Solving the Mysteries of Heart Disease

by Gerald D Buckberg

  Figure 7: Variations within the same form by Monet. Haystacks are above and Cathedral at Rouen below.

  Though not conscious of it when formulating my lecture, I believe the impact of Monet’s work predisposed my mind to search for the similarities and variances of the spiral. It was an unexpected alliance between great art and science.

  Heart Architecture = Classic Architecture

  The centerpiece of my presentation was always to be the heart, with the most powerful component to be my portrayal of Paco’s contribution. I would demonstrate how he started with an intact heart, then unfolded it to initially show the circumferential wrap, and then separated the helical spiral arms in order to display the rope-like or “worm-like” structure of the unfolded heart. The majesty of its beauty heightens as Paco then refolds the splayed out form to perfectly rebuild the intact structure. (Video 2, a “replay” of the last chapter’s video) I knew the audience would gasp at Paco’s remarkable innovation, especially when followed by MRI images that verified these reciprocal spirals… and radioisotope studies that confirmed how this structure explains mechanical heart function. These tests established the vital bond between form and function — the essential groundwork of cardiac surgery knowledge.

  Video 2: Paco Torrent-Guasp unwraps the heart.

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

  Figure 8: Similarity of spirals. Leonardo da Vinci shows heart flow into aorta (upper left), Greek columns (upper right), prehistoric graves (lower left), and in galaxies (lower right).

  Yet beyond its presence in our own human form, we can also witness spirals in what we build and create. In fact, one might wonder (as I did), if it was simply those aortic reciprocal spirals in the heart that so impressed Leonardo… or whether it was the commonality they shared with the clockwise and counterclockwise spirals that existed at the top of Greek columns built in 500 BC… or the spiral images placed on graves by prehistoric people in 5000 BC… or the galaxy. (Figure 8)

  Continuing to develop my presentation, I recognized further ways that man-made structures reflect our heart structure. The most obvious were comparisons of similarities between the heart’s configuration and classical architectural design.

  The Greeks built temples with columns to support its framework. These pillars needed to be placed close together in order to provide sufficient strength to support the upper horizontal beams and prevent them from collapsing. Yet this configuration only permitted a few people at a time to walk between the pillars for entry or exit. The next development was made by the Romans, who introduced a semicircle configuration, in which stresses were offset by a centerpiece at an upper central focal point. This was the point of greatest compression by arch forces. With greater space between pillars, more people could now walk through these semicircular forms, but there were still limitations. There was instability when higher and wider archways were used to facilitate traffic. This explains why the Roman Coliseum has three levels. A new design was needed.

  An apex-like structure (having a singular, highest focal point) emerged, its form evident even in the simple huts and tents created by Celtics or Native Americans. These structures differed as their stress forces proceeded downward — and were counteracted by a buttress construction on (and within) the ground that maintained the integrity of the cone. (Figure 9a)

  Figure 9a: Top is architecture of hut, with a conical dome and a wrap like a buttress, while bottom shows a cathedral with a dome and flying buttresses for external support.

  Figure 9b: a heart with a similar conical component that is surrounded by a buttress.

  Moreover, I found that creating larger tent-like structures to bring in even more people had required construction of an external buttress, which formed a brace. The Gothic arch then evolved. Its support simulates (Figure 9a) the heart’s “wrap” in the form of external flying buttresses that support the classic Gothic domes of grand cathedrals. How astounding that this man-made construction of a place to worship exactly parallels the cardiac dome containing an apex, which is braced by its surrounding and supportive basal wrap. (Figure 9b)

  This architectural similarity underscores my whimsical question, “Which was first — the church or the heart?” No answer is needed, since “truth” evolves from recognizing this unified game plan (incorporating nature, human, and the heart).

  The Heart of Nature’s Majestic Plan

  By this point in the research, I was certain that the heart fit within nature’s overall scheme. Yet this helical structure serves different functions in different natural realms. Yes, it gives the eland’s reciprocal spiral horns incredible strength and durability. But particularly important to our attendees’ understanding — was that this powerful helix structure is also responsible for the heart’s narrowing, shortening, lengthening, widening, twisting, and uncoiling motions. I planned to show a video clip during my lecture to reveal the overall splendor of these clockwise and counterclockwise movements of the working heart — motions that Paco called the “cardiac dance.”

  As often the case, each piece of new information is accompanied by a new question. I began to wonder about the right and left spiral arm muscles interweaving in the helical heart — that create the beautiful twisting and uncoiling actions of Paco’s “cardiac dance.” Could they be in the same ratio as described for other spirals?

  That thought spurred me down to the lab, where I eagerly unraveled Paco’s rope-like model of the heart. Nobody had ever made these measurements.

  I couldn’t believe what I found.

  The left and right-handed sides (or arms) of the helix were in that same ratio of 0.618. This was nothing less than staggering! It demonstrated the same Fibonacci proportional dimensions that correspond precisely to the ratio that Pythagoras described within the golden section (Figure 10) — and further certified the unity of man, the heart, and mathematics. It is there if you look, and then you see.

