Solving the Mysteries of Heart Disease

by Gerald D Buckberg

  To test further, we next made the septum bulge into the left side — by inhibiting the ejection of blood from the right ventricle by narrowing its outflow artery to the lungs (pulmonary artery). The tricuspid valve began to leak. We then returned the septum to its natural midline position by using drugs or mechanical devices… and complete recovery of tricuspid valve function resulted!139

  In each instance, the leaky valve was caused by the supporting structures that were connected to the septum — not by a problem with the valve itself. Recognizing how the valves’ architecture interfaces with the septum may generate new approaches for how leaky valves should be treated.

  Treat the Low Blood Pressure… or Treat the Heart?

  Nothing stimulates a prompt medical team response like a patient in an intensive care unit who suddenly develops low blood pressure. Fear of a heart attack or stroke rouses immediate action. A cascade of drugs like dopamine and epinephrine are commonly used to raise blood pressure and improve cardiac contraction. This includes instances when low blood pressure occurs in a patient with right heart failure.

  As I considered everything I had learned, I questioned if this was the best approach. It made me ask a fundamental second question. What should be corrected first: the low blood pressure itself… or the heart that regulates it?

  These inquiries surface because the drugs commonly used to raise blood pressure will narrow the body’s blood vessels — all of the body’s blood vessels. That means they also constrict small lung artery blood vessels — which raises lung vessel resistance — restricting the successful outflow of blood from the right ventricle into the lungs. So while raising the pressure is seen as a win, the heart may lose — since cardiac function worsens in the right heart failure patient when their lung vessel resistance is raised. Why? Because the right ventricle’s efficiency (produced by the septum’s ability to twist) is already impaired, and becomes further impeded if the septum’s twisting capacity is strained even more. Our chance to treat and reverse this condition is worsened by escalation of this powerful downward cascade.

  But a different approach can be taken to treat right heart failure and low blood pressure, taking advantage of a better understanding of the heart / function relationship. Simply stated — diminish this opposition to the right ventricle’s pumping out blood to the lungs — to offset the septum’s impaired ability to twist and challenge the increased lung vessel resistance.

  Lung vessel resistance can be lowered — by drugs like amrinone and milrinone — allowing heart function to improve as the right ventricle can more easily eject blood. So now the ventricle shrinks and the septum returns to its normal position. Normal septum twisting and shortening recover, and the improved heart action makes it eject more blood, producing increased blood pressure. A vast improvement over the outcomes of using drugs that narrow all the body’s blood vessels.

  Better decision-making regarding patient treatment comes from the awareness that drugs that dilate (expand) lung arteries may be preferable to those that narrow them.

  Unfortunately, persistent misunderstanding of anatomy and function relationships will allow flawed decisions to continue. This must change.

  Septum and Diastolic Dysfunction

  I then asked the most basic question I could ever ask: “Are we observing the heart properly?”

  My new understanding that the heart is composed of only three parts — a circumferential wrap and inner helix (with two arms) — is a view that completely differs from the conventional “topographic” approach where the “classic concept of “left ventricle, right ventricle, and septum” commands our total attention. Yet it is our willingness to learn a fresh approach that can lead to developing new answers to old problems.

  This concept becomes clear when an innovative look is taken toward addressing diastolic dysfunction (discussed two chapters previously) — that form of congestive heart failure experienced by 7.5 million patients just in the U.S. and Europe — caused by impaired suction for ventricular filling. This common disorder also perfectly reflects how the septum’s geometry influences the function of both ventricles.

  The important question of “what is the heart?” takes center stage. That’s because the traditionalists’ view of the three parts (left ventricle, septum, right ventricle)… considers the septum’s function to be isolated from the others.

  Figure 4: Upper two images show the anatomy of the helix containing the ascending (outer) and descending (inner) segments. The lower two images show a “simulated artery” that runs along (bisects) its outer and inner walls to demonstrate how the septum and the LV free wall are formed by the same outer and inner helix muscles.

