Solving the Mysteries of Heart Disease

by Gerald D Buckberg

  My educational goal widened, and I began to wonder if there was another means to reach an even broader audience.

  I have always been captivated by the rhythmical movements of the normal helical heart, motions that Paco called the “cardiac dance.” I reasoned, if it looks like a dance, why not create a ballet? Something that could enhance the understanding of the beauty of the normal healthy heart, demonstrate what happens when something goes wrong, and finally, reveal how restoring natural structure will return its natural harmony.

  I again entered uncharted territory, but now in art rather than scientific endeavors. I’d only seen ballets performed on TV, except for one performance in Paris while attending a conference, which happened to be Baryshnikov’s first public performance after he left Russia.

  But I knew that ballets always told a story, and there was no more wondrous tale of movement than the one told by the beating heart. Good fortune for this pursuit prevailed, as I had maintained a close relationship with my alma mater, the University of Cincinnati, which had an outstanding College-Conservatory of Music. Their dean was Doug Lowry, whose vision of leadership was dynamic, inspired, and eager to explore new avenues of expression. I visited Doug there, and he was enchanted by the elegant simplicity of this helical heart discovery. He arranged a meeting with several of their teaching staff.

  Their professor of dance was Shellie Cash, a graceful, creative, and committed person. My excitement and joy about the possibilities of looking at the heart through dance was infectious, as it ignited her flame by describing how the heart lives within nature’s world of spirals. Shellie was thrilled, as spirals connected to nearly all that she does within the choreography of dance. The freedom of imagination flourished during our brainstorming on how to use movement to express this new heart concept. How exhilarating to join these intensely inventive people to develop a variety of ideas as I entered another new world (of dance). I loved it.

  We set the ground rules of our collaboration, as Shellie and her staff would be in charge of generating the performance, and I was their consultant. My job was to ensure the dance truly embodied how the helical heart functioned.

  A New World for Everyone

  As it would turn out, this became a production unlike any they had ever done. Prior performances had nearly always been of classic ballets, relatively straightforward with the lighting and staging that would naturally be used to highlight the show. When you perform The Nutcracker, for instance, you essentially use the same music, sets, and dance moves to tell the same tale that has always been told. The similarity of a current performance to one given 25 years ago is predictable.

  But our production had to be totally innovative. We would start from scratch. We needed to demonstrate the normality of the helical heart, show its failure after becoming spherical following a heart attack, and celebrate its rejuvenation upon restoring normal heart shape. Our team incorporated different departments at the College-Conservatory of Music: set design, multimedia, lighting, sound, music. All brought their best talents, and Shellie’s skill as a leader allowed her to blend the gifts of these individuals from various disciplines into one integrated production. The College-Conservatory of Music had never put on such a multi-dimensional performance, in particular one that inextricably linked art and science.

  I learned again that interdependence created an environment in which we could thrive. Independent efforts could not have achieved our collective goal. In truth, working with others has defined my entire career. Interdependency is crucial when a trained surgical team performs an operation, or when my research fellows take the lead in conducting our studies. The power of working collaboratively brings about something much grander than is possible by pursuing individual accolades. The reward is exponential, not additive.

  Working in Tandem

  Shellie was the producer. She coordinated all the different pieces of the whole, thereby placing an even greater demand upon her beyond the simultaneous chore of choreographing an original ballet. She boldly took on the job.

  Her teamwork with grad student composer, Jenny Merkowitz, was spectacular. Jenny was equally fascinated by the project, and was also a dedicated student of the concept of golden proportion, which is so integral to the heart as well as to nature. The design department constructed a 20-foot model of the helical heart by placing fabric over an architectural framework that followed the simple design of Paco’s rope-like model. This gargantuan replica became the distinctive backdrop that would stay in place during the first, second, and final acts of the ballet. Its simplicity and intrinsic elegance were awesome.

  The same exceptional commitments to revel in the splendor of the helical heart existed in teams responsible for sound and lighting design, those creating multimedia projections of spirals on the stage floor and backdrops, as well as costume creation, and of course, within the talented student dancers Shellie’s casting had selected. The power of her leadership was palpable during rehearsals, as was her unwavering dedication.

  As my availability to travel back east to the College-Conservatory of Music was limited, Shellie would record videos of rehearsals and send those to me for review. In turn, I would respond when I saw things that might be incorrect, such as how to portray the bulging of the ventricle that develops from the non-contracting region after it is damaged by a heart attack. My personal experience with patients led me to sometimes make additional recommendations, such as having the two featured dancers wear grim expressions and slump their shoulders to exhibit the human experience that follows the development of heart failure after a heart attack. Likewise, when the heart returns to normal, they show the exhilarated smiles that express their newfound grace. So my “science focus” fused with the artistically presented human response that characterizes the tumultuous world of congestive heart failure. Such personal drama is portrayed throughout The Cardiac Dance; Spirals of Life.

  I attended the final rehearsals for the show. Sitting alone in the empty wings of the theater, I marveled at the interweaving of each of the departments of dance, music, lighting, multimedia, etc. The devotion and caring that each had brought to the production was brilliantly apparent.

