Solving the Mysteries of Heart Disease

by Gerald D Buckberg

  Interestingly, it was.

  And then it wasn’t.

  Today, debate continues in the medical community about how the heart’s form and structure can account for its function. Yet the prevailing belief — endorsed by most in the medical field and taught in medical schools — is wrong.

  Knowing the truth of how heart structure and function are intertwined is crucial for reasons that extend far beyond intellectual understanding. Incorrect knowledge creates the major limitation to developing successful treatments of diseases caused by the disruption of normality. Simply, we must understand how the heart works — in order to deal with problems that arise when it is not working correctly.

  That achievement cannot come without a solid knowledge of structure — because form defines function. This is why physicians and researchers have struggled throughout history for answers to how structure and performance are linked. Without this foundation, treatments will relieve symptoms, but sadly, will fail to correct the underlying disease.

  Current approaches to treating heart failure provide the cardinal example of this predicament, as heart failure continues to be the world’s leading cause of death. The heart failure death rate essentially remains unchanged over the last 20 years, despite all our advances in medications and technology.

  My prior chapters addressed heart failure caused by the poor contraction in a heart that stretches after a heart attack — but this dilemma happens in only 50% of heart failure patients. The other 50% develop failure because while their ventricles have good contraction, they cannot relax properly between beats. Yet in both cases — the vital factor is a disturbance in the normal structure / function relationship. Finding a way to correct the mechanical causes for both these conditions requires a powerful understanding of this interconnection between structure and function.

  But this is only the beginning, as gaining such knowledge can lead to a series of groundbreaking approaches for a wide range of major heart problems. A gargantuan leap may then take place, as our treatments will extend far beyond just alleviating symptoms — they will solve a series of diseases — that presently have no remedy.

  Contemporary Cardiac Conflict

  Unfortunately, even though knowledge and technology have advanced, confusion about the interdependence of structure and function still exists, as it is based upon different deductions made by two medical disciplines.

  The first field of study involves anatomists and pathologists. They examine hearts in an autopsy room, essentially looking at dead tissue, and then infer what happens in live tissue: the functioning living heart. In other words, they observe form (structure)… but deduce function.

  By contrast, the second group, the imaging community, uses MRI and echocardiograms to observe motion… and deduce the structure that made the heart move.

  In both, deductive reasoning is used in place of knowledge. Yet the answer is to know structure so it can explain function. Without this certainty, they may argue forever, as each holds onto their own bias. This mirrors the dilemma I have encountered throughout my professional life: the introduction of new ideas being rejected due to rigid adherence to conventional thinking.

  Now, the starting point of having a bias is a good thing. It introduces a theory that must be tested by an experiment. That is how research is done. But once that experiment begins, the answer is what nature tells you, not what you think — or want — to happen. Fiercely grasping onto what you previously believed is where the dilemma surfaces, and such rigidity has repeated itself again and again in history.

  For example, Ludwig Rehn encountered just such an obstacle in Frankfurt, Germany in 1896, when he performed the first successful cardiac operation by closing a stab wound by directly suturing (sewing) the heart. Before this point, the traditional belief was that cardiac surgery would be forever prohibited by nature, as everyone thought operating directly on a heart was taboo. Any surgeon who dared to do so was certain to lose the acceptance of his colleagues. Yet Rehn successfully showed that operating on the heart was feasible, and he became known as the father of cardiac surgery.

  Some Things Don’t Change (But Should)

  Today, operating directly on the heart has been widely adopted. Cardiac surgery is routine. Truth won, not traditional thinking.

  Yet divergent beliefs continue about how the heart works, and these beliefs have lengthy historical roots. The endurance of these disagreements on heart structure and function demonstrate the obstinate holding onto such bias… as deductions about heart movement — made from examinations of dead hearts in the 1600s — continue to be considered valid today.

  Back then, as now, the heart was thought to be highly complex: a cardiac Gordian knot, containing muscles that appear to go in all directions. Its structure was believed far too complicated to ever be understood.