  Yet a more comprehensive view emerges when the helical ventricular myocardial band concept is applied — in which the same inner and outer helix muscles form the septum and left ventricle free wall (the “outer” wall of the ventricle opposite to that of the septum) as seen in Figure 4.

  Suddenly an inescapable conclusion becomes apparent, as the septum is no longer seen as an independent structure: damage to one portion of the helix must affect all structures that are part of it. Consequently, an injury to the septum must also affect the left ventricular free wall. Said differently, diastolic dysfunction cannot be considered an isolated event that influences only one part of the heart.

  A prime example is found in some heart surgery patients who return with mild left heart failure symptoms several weeks after being discharged from the hospital. Its cause has remained a mystery for many physicians. Yet I knew that stunning of the septum (reflecting its injury) is commonplace during cardiac operations (as described earlier in this chapter), and believed my understanding of helix structure might unravel its connection to these later problems. To my surprise, I found the frequency of diastolic dysfunction occurring after surgery ranges from 44 to 75% — which precisely matches how often a bulging septum motion is observed during such surgeries.65 These dual observations of similar complications contrast sharply with the conventional conclusion that septum impairment is an acceptable outcome of surgery.

  Because the helix involves the septum and left ventricle outer wall, when you impair one part, you will always impair the other. After all, it is all the same muscle. Thus, such a reperfusion injury (septum stunning) imparts the same damage to the left ventricle free wall — thereby impairing its ability to uncoil — which will reduce suction and cause symptoms of left heart failure.

  This conclusion is easily missed if we only consider the conventional topographical view of three separate heart parts (left ventricle, the septum, right ventricle), whereby septum stunning and diastolic dysfunction (heart failure) are considered independent events. Such a lapse to appreciate the anatomy behind this devastating disease will hamper the evolution of new solutions.

  Conversely, using the helical ventricular myocardial band to escape the confines of traditional thinking will give us a fresh way to look at the heart, granting us a portal toward discovery and new treatments.

  Mysteries Solved

  Our detective work solved the mystery surrounding the septum described by Hegar in the 1800s. There is now clarity for its major role in determining many cardiac treatments, including those for: right heart failure, open-heart surgery, infant heart surgery, left ventricle assist devices, cardiac electrical events, heart valve problems, low blood pressure drug selection, diastolic dysfunction… and probably more to be uncovered.

  I am grateful to Paco Torrent-Guasp for unlocking this gateway to understanding the basic components of the wrap and helix that form the heart. The simplicity of this design represents a huge leap in knowledge, one that may allow us to successfully treat many different clinical issues that were previously and perplexingly insoluble.

  Accordingly, I envision that wide recognition of “the motor of the septum” will provide new understanding and guidelines to enhance how we diagnose and improve treatment in areas that have until now baffled us.

  CHAPTER 25

  Arts
and Science: Stonehenge and the Heart

  To me, the most exciting part of the learning cycle is the way in which new knowledge launches the next educational exploration. This process occurred again when I created the Basic Science Lecture on the Helix and Heart. I was astonished by the unity of how the heart fit into a natural design of similar spiral patterns that stretched from DNA to the nebula of the cosmos.

  Suddenly, the biologist mirrored the artist who observes an enriching blend of shapes and shadings in their surrounding world. What changes is not so much where you look, but how you see. My view now included the fluidity and efficiency of spirals as I watched them in the water swirling down a bathroom drain, the webs made by some species of spiders, and the gracefully carved scroll of a violin. And then, one day, I looked at a picture of Stonehenge — and saw something I never had before.

  Stonehenge is the group of very large standing stones located on Salisbury Plain in southern England, presumed to date back as far as 3500 BC. (Figure 1) I visited it in 1990 with my wife while driving through England after attending a conference in Oxford. We knew that many theories had been offered as to why it was built, but none had been proven. Beyond that, I thought little about it, until I developed my Basic Science Lecture that taught me of a coherence among things… if you look for it.