  My global view of the heart, and of the production, allowed me to introduce further suggestions as the ballet was taking final form. I helped define how the dancers’ motions represented actions of the normal heart, and especially after they are strikingly distorted by a disrupted heart form. But I also found myself posing ideas of a more aesthetic nature to enhance the message. For example, I worked with the multimedia person to ensure that background imaging was not emphasized in a manner that drew attention away from the dancers.

  Along the way, I learned the scope of effort needed to put on such an ambitious production. I began to appreciate the pivotal roles played by those individuals we never see (much like those participating in a cardiac operation). I became aware of how much planning it took to change scenes with the large helical heart fabrication, as it needed to appear, collapse, and then later fully reappear as it became re-erected and regained its vibrancy. I could otherwise never have appreciated the smooth coordination required of a stage crew to silently raise it back up with pulleys — all managed covertly while the dancers carried on.

  The cardiac surgical team of my world had now become the ballet production team, as this novel treat became a scintillating experience.

  Showtime!

  The day of the opening performance finally arrived: May 25, 2007. I was there with my wife, Ingeborg, along with a packed house from all over the Cincinnati area. There would be three public performances (all to capacity crowds). A professional videotaped version of the production would also subsequently be made (and can be viewed via a link at the end of this chapter).

  Before the live performance, a brochure was distributed that not only described the show’s background and cast, but also provided audience members an introduction to the helical heart concept. It revealed that even 400 years ago, there were scientists who b
elieved the heart had a helical structure with a surrounding horizontal wrap. However, unwinding the structure to define this configuration had not been possible until Dr. Francisco (Paco) Torrent-Guasp used dissection to successfully unfold this “Gordian Knot” of anatomic architecture — and amazingly demonstrate that the heart unfurled like a rope.

  I quoted Paco’s memorable remark that “Nature is simple, but scientists are complicated.” The brochure contained a drawing that showed how to recreate the heart’s helical configuration from a piece of paper in less than ten seconds. (Figure 1)

  Figure 1: Helical heart design made from strip of paper. Its beauty is its simplicity.

  Pre-Show Video

  Education was the goal of this The Cardiac Dance; Spirals of Life presentation, so we preceded the ballet with a nine-minute video, in which I cited the long-believed misconception that the heart basically constricted and dilated to function, instead of its proper twisting and uncoiling movements.

  Paco Torrent-Guasp was introduced, together with his simple design of a helix and a wrap. The astonishing unraveling of the heart was shown both through animation, and with a video recording of Paco unfolding the rope-like heart by performing a dissection using only his hands. This pre-show video also included animation from the Helix and Heart video that demonstrated the heart’s twisting and untwisting motions, along with its narrowing, shortening, lengthening, and widening movements.

  We then described the disease of heart failure, which is poorly understood by the general public despite its affecting 5 million patients just in the U.S. alone. Actual footage of beating hearts showed the contrasts between the normal elliptical form, and the spherical shape that occurs when there is heart failure. We amplified this by contrasting the “healthy shape” of the University of Cincinnati football, to the “unhealthy form” of the Xavier University (the cross-town rival) basketball.

  Following this, a clinical demonstration showed how heart failure changes both form and function, by first showing an MRI of a normal heart exhibiting its natural rhythmic action, and then contrasting it against the poor contractions of a dilated heart in congestive heart failure. The path of a heart’s journey from normal, then its disruption, and finally returned back to normal — was illustrated by an animation of the surgical technique of opening the now spherical ventricle, and rebuilding it to restore the normal and healthy elliptical form.

  Finally, the audience learned this was not some conceptual approach, as the video unveiled the results on heart performance following a cardiac operation that accomplished what the animation had portrayed. This was dynamically shown by using paired MRI images, which contrasted the dilated failing heart on one side of a split-screen… against the other side’s image of a patient’s reconstructed ventricle that had undergone this Surgical Ventricular Restoration procedure.

  This pre-show video provided the audience with a background that would enhance their understanding and appreciation of The Cardiac Dance; Spirals of Life performance that was just about to start.

  The Lights Dim….

  As Act I began, the corps of dancers interwove, linking together as each held onto an 18-inch wide meshwork cloth that started as a straight line. They proceeded to move into a spiral configuration. The narrator’s voice-over described the wide spectrum of spirals occurring in nature, ranging from the microscopic DNA to the macroscopic galaxy. The meshwork’s spiral configuration then blossomed into a helical heart configuration, as the dancers interwove this lengthwise “rope” in a manner that mimicked the helical design that Paco had demonstrated with his heart dissection.

  The concept of form affecting function was demonstrated in energetic fashion in Act II, as the dancers mirrored the heart’s joyous rhythmical twisting and uncoiling motions. These movements were later elegantly featured in the video made of this ballet production by using an overhead camera, a creative move reminiscent of Hollywood director Busby Berkeley’s elaborate musical productions in the 1930s. The elation, fluidity, and power of normality within the moving heart were thrillingly evident.

