If I was right, his contributions should place him within the legendary status of William Harvey, who defined circulation. Paco’s road map of heart design will create a legion of new breakthroughs in cardiac diagnosis and practice.
Curiosity Catalyzed
I talked with Paco for four hours during dinner after his presentation. As we finished and were about to go our separate ways, I posed a new question.
“Paco, where do you live?”
“About 100 kilometers from here,” he answered. “Why?”
“I would like go with you and learn further. Could we do that?”
Paco smiled and said, “Of course.” I hurried back to my beautiful suite overlooking the ocean and checked out, having never even opened my bags. I drove with Paco and Teresa, his lovely wife, to his hometown of Dénia, arriving at 2 AM.
My first chore the next morning was to change my plane reservations and reschedule my plans (I was going next to Lausanne, Switzerland to lecture), so I could arrive two days later. Paco and I spoke for 18 hours that day. I learned that Paco had begun uncovering this knowledge about heart structure almost 40 years earlier by performing dissections as a medical student in Salamanca, Spain. But his data and work had remained consistently unknown to medical, physiological, anatomic, and surgical societies.
Paco showed me a fabulous teaching tool that he developed: a silicon rubber heart model that permitted easy unwrapping, and then re-wrapping, of the heart’s apical and basal loops in only ten seconds. Its detailed markings mimicked the angles of the muscle fibers that existed in a dissected heart. It also displayed the cleavage planes — where the adjacent muscle tissue bundles could be separated to simplify the process of unwrapping the heart into a simple rope form, and then easily become rewrapped back to normality — just as it would in the dissection room.
I found this extraordinary. A secret that had been hidden for 2,200 years (280 BC to AD 1998) could now be revealed and displayed within ten seconds.
To further validate his model for me, he performed identical “dissections” on beef hearts obtained from a local butcher.
His demonstration of easily unwrapping the apical (helical) and basal (wrap) loops of the HVMB into an unfolded rope-like configuration needs to be seen to be believed. (Video 3)
Paco had unraveled the Gordian knot of anatomy.
We continued talking, and before I left the next day, I asked four additional questions: about embryologic development (the heart’s formation and early growth)… the heart’s electrical system… why his dissection differed from what was known about where the papillary muscles had their origin (that connect to valves at the junction between the atrium and ventricle)… and finally, how the right ventricle worked.
Video 3: Paco Torrent-Guasp unwraps the heart. Note that he begins by unfolding the circumferential wrap to show the helix. Then he unfolds the helix to demonstrate that the heart looks like a rope after being unwrapped.
www.vimeo.com/buckberg/unwrapping-heart-2
Paco did not have the answers, even though his knowledge of anatomy was astounding. Yet, I needed to have these initial questions solved if I were to fully support and advocate his approach.
I was galvanized because the far-reaching impact of this work was already apparent to me. This newfound potential to correlate structure with function could fundamentally explain the mechanical reasons behind many cardiac problems — by shedding new light on normality and how it is disrupted by disease — thereby guiding the evolution of novel treatment options. I centered all of my research efforts on this objective. If successful, a revolution in worldwide thinking would be created.
Figure 4: The heart configuration involves three spirals. The first (lower part of image) is at the ventricular vortex (at the apex). The second (middle of image) is where the circumferential wrap folds downward toward the apex to create the helix… that ends upward at the aorta (blood vessel that carries out blood from the left ventricle). The third (top of image) is where the two arteries leaving the heart — one going to the lungs (pulmonary) and the other to the body (aorta) — cross each other at 60° angles.
Nature’s Beauty… Unveiled Again
Paco’s discovery was gratifying for another reason. Forms within nature have always been fascinating to me, in particular, the spiral structure found in everything from DNA to galaxies. The heart described by Paco introduced yet another spiral, as its three spiral patterns create a wondrous cardiac configuration. Figure 4 illustrates this triple spiral design. First, the basal loop folds to become the helix, then it turns at the vortex (where the reciprocal spiral muscles form it) at the heart’s tip, and then its outflow arteries (aorta and pulmonary artery) cross each other.
How simple, graceful, and if correct… staggering.
Will This “New” Anatomy Match Function?
Fortified with what I now knew, it was time to find out if we could answer the definitive question that had enchanted and exasperated researchers for centuries: “Could this structure explain how the heart functions?”
This pursuit hurled me into my grandest journey.
Resolving this age-old mystery required creation of a new kind of battle plan. Fresh tools were at our disposal, since we had Paco’s model of the helical ventricular myocardial band. It helped us select specific sites to explore in a beating heart muscle. This allowed us to make motion recordings from within the helix that contained slanted (oblique) fibers, or in the wrap comprised of horizontal (transverse) fibers. The outcomes from this testing would allow us to confirm — or reject — Paco’s helical ventricular myocardial band theory. I knew that if these findings were positive, we could at long last reveal how the heart performs its wonderfully dynamic symphony of motions… during every single heartbeat!