  Figure 10: Relationship of helical heart to mathematics. Above, the helical heart, whose spiral is partially unfolded…adjacent to the spiral of mathematics formed by golden proportion. Below, the helix is unwrapped, and the proportional size of the descending (DS) and ascending (AS) segments is in complete harmony with the golden section.

  I could be only further awed at how the heart is part of this grand scheme. Cardiac muscle contains a hidden, yet remarkable harmony of spirals, beginning with the DNA double helix that provides the blueprint of life. Its reciprocal spiral configuration is similar to the heart’s clockwise and counterclockwise muscle arrangement. These double spiral muscles are the same ones fully active in a beating ventricle of a normal person without heart disease… providing the natural twisting and uncoiling movements responsible for ejection and suction. These natural motions are easily evident from the magnetic resonance and echocardiographic imaging scans that our patients may routinely undergo.

  This principle — that motion will be produced by its underlying architectural structure — emphasizes the credo that we must understand structure to treat heart disease.

  The Lecture

  The day of the presentation arrived. Here was the test of whether the fascination that had captivated me during my preparations could be transmitted to the 4,000 curious cardiac surgeons that attended this Basic Science Lecture.

  I asked them a fundamental question as I began: “Why would a heart surgeon get so involved in looking at spirals?”

  I posed this query because its answer addresses the foundation to our specialty: structure is the absolute centerpiece of surgery. Our approaches differ from medical ones that use drugs or electrical stimulation (pacemakers) to address specific ailments. Instead, our job is to restore the heart’s structure. We view disease as a distortion of normality, and our goal is to bring normality back. Our ability to succeed in this pursuit stems from how deeply we understand natural structure.

  This was the first time I had ever publically discussed the helical heart and explained why the helix is critical. I described
that its structure contained two arms composed of oblique (slanted) fibers that cross each other at 60° angles. This form allows the normal heart to pump out 60% of its volume (percentage of blood in the heart’s ventricle that is ejected out into the body per beat — the ejection fraction).

  Further, I explained that congestive heart failure develops because of a loss of the heart’s natural spiral shape. This distortion by heart attack or disease will make the normally conical or elliptical helical shape (like a football) become dilated or stretched as its form becomes spherical (like a basketball). The disrupted architectural pattern makes the angles of muscle fibers change to closer to 30°, which impairs function — causing the ejection fraction to fall to 30% or less. Again, I made an analogy to the high school quarterback who can throw a perfect spiral pass 50 yards, while the premier basketball player is inaccurate from only 20 yards. Performance is independent of the player’s underlying talent. Performance is related to form, and this is dramatically true for treating heart failure.

  I knew that unraveling this relationship was central, since conventional treatment options have never been aimed at fixing the distorted ventricular form. Rather, their primary objectives (by means of bypassing obstructed coronary arteries, or repairing or replacing a defective valve) have only focused upon correcting the reason behind why the elliptical ventricle became a dilated spherical shape. Missing was the understanding of the need to correct the dilated ventricle itself. Instead, heart transplantation or mechanical assist devices were used to replace the heart if the dilation was extensive. The valid (and preferred) treatment option of using a surgical procedure that returns the natural conical shape to the dilated heart… was never considered.

  Yet I pointed out that the spherical shape remains following conventional treatments of all ventricles stretched beyond 60 ml/m 2. This easily explains the often dire outcome of progressive heart failure — regardless of whether the cause was a heart attack, leaking heart valves, or disease in the heart muscle itself. I further noted that the alternate approach of heart replacement by transplantation was not common due to the limited donor pool, and that mechanical ventricular assist devices were problematic due to infection and abnormal blood clotting.

  These well-known limitations led me to introduce the phrase “fix the ventricle” — a novel strategy I believed would be an essential part of all future treatments of congestive heart failure.

  I saw a new world before us: we must return the spherical chamber to its natural elliptical form.

  Restoration = Rebuilding

  My Helix and Heart lecture was delivered before the STICH Trail began, and had a dual purpose. Our international RESTORE team (whose membership was described earlier) would present our findings on approximately 1,200 consecutive congestive heart failure (CHF) patients for the first time at this AATS meeting. Their surgical approach to rebuild the stretched ventricle was based on the breakthrough work of Dr. Vincent Dor of Monaco — who taught how to restore the natural elliptical form by excluding the heart attack scar that had created the dilated spherical heart. (Figure 11)

  Figure 11: How ventricular restoration rebuilds normal shape. Upper left is normal conical or elliptical shape. Upper right is failing heart with spherical shape, caused by scar (in white). Below is restored heart configuration, with return to normality.

  Connie Athanasuleas would report on our team effort, his presentation describing the astounding success achieved in congestive heart failure patients after their ventricular shape and volume was rebuilt into a normal configuration.

  During my basic science lecture, I would additionally focus on my reasons for beginning the RESTORE team, a group that stemmed from my asking, “Who are we, as physicians, to invent the rules on how the heart should be treated? Instead, it seems most important to follow nature’s design — and thus dedicate our efforts toward rebuilding the natural architecture.”

