupled to a lumped-parameter (0D) closed-loop model of the remaining circulation. We thus obtain a one-way coupled electromechanics-fluid dynamics model in the left ventricle. To extend the left ventricle motion to the endocardium of the left atrium and to that of the ascending aorta, we introduce a preprocessing procedure according to which an harmonic extension of the left ventricle displacement is combined with the motion of the left atrium based on the 0D model. To better match the 3D cardiac fluid flow with the external blood circulation, we couple the 3D Navier-Stokes equations to the 0D circulation model, obtaining a multiscale coupled 3D-0D fluid dynamics model that we solve via a segregated numerical scheme. We carry out numerical simulations for a healthy left heart and we validate our model by showing that meaningful hemodynamic indicators are correctly reproduced.

Two crucial factors for accurate numerical simulations of cardiac electromechanics, which are also essential to reproduce the synchronous activity of the heart, are: i) accounting for the interaction between the heart and the circulatory system that determines pressures and volumes loads in the heart chambers; ii) reconstructing the muscular fiber architecture that drives the electrophysiology signal and the myocardium contraction. In this work, we present a 3D biventricular electromechanical model coupled with a 0D closed-loop model of the whole cardiovascular system that addresses the two former crucial factors. With this aim, we introduce a boundary condition for the mechanical problem that accounts for the neglected part of the domain located on top of the biventricular basal plane and that is consistent with the principles of momentum and energy conservation. We also discuss in detail the coupling conditions that stand behind the 3D and the 0D models. We perform electromechanical simulations in physiological conditions using the 3D-0D model and we show that our results match the experimental data of relevant mechanical biomarkers available in literature. Furthermore, we investigate different arrangements in cross-fibers active contraction. We prove that an active tension along the sheet direction counteracts the myofiber contraction, while the one along the sheet-normal direction enhances the cardiac work. Finally, several myofiber architectures are analysed. We show that a different fiber field in the septal area and in the transmural wall effect the pumping functionality of the left ventricle.

In this paper, we investigate the hemodynamics of a left atrium (LA) by proposing a computational model suitable to provide physically meaningful fluid dynamics indications and detailed blood flow characterization. In particular, we consider the incompressible Navier-Stokes equations in Arbitrary Lagrangian Eulerian (ALE) formulation to deal with the LA domain under prescribed motion. A Variational Multiscale (VMS) method is adopted to obtain a stable formulation of the Navier-Stokes equations discretized by means of the Finite Element method and to account for turbulence modeling based on Large Eddy Simulation (LES). The aim of this paper is twofold: on one hand to improve the general understanding of blood flow in the human LA in normal conditions; on the other, to analyse the effects of the turbulence VMS-LES method on a situation of blood flow which is neither laminar, nor fully turbulent, but rather transitional as in LA. Our results suggest that if relatively coarse meshes are adopted, the additional stabilization terms introduced by the VMS-LES method allow to better predict transitional effects and cycle-to-cycle blood flow variations than the standard SUPG stabilization method.

We developed a novel patient-specific computational model for the numerical simulation of ventricular electromechanics in patients with ischemic cardiomyopathy (ICM). This model reproduces the activity both in sinus rhythm (SR) and in ventricular tachycardia (VT). The presence of scars, grey zones and non-remodeled regions of the myocardium is accounted for by the introduction of a spatially heterogeneous coefficient in the 3D electromechanics model. This 3D electromechanics model is firstly coupled with a 2-element Windkessel afterload model to fit the pressure-volume (PV) loop of a patient-specific left ventricle (LV) with ICM in SR. Then, we employ the coupling with a 0D closed-loop circulation model to analyze a VT circuit over multiple heartbeats on the same LV. We highlight similarities and differences on the solutions obtained by the electrophysiology model and those of the electromechanics model, while considering different scenarios for the circulatory system. We observe that very different parametrizations of the circulation model induce the same hemodynamical considerations for the patient at hand. Specifically, we classify this VT as unstable. We conclude by stressing the importance of combining electrophysiological, mechanical and hemodynamical models to provide relevant clinical indicators in how arrhythmias evolve and can potentially lead to sudden cardiac death.

We propose a nonlinear reduced basis method for the efficient approximation of parametrized partial differential equations (PDEs), exploiting kernel proper orthogonal decomposition (KPOD) for the generation of a reduced-order space and neural networks for the evaluation of the reduced-order approximation. In particular, we use KPOD in place of the more classical POD, on a set of high-fidelity solutions of the problem at hand to extract a reduced basis. This method provides a more accurate approximation of the snapshots' set featuring a lower dimension, while maintaining the same efficiency as POD. A neural network (NN) is then used to find the coefficients of the reduced basis by following a supervised learning paradigm and shown to be effective in learning the map between the time/parameter values and the projection of the high-fidelity snapshots onto the reduced space. In this NN, both the number of hidden layers and the number of neurons vary according to the intrinsic dimension of the differential problem at hand and the size of the reduced space. This adaptively built NN attains good performances in both the learning and the testing phases. Our approach is then tested on two benchmark problems, a one-dimensional wave equation and a two-dimensional nonlinear lid-driven cavity problem. We finally compare the proposed KPOD-NN technique with a POD-NN strategy, showing that KPOD allows a reduction of the number of modes that must be retained to reach a given accuracy in the reduced basis approximation. For this reason, the NN built to find the coefficients of the KPOD expansion is smaller, easier and less computationally demanding to train than the one used in the POD-NN strategy.