Many would think the key to such discovery would be sophisticated and expensive investigative equipment. But we did not have access to fancy MRI or Echo machines that cost $500,000 or more. Instead, we only had some inexpensive crystals to place in the heart. They acted like probes, recording an impulse that tabulated how the heart moves as it contracts. We used a device costing just $10,000 to record these findings. But that was all we needed.
Still, we knew we were facing a formidable challenge: how do we determine the probes’ placement? We were essentially looking at a working heart without “signposts,” as if trying to establish tactical positions within an unmarked battlefield. Doubt was inescapable.
While such uncertainty is always a part of research, I also realized we were armed with the unique architectural road map provided by Paco’s model. But only if its guidance was correct.
To the Lab
Imagine the anticipation in our laboratory.
We started by mounting Paco’s silicon model adjacent to our operating table, where it displayed the wrap and underlying helix muscles. With this precise replica of the heart directing us, we could position the recording (sono-micrometry) crystals in a living heart in the exact regions that Paco identified as the underlying helix and the wrap.
If Paco’s model was right, and the crystal markers were correctly placed — the data inscribed from these recordings during each heartbeat would confirm that the three muscles (the two arms of the helix and the wrap) accounted for all of the heart’s movements.
But if not, we must join the other frustrated investigators who had failed to find mechanical reasons for cardiac movement.
It was a daunting challenge to take on!
Our strategy was simple. Pairs of tiny crystals would be inserted (one cm apart) either into the horizontal fibers of the wrap, or along the diagonally angled helical bands on the outside and inside of the ventricle. The contraction movement of these muscle fibers would then be recorded in thousandths of a second to rapidly follow their motion.
Everything was in place. Nothing like this had ever been done before.
Needle in the Haystack?
Fortunately, we were not looking for a needle in a haystack, since we had Paco’s
helical heart model as the guidepost. Our search for the “holy grail” — understanding why the heart moved — began with our Spanish research fellow, Manuel Castella, doing these studies. I spoke with Paco and he was proud that another Spaniard would play such a key role, half a world away.
The study began. Tracking results were recorded. Our first answers came back.
We did not find success. This was clear as soon as Manuel walked into my office from the lab after our first experiment. His face was not hard to read.
“What happened?” I asked.
“We have a problem. The crystals are revealing abnormal and irregular contractions in an area of the heart. Actually, in three areas. I’m sorry, Dr. B., but it’s not working as expected. The heart simply doesn’t function the way Paco said it would.”
I could see that Manuel was personally frustrated, as well as concerned about my reaction. But I wasn’t looking for only “my” answers. I was seeking truth. Manuel’s training needed to include this lesson. As Claude Bernard stated, if results are incorrect, it means either your idea is wrong, or your procedure is not being done properly. Exploring these barriers would become an essential part of our search, because Paco’s model can only be considered valid if it passes all tests. A dazzling hunt was about to begin to understand every roadblock — to see if each reflected permanent obstacles, or could be explained and resolved.
I smiled reassuringly at Manuel. “Nature is telling us something. Let’s find out what.”
We returned to the lab.
The first issue related to the absence of a clear contraction from recordings of a pair of crystals in the deeper tissues on the lower side of the heart. Could this mean that the fiber arrangements in this region were different than what we had expected from the helix and wrap?
Manuel and I agreed on the next step. “Do an autopsy to find exactly where the crystals were positioned — a key factor — before we draw any conclusion.”
We were on target, as the autopsy examination showed the recording crystals, inserted through the heart muscle, touched a papillary muscle on its inner surface. This small muscle contains longitudinal fibers that interact with heart valve structures. Paco’s model was validated, because this tiny site has no helical or transverse fibers.
The second goal was to understand why there were persistently poor recordings at the heart’s tip. This tip (called the apex) is formed by the vortex of the heart’s inner and outer helix (as shown in Paco’s model). I thought about this and told Manuel, “The heart’s form and function simulates nature. For example, when it twists, the motion resembles the whorl of a hurricane or a tornado.”
So I asked, “What happens in the eye of each of those storms?”
Manuel’s face lit up. “Nothing. It’s the area of calm.”
“What if that was the same for the heart?” I posed. “The apex at the tip of the ventricle is very thin and located just beyond the twist of the vortex. Could this be an area that does not move?”
Exhilarated, we tested and confirmed this. The motionless cardiac tip does reflect the calm eye of a storm. Most importantly, nature demonstrated something, and we used that lesson to understand something else. This was proven from the normal shortening function that we recorded when crystals were placed adjacent to the apical vortex (but not on the tip of the vortex itself).
Finally, we faced the third roadblock. Recordings from the right ventricular wall showed these fibers contracting as if they were oblique (diagonal) — like those helical fibers in the left ventricle. It contradicted our belief they should be transverse (horizontal). How could this be?
Manuel feared this might be a crushing blow to the helical heart concept. Yet, just as one does when his car is lost on a trip, we needed to consult our road map.
I said, “Let’s take another look at Paco’s model.”
So we opened the model, peered closer, and there it was.