  Today, the imaging community retains these same beliefs, despite their improved abilities to observe cardiac movements. Admittedly, only two-dimensional diagnostic tools were initially available, such as observing dye injected into the ventricle to show how the heart wall contracts, or using the echocardiogram to watch the heart wall thicken and relax during each heartbeat. Those imaging tests reinforced the long-accepted four heart actions of: narrowing, shortening, lengthening, and widening. But the current introduction of modern three-dimensional imaging showed two more motions: twisting and uncoiling. These last two of the six motions form the core of the working heart’s movements.

  Such truth is known, yet this knowledge has not yet seeded new thinking, as mainstream physicians, nurses, medical students, and the general public continue to describe heart function using the conventional four cardiac motions previously mentioned. For them, contraction for emptying is traditionally portrayed as the making of a fist, followed by opening the closed hand for filling.

  Yet truth is what nature prescribes, not how man interprets it. Cardiac motion in humans has not changed for over 100,000 years… and twisting remains the most important motion.

  Hallowed History

  My long quest to understand the heart has been enthralling. It was along this pursuit that I recognized that today’s conventional description of heart movement precisely matches what William Harvey stated in 1628, in his classic book, The Anatomical Exercises, De Motu Cordis De Circulatione Sanguinis (often simply called De Mortu Cordis).76 It detailed the body’s circulation system and was a monumental contribution. The title “Father of Circulation” bestowed upon Harvey was well-earned.

  Intriguingly, my efforts to learn more of Harvey’s enormous discovery on the circulatory system had led me to the rare book room in the UCLA library… where they kept one of the only twenty original copies worldwide of Harvey’s text. How magical to enter this inspiring chamber resembling a cathedral and have the unique opportunity to hold a treasure, one we all regarded as part of the Holy Grail.

  But the real significance of this landmark experience became my realization that humanity’s imperfections existed even within such noble history. Mixed with the brilliance of Harvey’s contribution toward understanding the circulation were his mistaken deductions about cardiac function. Harvey admits his limited comprehension by stating, “I believe that the motion of the heart was to be understood by God alone” as he watched the heart move.76

  Claude Bernard’s edict of letting nature define what is truth, rather than only using deduction, was relevant again. It is not that Harvey was entirely wrong about the heart’s mechanism. The heart does have the compressive motion as he portrayed. But Harvey’s explanation is incomplete. Missing are the twisting and uncoiling movements described in this chapter, which are key to the normal heart motions of ejecting and filling during each heartbeat. The intent of this chapter is to uncover the muscles that cause this fundamental twisting motion. Harvey’s failing to observe this motion does not diminish his majesty. Instead, it simply points to the beauty of the endless trail to learn, discover, and grow.

  We know this now, as today’s 3D imaging displ
ay of the heart’s twisting and uncoiling movements confirm these fundamental basic motions. …But do we need such sophisticated new tools to tell us the truth about heart motion?

  We do not, as the following look into the past will surprisingly reveal.

  Hidden History

  During the 1600s when Harvey lived, Giovanni Borelli, an Italian physiologist, physicist, and mathematician, proclaimed that the heart twisted — resembling the wringing of a towel in a wine press — to eject blood through the body.103 Even before him, Leonardo da Vinci described watching a knife rotate during each heartbeat after being inserted into the heart of a pig about to be slaughtered.

  But even these were not the first times such descriptions appeared. Walking further back in history reveals that at around 280 BC, Erasistratus, the recognized father of physiology, described this twisting. His observations were later reinforced in AD 180 by Galen, the physician to the gladiators mentioned earlier in this book, who observed the heart uncoil each time as blood is forcefully sucked into it.

  Nature’s tale is consistently revealed through its movements. But this truth is only apparent to the curious eye.