  Figure 1: Stonehenge with Sarsen Circle and interior Bluestone Trilithon Horseshoe

  Twenty-four years after my visit, I was mesmerized by an image showing Stonehenge’s complete layout. I stared because I saw similarities to the heart.

  This vision launched my new search to see if this correlation could be justified.

  Exploring the Speculative World of Stonehenge

  Construction of Stonehenge began approximately 5,500 years ago, and took over 1,800 years to complete. Its form continues to capture the interest and imagination. It is an ancient wonder of the world. Nearly everybody has heard of it, many have seen it, and some theories as to its origin and meaning exist. But no one understands it.

  The harmony of its construction stretched over 50 generations of builders, suggesting that a powerful underlying architectural principle existed and had been passed down… yet nobody knows what that principle was. The tendency to offhandedly reject my suggesting a correlation between Stonehenge and so unlikely a candidate as the heart presents a typical response to any challenge of traditional thought — indeed paralleling what has occurred so often with results of my medical research. But evidence is the true determiner, not belief. So I began looking for data to test this comparison.

  It wasn’t long before I found it.

  I became captivated by a book called The Power of Limits: Proportional Harmonies in Nature, Art, and Architecture, by Gyorgy Doczi, a Hungarian architect and scholar.110 He explores some basic mathematical ratios that are common within natural structures — and within those that are human-made.

  Doczi emphasizes that one pattern within this world of harmony stems from the golden section of Pythagoras. As described before, it defines proportionality, where the smaller portion relates to the larger portion in the same ratio as the larger portion relates to the whole (further detailed a bit later). This famously recognized “golden section” becomes the foundation of the Fibonacci ratio of 0.618… a proportion that also exists in all spiral structures.

  The heart is neither described nor analyzed in his book, but the principles Doczi discusses are universal. For example, I previously found the proportions of the Fibonacci ratio in the lengths of the right- and left-handed sides (arms) that construct the helical heart segments. I was astounded to learn that Doczi found the same mathematical golden proportion relationship within Stonehenge’s architecture. This intriguing observation further motivated my quest to find the structural commonality between the heart and this eternal megalithic structure.

  Parts of the Whole

  With help from Doczi’s book, I began my investigation to better understand Stonehenge.

  Figure 2: Overview of Stonehenge, within the outer circular rim. The inner components include the Sarsen Circle and Trilithon Horseshoe. The Heel Stone (small unshaded circular shape) is beyond the outer rim and the Summer Solstice is observed when viewed from these inner components.

  Stonehenge’s round outer wall of stones make up the Sarsen Circle. (Figure 2) Existing within this circumference is the Bluestone Trilithon Horseshoe with its U-shaped arms. Its open endpoints aim toward Stonehenge’s four outer wall pillars that have three beams (or lintels) on top of them. These structures are associated with the two best-known “views” in Stonehenge. (Figure 3)

  The first is the overall architecture containing its Sarsen circle, Trilithon horseshoe, and outer pillars. The second “view” reveals itself only once a year, at the summer solstice, when the sun’s yellow disc rises between the pillars and beyond the Heel Stone. The observer witnesses this by sitting on a stone (called the “Altar Stone”) in the center of the horseshoe. This perennial observation has intrigued scholars for centuries.

  Figure 3: Classic views of Stonehenge. On top is Sarsen Circle and Trilithon Horseshoe. On bottom are the pillars and beams through which the summer solstice is seen behind the Heel Stone.

  But my own fascination with Stonehenge stemmed from a different source — my knowledge of the design of the helical heart, whose structure contains a helix and surrounding wrap of muscle. (Figure 4) That awareness, along with my recent discovery of The Power of Limits, made me wonder about possible similarities between the heart and Stonehenge. I knew parallels existed, since the megalithic structure permits us to see the moving cosmos, outside us… while the helical cardiac structure is responsible for the moving blood, inside us.

