In the operating room, Hisa started the heart-lung machine to decompress (vent) the stretched and poorly contracting dilated heart to bring it to normal size and shape. He then used an echocardiogram to watch the heart contract — and found that after the stretch was temporarily taken away by decompression — the area that contained healthy muscle would immediately regain strong contraction! Conversely, the decompressed diseased muscle remained non-functional.112
Hisa used this unique observation to introduce a new technique called the “site selection process.” This echo analysis provided a perfect functional equivalent to using the biopsy method. By revealing this uneven disease distribution, the surgeon could now safely choose to exclude only the unhealthy and non-working region.
The New Patch Approach
Ideas are great starting points. But truth comes from testing.
Our central mission was to change the ventricular form, and Hisa applied his new approach in two patients with large, dilated, non-ischemic hearts (that did not have heart attacks). The normal elliptical shape was rebuilt — using the patch approach we had discussed during our bus ride to Rome. The outcomes were superb! This procedure was either called The Pacopexy (the term I coined to honor Paco), or the Septal Anterior Ventricular Exclusion or SAVE procedure (Hisa’s name).108, 112
Hisa called me to report on his successes with both the patch procedure, as well as using site selection to determine what portion to exclude. Our joint exhilaration was palpable as we shared this thrill, undaunted by the 6,000 miles of ocean between Japan and UCLA.
Sharing with the World
While two surgeons brainstorming ideas during a ride through pastoral Italy proved fruitful, the real value is when discoveries are shared and adopted by the larger medical community.
I introduced this new step in thinking, along with my discussing the helical heart, when I delivered the Basic Science Lecture at the American Association of Thoracic Surgery in 2001 as described in the last chapter.108 The audience of approximately 4,000 cardiac surgeons listened intently as I explained how form was the centerpiece of correcting the spherical world of dilated heart failure — whether caused by scar from a heart attack, valve disease, or diseases in ventricle muscle. The cornerstone of “treat the form, not the disease” was new and seemed well-received by those in attendance.
At this same meeting, Hisa described our new procedure for treating patients with an enlarged ventricle due to cardiac muscle disease, which returns these failing dilated spherical chambers to their natural smaller elliptical form. He reported that heart failure symptoms were dramatically relieved and mortality was diminished — a landmark finding as many of these patients would have otherwise succumbed within the first year from only traditional treatments.108 Hisa further presented his triumphant initial clinical experiences in 36 consecutive patients using site selection with the Pacopexy / SAVE procedure.
There was substantial interest in Hisa’s outcomes… yet his manuscript was rejected by the reviewers of the Journal of Thoracic and Cardiovascular Surgery. This was an astonishing reaction since no data like this had ever been presented in the world medical literature. Hisa had introduced a revolutionary method to identify the site of disease in the heart, and described a breakthrough operation that rebuilt normal ventricular shape. I read the responses of the reviewers. Their rebuffs made no sense. I suspect the reviewers disregarded how he had avoided the problems of the Batista procedure (by site selection), and failed to appreciate his ingenuity in designing a whole new operative procedure with stunning outcomes.
The open mind met rigidity, and as so often occurs, tradition trounced innovation.
Undaunted by the journal’s spurning of his paper, Hisa’s continued work has shown a 69% five-year survival rate for patients who previously would have had a 50% two-year death rate. Truth wins, not editors.
Such new ideas are fuel for the future.
And Hisa took them even a step further.
Using the Patch Procedure with Heart Attacks
The concept of “treat the form, not the disease” was reinforced again, as Hisa now also applied this approach to treating heart attack patients with large ventricles — in those patients he knew would not respond well with the normal Dor procedure. Together with his colleague, Tadashi Isomura, Hisa utilized the Pacopexy / SAVE procedure in end stage heart failure patients with enormously dilated hearts. The data tells the story, as the seven-year survival rate was 72% — versus 61% if the ventricular size was surgically reduced, but its shape was not made elliptical.113 Additionally, eight-year survival rose to 84% when the reduction in ventricular volume was more substantial. A wonderful contribution and highly significant improvement for those with very sick, very dilated hearts.
Restoring Geometric Structure Works!
Overall, the results following restoration of the ventricle’s normal form for both heart attack and direct muscular disease were vastly superior to those from traditional medical treatment, as the numbers make very clear.
Following conventional medical treatment, 50 to 70% of patients in NYHA Class III and IV categories will succumb during the first two years, and their quality of life is awful, as it was in my father’s case. In contrast, when patients in these same categories undergo ventricular restoration, their condition improves to a Class I and II score. This spectacular and unheard-of change translates to a 70% survival, when measured at five years (further follow-up is needed to observe survival rates for even longer intervals).
On top of this, ventricular restoration adds another significant benefit to this functional improvement — by counteracting sudden death — which otherwise is a fatal event in 50% of all congestive heart failure patients. The stretched ventricle is the primary cause of this lethal arrhythmia, and this terminal event is nearly entirely avoided by reshaping this expanded ventricle. This approach also surpasses conventional methods of implanting a defibrillator to circumvent sudden death, as these patients will still die of congestive heart failure. So returning ventricular shape toward normal by ventricular restoration offsets both sudden death and heart failure.