  Turning Point

  Acceptance of the twisting theory plummeted when William Harvey submitted his report on the circulatory system. The leaders of medicine in the 1600s embraced his conclusions, and armed with this perceived truth, stated that Galen’s theories were inadequate and inaccurate. They were equally convinced that Harvey had also refuted Vesalius, the Flemish founder of modern anatomy, who totally supported Galen’s concept that the pulse reflected nature, as evident in the “ebb and flow” of ocean waves and currents.

  Harvey believed that the heart exerted a bellows action upon the circulation, mimicking exactly what happens at a fireplace when a bellows is compressed to add more oxygen to the flames. He insisted that pressure was the guiding force for moving blood from a high to a lower pressure area within the heart, simulating a piston pump.

  Seeing is Believing… Or is It?

  Harvey was wonderful, but not perfect. His conclusions about the heart’s constricting and dilating motions were true — but they are only a minor part of its action. Yet his concepts blotted out all prior descriptions of cardiac coiling and uncoiling actions… and astoundingly have persisted despite current 3D imaging that firmly demonstrates twisting in normal hearts.

  Most cardiac surgeons still live within the world of looking without seeing. We have clung to the imagery of compression represented by the clenched fist that we learned as medical students. It even carries through into the operating room where the twist happens… but we only observe what we long believed was true. Our focus upon the four motions Harvey described — shortening, lengthening, narrowing, and widening — makes us miss the vital twisting and uncoiling movements, because we fail to understand the structure that makes this happen. Yet as you can see, the twisting heart is evident in the operating room. (Video 1 twisting)

  Video 1: The cardiac twisting motion in a patient undergoing cardiac surgery, as seen in the operating room.

  www.vimeo.com/buckberg/normal-heart-twisting

  Up to this point, this chapter has given you an overview of yesterday. Now I will unveil my voyage into tomorrow. It is linked to my becoming aware of the heart’s true structure, and the ways in which this incredible knowledge will explain the mechanical forces that make the heart twist and uncoil. This is essential, because without this information, it is not possible to understand why the heart moves in such a way.

  Hidden in Plain Sight: The Helix

  It turns out the persistent belief that the heart is a complex rather than a simple structure has impeded acceptance of a different theory — one that involves a helix (spiral) configuration. Yet the reciprocal spiral coils of the helix are common in nature (as will be described in the next chapter).

  As we’ll learn, this helical heart architecture — and its surrounding wrap — defines the structure that accounts for each of the six cardiac actions.104–108 This geometry was actually observed in the 1600s by English physiologist Lower and again in the 1700s by French anatomist Senec — but there has yet to be wide recognition of its impact on cardiac performance.

  Heart structure never changes, but our perception of it does. In fact, this helical configuration was confirmed by a broad spectrum of the world’s most prominent anatomists in the 1940s.107 But they were perplexed by how the heart’s muscle’s configuration could create the geometric structure they were seeing. Moreover, this limitation prevented them from understanding how the heart’s design could mechanically explain every cardiac motion — yet all agreed that the helix and surrounding wrap were the centerpieces of the heart’s architectural form.

  We just needed someone to provide these explanations.

  Amazingly, such a person existed.

  The next steps to my astounding adventure were about to begin.

  Unraveling the Gordian Knot

  En route to Murcia, Spain in 1998 to speak at the Spanish Cardiovascular Surgeons meeting, I had a stopover in Barcelona. While there, I visited surgeons at the University Clinics in Barcelona to describe how to use Dor’s procedure to treat heart failure. We then did two operations.

  After completing these procedures, Jose Pomar, the chief of Cardiovascular Surgery, asked, “Do you fully understood ventricular structure?” When I admitted my knowledge was limited, he told me of a retired cardiologist named Francisco Torrent-Guasp, who had made a remarkable discovery about the internal cardiac structure. “Would you like to meet him?” I readily agreed.