  But was there more?

  The heart has a cone-shaped helical loop, with a vortex at its apical tip — and only functions efficiently if its conical shape is supported by a surrounding external buttress (the wrap).

  Figure 4: Helical Ventricular Myocardial Band of Torrent-Guasp showing (top image) the intact heart has a wrap and a helix that has a vortex at its tip. Beauty is simplicity, as the second image shows unwrapping, and how the inner and outer shells form the helix. The heart is made of a simple rope, as seen on the third and fourth images where the helix is unfolded.

  In the same way, Stonehenge has the sun, which may be considered as its “conical tip,” and which we can view each summer solstice by looking through Stonehenge’s structural portals. (Figure 9) How extraordinary that the space between the outside of the inner arms of Bluestone Horseshoe — and inside the surrounding Sarsen Circle — reflects a buttress for Stonehenge’s conical central area. I saw an architectural pattern in this gigantic megalithic structure that I needed to explore further. I wanted to see how it might mimic the cone and base of the heart (as you will see later in Figure 9).

  Still, I wondered if this parallel configuration was merely a visual coincidence that I conceptualized to justify my desire to see a similarity. I did not yet know the answer.

  Seeking the Balance

  I needed to go deeper than focusing only upon the surface. So I began to question whether Stonehenge’s construction had a measurable composition that matched the heart’s configuration.

  The key to this analysis must be simplicity. Such clarity conforms to how other scientists have linked mathematics to nature, like da Vinci and Einstein. Doczi explored this theme in The Power of Limits, offering a breathtaking demonstration of the interaction of basic mathematical components within Stonehenge’s stark construction. The structural breakdown is amazing, as we find this unique megalithic structure contains the circle, a square, rectangles, Pythagorean triangles, as well as displays of the harmonic matching (or reciprocal) relationships between rectangles — all marvelously merged into a single structure. (Figure 5 and 6)

  Figure 5: Mathematical representation of Stonehenge from Doczi that shows the Sarsen Circle, and how the inner Bluestone Trilithon Horseshoe interfaces to reflect a square and reciprocal rectangles, and conforms
to the Golden Section (shown in upper box where measurements equal 0.618…), where the small is to the large, as the large is to the whole.

  Figure 6: The beams and supporting stones that frame views of summer solstice beyond the Heel Stone contain triangles with Pythagorean dimensions.

  A stunning concept, as these vital geometric shapes within Stonehenge incorporate the conceptual seeds behind many things we observe mathematically.

  Astounding, yes. But where is the heart?

  Broader View

  This was only the first step into finding the similarity between Stonehenge’s design and the heart’s architectural form. The challenge was to cite what was known, and then broaden our view.

  The Greeks originated this concept of “broadening our view” and it offered rich significance. They knew that many people would look at something, but go no further. They would add no new insights, nor undertake investigations. In response, the Greeks adopted the mantra of searching where nobody has searched before to expand their understanding. I’ve adopted this concept in my research and clinical career, and use this approach in this memoir. I hope that my simply looking — has evolved into my having vision.

  My conceptual leap to compare Stonehenge and the heart was not a capricious undertaking. Sir Theodore Cook’s 1914 book, The Curves of Life,140 defines how nature reproduces its most efficient patterns and displays them in vastly different arenas. The essence of his teaching became clear to me during my Helix and the Heart presentation at the AATS. This allowed me to show that the heart’s design includes a macroscopic helical (spiral) weave of muscles, and simultaneously show a similar interweavings of microscopic helical patterns — within the collagen that forms the ventricle’s framework, in the proteins that make the heart muscle move (such as actin, myosin, and tropomyosin), within the chemical calcium ions that excite this motion, and finally throughout the helical electrical network of nerves that stimulate the muscles to perform their movement.108, 141 This same spiral pattern abounds in nature.