Valve Disease Results… Not Yet In
The final breakthrough involves the third major cause of producing severely dilated hearts: the leaking heart valve.
How this dilation (expansion) happens is straightforward, as a leak in the aortic valve (between the left ventricle and aorta) or mitral valve (between left ventricle and left atrium) will make the heart work harder. For example, a heart might normally pump out 100 cc of blood, but the leaky valve may allow 100 cc to flow backward into the ventricle each time. So now, the heart must pump 200 cc during every heartbeat to effectively eject out 100 cc. That causes the ventricle to enlarge. In doing so it must stretch in order to squeeze harder to compensate, but this dilation can make it wear out, resulting in heart failure.
Though the leaky valve heart becomes spherical, this change is different from our earlier situations. There is no scar or infectious tissue in ventricular walls — so that excluding any portion of the ventricle will safely rebuild the heart’s normal elliptical shape and offset heart failure.
Unfortunately, awareness of this approach has still not impacted current thinking for treating patients with valve disease who have dilated hearts. This absence of interest continues, despite clear evidence that valve replacement alone, fails to improve long-term survival in patients with large ventricles (when ventricular volumes are greater than 55–60 ml/m2).114, 115 They succumb from the same heart failure and sudden death complications as patients whose heart dilation is caused by a scar or from heart muscle infection.
So data is not yet available on the effectiveness of rebuilding a normal elliptical shape in patients with leaky valves, as this treatment has not yet been recognized, embraced, or even studied. The nature of this opposition is twofold: a lack of acceptance (due to the faulty STICH trial results) that changing the ventricular shape can dramatically improve function after a scar forms from a h
eart attack… and doubts regarding the Batista Procedure (as it was considered dangerous). These false conclusions caused the medical community to reject out of hand that ventricular restoration of a normal but stretched muscle — can be life-saving in patients with valve disease.
Yet these barriers are not unassailable. Someone saw this truth, evidenced by Batista’s excellent success operating on the enlarged dilated hearts of patients with valve disease. My term for this concept is a “valve ventricular approach,” which I believe should be further explored. His findings may yet establish a new method for treating dilated hearts in patients with valve disease.
However, interest in such an approach is particularly slow in the United States. Ventricular stretching from leaky valves is progressive (meaning it continues to worsen as time goes on), and valve repair or replacement is usually performed on patients here before such extensive stretching has time to occur. So the need for ventricular restoration is less common.
But many patients in Asia, Africa, and the Middle East die because of large dilated ventricles from rheumatic fever (which produces valve damage). They don’t have our timely medical follow-up examinations to check how the ventricle is responding. By the time of their first examination, there is sometimes a severely dilated ventricle from a leaky valve. So they may be more likely to benefit if their ventricles were restored to an elliptical shape, at the same time as their valves are treated.
Wake-Up Call: Restoring Hearts, Restoring Lives
It is now clear that returning the heart’s normal elliptical shape and dimensions will improve symptoms and survival in heart failure patients far beyond the expected outcomes when correction of the spherical heart is not performed.
But these approaches have still to be accepted. Resistance to them is due in part to residual effects from the flawed STICH trial. These misguided outcomes resulted in keeping the cardiologists and surgeons from even considering an approach to heart failure that rebuilds the ventricle. This is frustrating because we have the answer, while no one is willing to consider the question.
Wake-up calls are needed to counter the medical community’s inability to successfully treat such terminal heart diseases. Yet the driving force for this change may come from the greater awareness of suffering patients — who rather than passively rely upon “confident experts” that continue using unsuccessful traditional treatments — may instead strongly encourage their physicians to look beyond what they already believe and practice.
Too often, our medical leaders have blinders on. They are unwilling to admit that knowledge can come from unexpected places: from a cardiologist in Spain who uncovers the authentic architecture of the heart, or from a surgeon in Brazil or Japan that does innovative operations. One needs an open-minded approach that pursues the truth. This can bring healing to hearts… and significantly better quality and longer lives to our patients.
New knowledge and effective treatments exist now! The prevailing shortsightedness must be tossed aside and replaced by the passion to learn about and then use these innovative ways to overcome the devastating effects of heart failure.
This sea change may indeed start with the reader.
Yes, with you.
CHAPTER 21
Art and Science: The Helix and Heart Video
The positive and enthusiastic responses to the Helix and Heart lecture at the American Association of Thoracic Surgery Association conference made it clear that I needed to bring my marvelous voyage with Paco Torrent-Guasp to a wider audience. I knew others would also be captivated by the unraveling of the heart to show its structure. My goal was to encourage greater awareness and acceptance of his findings, which would lead to unprecedented improvements in cardiac care.
This quest to both learn and teach flourished after my initial return from Spain, and is delightfully illustrated by how I further explored Paco’s discovery. I played a video of Paco unfolding the heart to a UCLA colleague, Carmine Clemente, who is a renowned anatomist and author of an anatomy textbook used by over 1,500,000 students worldwide. Carmine was so impressed by this first exposure, that he invited me to the anatomy lab to see if we could unwrap a heart.