  Treasured Tradition: Learning from Others

  My exploring the grandeur of this cardiac architecture — in particular, the heart’s apex and surrounding wrap — led to intriguing analogies to other aspects of human existence. This proved to be especially moving for me due to a personal experience in 1982. I recalled a visit to Jerusalem, Israel where I purchased a prayer shawl, or “tallis,” for my dad. Every Saturday, he would take it with him to worship. Returning home on one of those occasions, he told my mom, “While wearing this tallis in synagogue, it felt like Gerald’s arms were around me.” Tears still well up in my eyes each time I recount this. I picture my father surrounded by my gift… and me. Yet the broad parallels of the helix and wrap even mirrored this undeniable human quality. (Figure 12)

  Figure 12: The helix and wrap and the human. On left is heart with a conical apex, surrounded by wrap. On right, a painting from Chagall showing a rabbi, who forms the conical part as he is wrapped in a prayer shawl for heavenly support.

  But there was even more to the connection.

  When I visited my mom during her final illness, I learned you ultimately gain the traits of those you love and respect by recognizing their special qualities. When they depart, these characteristics become yours completely. While your arms and shoulders may have been what literally embraced them, it is your receiving their gift of guidance… that allows you to see further than you otherwise could.

  For me, this was not only true of my father and mother, but also of the many mentors who have impacted my life. You love, admire, and ultimately learn from them. You take on their best qualities, and hopefully honor them by passing those along. As our teachers advise and serve as a source of wisdom, they become a focus — an apex — from which we, whose arms wrap around them, then emerge to teach others. A proper legacy is when your students will take what you offer, and then give it to their students.

  This tradition of learning, teaching, and guiding is something I strive to continue.

  “My Apex”

  I hoped to pass along such wisdom during my basic science lecture at AATS.

  As I’ve said, the origins of this presentation came from my transformative meeting with Paco Torrent-Guasp three years earlier. Paco had developed his ideas 40 years earlier as a medical student. But despite their truth, these ideas were discarded by “experts” in anatomy and cardiology. This age-old dilemma was discouraging to Paco, but my eyes opened anew as I suddenly saw how his wisdom might become a legendary contribution.

  Fortunately, all his findings were recorded in a book in Spanish that he gave to me (copies were not available in the U.S.). It was captivating. One exciting and notable detail was that the description of the vortex formation at the apex of the heart also corresponds to the tip of a hurricane… where its powerful spiral movements mirror the same rotations that exist in the heart as it produces efficient ventricular function. (Figure 13)

  Figure 13: On left is view of heart that shows the whorl shape that starts at the spiral in its apex. On right are the whorls of a hurricane that have the same configuration as exists within the heart.

  Recognizing the importance of similarities and differences in related forms, I had my lecture include the previously mentioned contrast to the hurricane (like the tornado) that does not contain a circumferential buttress or wrap to contain its energy. As a result, its top portions make larger and larger whorls, causing its trajectory to expand many miles wide. The wrap brace allows the heart to expend its energies into producing blood flow to the body, rather than allowing lateral explosion of its forces.

  Conversely, I pointed out that the heart has the basal wrap around it, and this buttress maintains its physical integrity (otherwise, the heart would literally explode or implode when ejecting or sucking in blood). With this wrap harnessing its power, the heart pumps blood through over 60,000 miles of vessels, over 100,000 times a day, and 35 million beats a year throughout your life.

  Yet there was something else even more profound that I needed to address.

  I had found Paco’s unraveling of the heart miraculous wh
en he first unfolded it like a rope or worm for me, and I asked, “How did you come upon that idea?” Paco replied that he had studied the evolutionary development of humans. He described how we evolved from worms over one billion years ago, with a vascular tube (rather than conventional heart) that looks much like a rope. By 400 million years ago, a fish had evolved, with gills and a single pumping chamber (heart). Then by 200 million years ago, amphibians and reptiles developed, leaving the water to walk, having a two-chambered heart with just a single atrium and ventricle. Then by 100,000 years ago, the human emerged, with our recognizable four-chambered human heart. I was astounded by this knowledge, and certain my surgical colleagues would be equally delighted as I shared it. And I would find there was still more that was just as extraordinary.

  Recognizing a certain familiarity to these different stages, I reviewed the development of the heart’s anatomy during the brief gestation period of the human fetus — and found something quite stunning. At 20 days, the blood vessel system of the human embryo looks just like a worm. At 25 days, the first generation of a heart appears with a single pumping chamber, as occurs with a fish. At 35 days, the heart appears like that of the amphibian and reptile. Finally, at 50 days, the human heart is now formed. During this 50-day gestation period in all humans — we have each bridged one billion years of history.

  The Essence of Learning

  I gained important insights in preparing for this presentation, not only about how the heart functions and its deeper connection to nature’s grander scheme, but also how the world responds to such new knowledge. Harvey’s landmark writings from the 1600s taught us a wonderful lesson about our masters — they may be superb, but are not perfect. Yet the “experts of today” closely mirror those who wrongly believed Harvey — those who had cast away the valid concepts of Erasistratus and Galen about twisting and sucking. Sadly, critics continued to create barriers that curtailed others from properly recognizing Paco’s legendary contributions to cardiovascular medicine.