Since myocardial fibers drive the electric signal propagation throughout the myocardium, accurately modeling their arrangement is essential for simulating heart electrophysiology (EP). Rule-Based-Methods (RBMs) represent a commonly used strategy to include cardiac fibers in computational models. A particular class of such methods is known as Laplace-Dirichlet-Rule-Based-Methods (LDRBMs) since they rely on the solution of Laplace problems. In this work we provide a unified framework, based on LDRBMs, for generating full heart muscle fibers. First, we review existing ventricular LDRBMs providing a communal mathematical description and introducing also some modeling improvements with respect to the existing literature. We then carry out a systematic comparison of LDRBMs based on meaningful biomarkers produced by numerical EP simulations. Next we propose, for the first time, a LDRBM to be used for generating atrial fibers. The new method, tested both on idealized and realistic atrial models, can be applied to any arbitrary geometries. Finally, we present numerical results obtained in a realistic whole heart where fibers are included for all the four chambers using the discussed LDRBMs.

The COVID-19 epidemic is the last of a long list of pandemics that have affected humankind in the last century. In this paper, we propose a novel mathematical epidemiological model named SUIHTER from the names of the seven compartments that it comprises: susceptible uninfected individuals (S), undetected (both asymptomatic and symptomatic) infected (U), isolated (I), hospitalized (H), threatened (T), extinct (E), and recovered (R). A suitable parameter calibration that is based on the combined use of least squares method and Markov Chain Monte Carlo (MCMC) method is proposed with the aim of reproducing the past history of the epidemic in Italy, surfaced in late February and still ongoing to date, and of validating SUIHTER in terms of its predicting capabilities. A distinctive feature of the new model is that it allows a one-to-one calibration strategy between the model compartments and the data that are daily made available from the Italian Civil Protection. The new model is then applied to the analysis of the Italian epidemic with emphasis on the second outbreak emerged in Fall 2020. In particular, we show that the epidemiological model SUIHTER can be suitably used in a predictive manner to perform scenario analysis at national level., Comment: 25 pages

In the framework of accurate and efficient segregated schemes for 3D cardiac electromechanics and 0D cardiovascular models, we propose here a novel numerical approach to address the coupled 3D-0D problem introduced in Part I of this two-part series of papers. We combine implicit-explicit schemes to solve the different cardiac models in a multiphysics setting. We properly separate and manage the different time and space scales related to cardiac electromechanics and blood circulation. We employ a flexible and scalable intergrid transfer operator that enables to interpolate Finite Element functions among different meshes and, possibly, among different Finite Element spaces. We propose a numerical method to couple the 3D electromechanical model and the 0D circulation model in a numerically stable manner within a fully segregated fashion. No adaptations are required through the different phases of the heartbeat. We also propose a robust algorithm to reconstruct the stress-free reference configuration. Due to the computational cost associated with the numerical solution of this inverse problem, the reference configuration recovery algorithm comes along with a novel projection technique to precisely recover the unloaded geometry from a coarser representation of the computational domain. We show the convergence property of our numerical schemes by performing an accuracy study through grid refinement. To prove the biophysical accuracy of our computational model, we also address different scenarios of clinical interest in our numerical simulations by varying preload, afterload and contractility. Indeed, we simulate physiologically relevant behaviors and we reproduce meaningful results in the context of cardiac function.

We propose an integrated electromechanical model of the human heart, with focus on the left ventricle, wherein biophysically detailed models describe the different physical phenomena concurring to the cardiac function. We model the subcellular generation of active force by means of an Artificial Neural Network, which is trained by a suitable Machine Learning algorithm from a collection of pre-computed numerical simulations of a biophysically detailed, yet computational demanding, high-fidelity model. To provide physiologically meaningful results, we couple the 3D electromechanical model with a closed-loop 0D (lumped parameters) model describing the blood circulation in the whole cardiovascular network. We prove that the 3D-0D coupling of the two models is compliant with the principle of energy conservation, which is achieved in virtue of energy-consistent boundary conditions that account for the interaction among cardiac chambers within the computational domain, pericardium and surrounding tissue. We thus derive an overall balance of mechanical energy for the 3D-0D model. This provides a quantitative insight into the energy utilization, dissipation and transfer among the different compartments of the cardiovascular network and during different stages of the heartbeat. In virtue of this new model and the energy balance, we propose a new validation tool of heart energy usage against relationships used in the daily clinical practice. Finally, we provide a mathematical formulation of an inverse problem aimed at recovering the reference configuration of one or multiple cardiac chambers, starting from the stressed configuration acquired from medical imaging. This is fundamental to correctly initialize electromechanical simulations. Numerical methods and simulations of the 3D-0D model will be detailed in Part II.