We set out to duplicate what Paco had done. The scene was remarkable in another way. The world’s most famous anatomist and an internationally recognized heart surgeon, began to work in the same place that the freshman medical students start their professional journeys. We were alone at the exact tables where the first anatomy courses start — the perfect location for two curious professors to pursue their constant search for new knowledge. Our passion to understand was just as exuberant as that of someone new to the field.
Unfortunately, we failed in our task, as we did not possess Paco’s technical facility at dissection techniques. Yet neither of us was dissuaded. Pausing a moment to appreciate our quest, I simply asked Carmine, “Why don’t all of the university faculty act just like us, pursuing our endless journey into learning?”
Six months later, Paco came to Los Angeles and we used my laboratory for him to demonstrate his heart dissection. He taught us his method and we were both intrigued and astounded by its simplicity. The depth of Carmine’s interest became evident when he requested drawings of Paco’s dissection for use in his anatomy text. His excitement became transmitted to other anatomists, as the Moore and Dalley text, another major anatomy volume, delayed its publication until images of Paco’s dissection could be added. Carmine also asked me to give a one-hour lecture at the upcoming meeting of the American Association of Clinical Anatomists, which I gratefully accepted.
I was pleased that we’d seen some acceptance of Paco’s findings, as now two major anatomy texts — one written by Clemente and the other by Moore and Dalley — included images of his unfolding the heart. Yet the importance of these findings was even more powerfully imprinted upon me when I heard Dalley’s comment after he first watched the helical heart dissection.
He stated, “New findings change many things, but not anatomy; today Torrent-Guasp has changed anatomy.”
Unfortunately, newer anatomy textbooks are hardly ever read by those that provide continuing education courses to physicians after they leave medical school. These teachers include pathologists, cardiologists, and specialists in echocardiography. Yet they rarely re-examine the basic anatomy that forms the source of what they’re teaching. The older anatomy books do not contain Paco’s breakthrough findings — and as a result, very few in clinical medicine know about it. This discrepancy exists because our teachers and mentors often believe they already know what they need to know. My recommendation is that they should always remain students.
Yet among those who did know of Paco’s work, vehement opposition to the utter simplicity of his discovery arose from some leaders in the pathology and echocardiogram imaging communities. Efforts to discredit his theories included claims that Paco had used incorrect tissue planes during his efforts to separate the heart muscles. His critics could not envision how he found the connective muscle sheath surfaces that allowed him to prove his concept. Additionally, leaders in echocardiography refused to accept there was a circumferential wrap around the helix.
But proof must come from action, not words. The only important test is whether the finding can successfully explain the relationship between form and performance. Coming up with possible conceptual arguments against a new point of view is not helpful. There is one simple yardstick: watch the heart function and then describe mechanically why it happens. This task is made easier by using new imaging tools like advanced echocardiography and magnetic resonance imaging that provide a 3-dimensional dynamic view. If your concept explains everything we see the heart is doing, you have an answer that merits serious consideration.
Unfortunately, this theme of resistance to changing traditional thinking is ongoing. That obstruction is particularly true in this case because of certain inbuilt limitations — since pathologists observe structure in the dead heart during autopsy and then deduce function in the living one �
�� while imaging personnel observe function in the living heart and then deduce its structure. But reality demands that you must understand structure, so you can use the correct form to explain function.
For reasons that are not evident, some medical authorities believe that something exists scientifically — simply because it’s what they said. Their word becomes the law, rather than their having proved it. This approach is indelibly imprinted within the many major journal publications that presumably define “state of the art” information.116, 117 Yet astonishingly, they exclude mentioning the wrap around the basal loop, a circumferential muscle that has been a centerpiece of every anatomic description dating back 400 years!118
Spreading the Word
The truth is that many people knew about the helix, just as many were aware of the basal loop. But nobody understood how they functioned together. What Paco did was unfold the entire structure in a way that could now identify how the heart’s structure explained all of its major functions.104–106
My goal now was to spread this understanding to others so it would become a game-changer in the medical world’s view of cardiac care. I realized that this was not unlike the transformation attempted by French impressionists in the art world, nearly 150 years ago. They faced harsh opposition from the traditional art community, for until then, art reflected a realistic representation of what you were seeing. Impressionists changed that by rendering and dramatizing the feeling of what you’re looking at. They portrayed the brilliance of its brightness, the elegance of its beauty, and the passion of its exultation. The grandeur of its artistic meaning exploded from the canvas, differing from what others had seen before. The heart now parallels this, as its power erupts from our having learned the grand design of the cardiac motor.
The wonderful reception of my Basic Science Lecture at AATS became my springboard for now introducing this information to cardiologists, to those working in the other medical fields, as well as to others who wanted to understand the heart. A starting point had been established, as we had shown the impact of this knowledge in dealing successfully with congestive heart failure. The potential for sweeping applicability now became possible.
Solving the Mysteries of Heart Disease Page 38