  This happiness was then highlighted by a pas de deux of jubilant movement by the two principal dancers, who are portrayed as lovers. The vigor and merriment of being enraptured by healthy normality, exhibited by their shining faces and upright shoulders… would then collapse as a heart attack disrupted cardiac form and function. The magnitude of this dysfunction was dramatized by a startling collapse of the background’s gigantic natural helical heart structure that was constructed by our design team. A brilliant conception by our creative group that had breathtaking impact. Simultaneously, the spirals of the multimedia presentations on stage became circles and the devastation of dysfunctional movement in the dancers took hold.

  Dis-Harmony Heartache

  In Act III, the dancers portrayed the consequences of this dysfunction. The heart attack and ensuing heart failure erased the ecstasy of the healthy heart’s normal rhythmic function. It sapped away their merry smiles and replaced them with dismal expressions. These glum faces were married to slumped shoulders and irregular body motions as the heart’s spiral helical shape was replaced by a circular form. The dancers showed that as a result of the heart attack, part of the heart contained dead muscle that no longer could squeeze, and now bulged as the heart contracted. At the same time, they displayed the limited function of the remaining living muscle that was undamaged by the heart attack.

  The group movements representing this affliction provided a prelude to the second pas de deux performed by the two lead dancers, who portrayed the sadness stemming from the burden of a troubled heart. The duet ends with the dancers wrapped in each other’s arms, a sorrow within them, within the music, and shared by the audience.

  Then, slowly… a bright light shines upon them. The beam signifies their entering the anesthesia area, just before the female dancer is lofted and then carried into the operating room to undergo the left ventricular restoration procedure.

  (Astonishingly, Jenny Merkowitz, our composer, was later analyzing the musical timing track of the play, and found that this bright light had occurred exactly at a point that was 0.618 of the play’s total length. She could not believe it! Somehow, this numerical golden proportion ratio had made its way into the play… in the same way that it became evident when I unwound the heart to discover this identical proportion between the lengths of the two spiral muscles creating the helix).

  Restoration Rejoicing

  A reappearance of the meshwork material linking all the dancers opened the fourth act. The dysfunctional heart shape was represented by this circular cloth wall, which showed an irregularly contracting muscle with a circular form containing a bulge where the heart attack had happened.

  But then our dancers simulated cardiac surgery, and this poorly functioning circular segment was opened at the heart attack’s scarred region. Individual dancers entered the chamber, carrying a patch-like structure to demonstrate how surgeons rebuild cardiac shape. The irregular heart motions that had been coupled with the sad-faced corps de ballet (the “chorus” of non-soloist dancers) were now repaired. The dancers’ gleeful demeanor resurfaced as the heart’s harmonic rhythmic twisting motion returned. The heart and the human became one.

  Revitalization

  The last act captured the rejuvenation both within the heart and within the person. The spherical heart with irregular action returned to the elliptical configuration that brings normality. This marvelous wonder that flows from coordinated and cohesive heart motion was embodied by the dancers, whose movements seemed to explode from their happiness as they reveled in their newly found energy and joie de vivre. Their smiles, proud stance, and rhythmical motions became a source of dignity within themselves as their blissful rendering of completeness captured the audience, who joined them in the thrill of normality restored.

  This resurrection was accompanied by restoration of the immense helical heart backdrop behind the dancers, whose structure reflected the exquisite symphony of nor
malcy. Moreover, the cardiac reciprocal spiral shape, initially performed by the dancers when they first formed a natural helix, returned as well. Their encore of healthy motions portrayed the marvels of the hearts’ natural narrowing, shortening, widening, lengthening, and twisting movements.

  The performance was met with resounding applause. The dancers’ faces gleamed as they took their bows. It was clear that Shellie and the rest of her team were equally gratified.

  Personally Fulfilling

  The creation of The Cardiac Dance; Spirals of Life was profound for me. Not only did I witness Paco’s concept of the heart transform into a beautiful work of art, I was also required to play a totally different role than I had as a cardiac surgeon and researcher. I became part of a new world of inventive individuals, each blending their unique ideas with others to generate something visibly pleasing. It was exhilarating.

  Shellie said it was the best, most creative thing she had ever done. Additionally, the background set manager told me how thrilled he was to have participated in the College-Conservatory of Music’s most collaborative production, as artists from so many disciplines merged toward a singular lofty goal.

  I was equally grateful to have been a part of it, and extremely appreciative that everyone put forth their best efforts to realize this vision of telling the heart’s story through dance.

  “Touring” the Show

  The primary thrust of this ballet was to create a teaching project — a means to enlighten others about the helical heart. So we restaged the ballet and recorded it. The video turned out beautifully, and copies were sent to all divisions of cardiac surgery throughout the United States and Canada.

  Response was positive, and I was invited to present the video at the American Association of Medical Colleges meeting in Boston. The educators raised thoughtful questions after the presentation. They recognized that a powerful part of this educational format was to capture the imagination of the students, many of whom are not yet burdened with the information of yesterday, and whose thoughts will create a fresh tomorrow. My goal was successful in using art to stimulate a new awareness and understanding of the human heart. The “student’s mind” of everyone who viewed the ballet became stirred, regardless of age or professional status.