  After the conference in Murcia, we traveled to Alicante, Spain, where Torrent-Guasp was to present his work before a group of cardiac surgeons that had attended the Murcia meeting. While I didn’t know it then, this unplanned trip would open grand new doors to my understanding… and set the framework for my research and clinical efforts for the next 20 years, right up to today.

  Paco, the Bearer of Answers

  Arriving in Alicante, I was excited that my room was a suite on the top floor of a fabulous hotel overlooking the Mediterranean Sea. But rather than sitting to relish the view, I went immediately downstairs to see “Paco” Torrent-Guasp. (Paco is short for Francisco.) (Figure 1)

  It was a memorable first meeting. We talked briefly before his presentation and I showed him some images of heart structure. Paco looked directly at me and said, “You do not understand cardiac anatomy.”

  Figure 1: Francisco “Paco” Torrent-Guasp

  I couldn’t believe he’d say this to someone who’d been practicing heart surgery for nearly 30 years. Yet a primary objective to my travel is to gather new knowledge, so I awaited his presentation to learn about the differences in our views.

  Paco proceeded to show us how he had “unraveled the heart” — figuratively and literally. I was captivated as he displayed how the heart’s muscles would completely unfold to look like a string or an unrolled rope.

  This architecture had a simple form containing a coiled helix (with obliquely angled or slanted fibers) that was surrounded by a wrap around its circumference (of transverse/horizontal muscle fibers)! Equally stunning was when he refolded the model, as it reformed the heart. This revelation is shown in an astonishing video of Paco “dissecting” the helical heart by using only his fingers to reveal its folding and unfolding characteristics, as described by its narrator. (Video 2)

  Video 2: Paco Torrent-Guasp unwraps the heart.

  www.vimeo.com/buckberg/unwrapping-heart-1

  Figure 2: Unfolding of Torrent-Guasp’s heart model. a) the intact heart. In b) the circumferential wrap of the base is unfolded as it covers the right ventricle. In c) the base wraps around the left ventricle and the helix is shown. In d) the helix of the apical loop is unfolded (on the right side) and its two parts of the inner coil (called descending segment or DS) and outer coil (called ascending segment, or AS) are shown. The left side shows the unfolding of the wrap or basal loop to display its right side or RS, and left si
de or LS. In e) the heart becomes an unfolded rope.

  This unraveling reveals the different areas of the heart, as are indicated in Figure 2.

  At this point, Paco declared, “Nature is simple, but scientists are complicated.” This elegant observation reflects the clarity of his thinking.

  Figure 3: A view of the Torrent-Guasp dissection, showing the spirals that form the heart’s tip or apex.

  Paco further demonstrated that this helix has a vortex at its tip, meaning the heart muscle goes downward at a 60° angle, then makes a loop to coil around this tip, to finally move back upward at the same 60° angle — evolving a pattern that has a wondrous spiral-like arrangement that was best observed from the heart’s tip: its apex. (Figure 3)

  Paco’s excitement about how this elegant structure could transform into movement was palpable. He called the working heart’s motion… the Cardiac Dance.

  His observations also had historical precedent, since his external cardiac structure mirrored what English physiologist Richard Lower had noted in the 1600s. Yet Paco took the colossal next step: uncovering the architecture’s muscle pathways and solving the three-dimensional structure of the heart!

  Paco called this heart configuration the helical ventricular myocardial band (HVMB), and named the helical muscles that go down to form the apex (tip) and then curl around to go back up… the apical loop. This apical loop can shorten and lengthen. He called the surrounding transverse/horizontal muscle (wrap)… the basal loop, which can narrow (compress) and widen the helix.

  What Paco presented was nothing less than astonishing! It erased misunderstanding — and introduced a new and uncomplicated understanding of the heart’s structure!

  Its sheer straightforwardness made me revisit my favorite phrase, “Elegance is simplicity, confusion is complexity.” Just as Einstein formulated E=mc2, and Newton defined F=ma, Paco’s documentation of a helix and wrap puts his contribution within the tiny number of monumental discoveries that shall change thinking forever.