An analysis of the COVID-19 epidemic is proposed on the basis of the epiMOX dashboard (publicly accessible at https://www.epimox.polimi.it) that deals with data of the epidemic trends and outbreaks in Italy from late February 2020. Our analysis provides an immediate appreciation of the past epidemic development, together with its current trends by fostering a deeper interpretation of available data through several critical epidemic indicators. In addition, we complement the epiMOX dashboard with a predictive tool based on an epidemiological compartmental model, named SUIHTER, for the forecast on the near future epidemic evolution.

Predicting the electrical behavior of the heart, from the cellular scale to the tissue level, relies on the formulation and numerical approximation of coupled nonlinear dynamical systems. These systems describe the cardiac action potential, that is the polarization/depolarization cycle occurring at every heart beat that models the time evolution of the electrical potential across the cell membrane, as well as a set of ionic variables. Multiple solutions of these systems, corresponding to different model inputs, are required to evaluate outputs of clinical interest, such as activation maps and action potential duration. More importantly, these models feature coherent structures that propagate over time, such as wavefronts. These systems can hardly be reduced to lower dimensional problems by conventional reduced order models (ROMs) such as, e.g., the reduced basis (RB) method. This is primarily due to the low regularity of the solution manifold (with respect to the problem parameters) as well as to the nonlinear nature of the input-output maps that we intend to reconstruct numerically. To overcome this difficulty, in this paper we propose a new, nonlinear approach which exploits deep learning (DL) algorithms to obtain accurate and efficient ROMs, whose dimensionality matches the number of system parameters. Our DL approach combines deep feedforward neural networks (NNs) and convolutional autoencoders (AEs). We show that the proposed DL-ROM framework can efficiently provide solutions to parametrized electrophysiology problems, thus enabling multi-scenario analysis in pathological cases. We investigate three challenging test cases in cardiac electrophysiology and prove that DL-ROM outperforms classical projection-based ROMs., Comment: 28 pages

We propose four novel mathematical models, describing the microscopic mechanisms of force generation in the cardiac muscle tissue, which are suitable for multiscale numerical simulations of cardiac electromechanics. Such models are based on a biophysically accurate representation of the regulatory and contractile proteins in the sarcomeres. Our models, unlike most of the sarcomere dynamics models that are available in the literature and that feature a comparable richness of detail, do not require the time-consuming Monte Carlo method for their numerical approximation. Conversely, the models that we propose only require the solution of a system of PDEs and/or ODEs (the most reduced of the four only involving 20 ODEs), thus entailing a significant computational efficiency. By focusing on the two models that feature the best trade-off between detail of description and identifiability of parameters, we propose a pipeline to calibrate such parameters starting from experimental measurements available in literature. Thanks to this pipeline, we calibrate these models for room-temperature rat and for body-temperature human cells. We show, by means of numerical simulations, that the proposed models correctly predict the main features of force generation, including the steady-state force-calcium and force-length relationships, the length-dependent prolongation of twitches and increase of peak force, the force-velocity relationship. Moreover, they correctly reproduce the Frank-Starling effect, when employed in multiscale 3D numerical simulation of cardiac electromechanics., Comment: The codes implementing the proposed models are available in an open-source repository at https://github.com/FrancescoRegazzoni/cardiac-activation. The datasets accompanying the article are available at https://doi.org/10.5281/zenodo.3992553

Traditional reduced order modeling techniques such as the reduced basis (RB) method (relying, e.g., on proper orthogonal decomposition (POD)) suffer from severe limitations when dealing with nonlinear time-dependent parametrized PDEs, because of the fundamental assumption of linear superimposition of modes they are based on. For this reason, in the case of problems featuring coherent structures that propagate over time such as transport, wave, or convection-dominated phenomena, the RB method usually yields inefficient reduced order models (ROMs) if one aims at obtaining reduced order approximations sufficiently accurate compared to the high-fidelity, full order model (FOM) solution. To overcome these limitations, in this work, we propose a new nonlinear approach to set reduced order models by exploiting deep learning (DL) algorithms. In the resulting nonlinear ROM, which we refer to as DL-ROM, both the nonlinear trial manifold (corresponding to the set of basis functions in a linear ROM) as well as the nonlinear reduced dynamics (corresponding to the projection stage in a linear ROM) are learned in a non-intrusive way by relying on DL algorithms; the latter are trained on a set of FOM solutions obtained for different parameter values. In this paper, we show how to construct a DL-ROM for both linear and nonlinear time-dependent parametrized PDEs; moreover, we assess its accuracy on test cases featuring different parametrized PDE problems. Numerical results indicate that DL-ROMs whose dimension is equal to the intrinsic dimensionality of the PDE solutions manifold are able to approximate the solution of parametrized PDEs in situations where a huge number of POD modes would be necessary to achieve the same degree of accuracy., Comment: 28 pages