“Look at that!”
Paco’s model showed that this part of the right ventricular wall did contain deeper oblique fibers — similar to those on the surface of the left ventricle. An unforeseen finding, since we had deduced (but incorrectly) that this part of the wrap only contained transverse fibers.
The crystals simply told us what was there, not what we expected. They worked perfectly, and by doing so, they confirmed the accuracy of the fiber orientations within Paco’s model! It was a stunning finding. We now had overcome all of the apparent roadblocks.
It was an amazing experience, because every time we came across responses we didn’t anticipate, we were able to figure out why — using Paco’s model for guidance. His myocardial band model could explain every logjam we encountered, and in doing so, solidified our confidence about the gigantic importance of Paco’s discovery.
All of this took place over several exhilarating months, with new findings emerging during every step of the journey. Paco’s helical model truly became the Rand McNally map that led to a unique and spellbinding understanding of how the heart mechanically works.
(Sequential) Timing is Everything
Our initial venture into decoding normal structure and function led us to an unanticipated prize. Manuel called, as he had found something, but did not disclose it. Instead, he urged me to come down to the lab.
“Dr. B., I know the general consensus is that the heart muscles all contract simultaneously to pump blood, like a closing fist. But look at these tracings.”
He handed me recordings of crystal movements as the heart contracted.
“I hadn’t noted it before,” he continued, “but the crystals in each of the three muscle regions we tested do not all move at once [simultaneously] during a heartbeat. They moved sequentially.”
Examining the data, I grinned. “This is fantastic! You’re right — it shows the muscles are contracting sequentially — one after the other after the other. These direct muscle recordings confirm that the conventional belief of synchronous action [all moving together] like closing fingers all at once to make a fist is absolutely wrong. Instead, they follow each other, like a whorl of a contraction. Great work!”
The power of our understanding of form and function blossomed. The magnificence of Paco’s insight explained all six motions of function by a cardiac structure of just three primary muscles in the heart (the two helix layers and the wrap)! Its beauty lay in its straightforward nature: the wrap narrows the ventricle and subsequently widens it… while the helix shortens the chamber and subsequently lengthens it… and twisting is caused by the differential rotation of the helical muscle (one portion going clockwise and the other counterclockwise), which subsequently uncoils to return the ventricle to its starting point.
How thrilling and elegant.
Controlled Power
Our explorations also led us to recognize another aspect of heart structure — one that helps explain the heart’s incredible strength.
The heart’s powerful spiral muscles that produce the twisting helix would essentially “explode” during its ejection of blood to circulate throughout the body — if not for the wrap that contains it. That is, as the helix squeezes forcefully, the sides of these inner spiraling muscles would naturally splay outward. But they are held together by this surrounding wrap. (Figure 5)
My previous analogy between the twisting action of a heart and the whorl of a hurricane was only partially correct. There is no wrap around a hurricane, so the hurricane spreads out far and wide (25 to 150 miles or more) because it has no confinement. Conversely, the heart is more efficient because a wrap is part of its design, and this containment maximizes power to perform its majestic functions. No energy is wasted. The wrap also imposes a similar benefit when the heart develops suction. It prevents ventricular implosion — offsetting the ventricle’s tendency to collapse — as the wrap holds the chamber open to avoid this consequence.
Figure 5: The bottom three figures show the relationship of the circumferential wrap (horizontal lines) and the figure 8 helix, with relaxat
ion (diastole) on left, and ejection and suction in center and right. The wrap surrounds the helix and prevents its arms from exploding during ejection and imploding during suction.
Upper image shows how heart design is same as cathedral’s gothic dome and surrounding buttresses.
This inner conical shape and outside wrap made me realize that the heart’s structure resembles a church’s gothic dome. Think of the way this style of architecture contains buttresses that keep the dome from pushing outward and then toppling down. (Figure 5) This unique commonality led me during lectures to playfully ask my medical audience, “Which came first — the heart or church?”
A New Future
Our team was ecstatic as each of our preliminary experiments confirmed Paco’s prediction of these major muscle fiber bundles — and explained the reasons behind heart movement. Paco had indeed solved the ancient enigma of myocardial architecture! We were so grateful for his discovery, which gave us the chance to help uncover this vast new universe.
The next question I asked myself was, Did I wish to spend many ensuing years studying this cardiac structure in order to understand the mechanics behind normal and abnormal heart motion?
My response was a resounding yes, especially since a broad spectrum of new imaging technology was forthcoming. These tools could be used to further verify Paco’s architectural findings. And they did. New evaluations by magnetic resonance imaging, velocity vector imaging, and 3D speckle tracking echocardiography — all revealed an even clearer picture of the interaction between the helical and transverse muscle fibers.104–106 For the first time, we’d solved the ongoing divide between what you see — and understanding why you see it. We could use Paco’s concept of the heart’s architecture to account for the results that the imagers found every time. Bravo for Paco! His theories became further validated as each newly available technology confirmed our measurements.
Solving the Mysteries of Heart Disease Page 33