In medicine, understanding the true harmony of nature is crucial, since disease reflects a divorce from nature, and its damage can be mended only if we know what is normal so we can restore it.
Life is motion. Such elegant beauty of movement is nowhere more prevalent than in the heart’s twisting sequence during each heartbeat. Nature provides examples of sequential movement everywhere. Just imagine sitting atop a hill during a late summer evening, thrilled to observe the flickering lights of fireflies during their dazzling dance. If you watch long enough, you realize this twinkling progression is not arbitrary. Nobody knows for certain what the patterns mean, but the fireflies do not all glow at once. The light show of sequential displays repeats over and over within each group.
A comparable mechanism exists within the heart, determining its series of movements, as evidenced in the helical heart uncovered by Paco and explored further in my own studies.104–106 Therefore, in order to develop a treatment that corrects a disruption of the heart’s exquisite rhythmical pattern — we must take into account how electrical stimulations to the helix and wrap produce the heart’s series of narrowing, shortening, lengthening, widening, twisting, and uncoiling motions.105
Unfortunately, it’s difficult to research this due to the way physicians conventionally interpret EKG results, which reflects their belief that the EKG impulse tracings represent the heart squeezing all at once… like a fist.
This misunderstanding is further evidenced by the persistent use of terms like “synchrony” for normality — and “resynchronization” as a treatment to return synchrony when movement in different areas of the heart becomes out of balance. The cardiology world thinks these parts (both ventricles and septum) beat at the same time synchronously. But like the pantomime of the clenched fist, the idea of synchrony does not match reality.
As cited in a previous chapter, a source of this confusion was that two-dimensional echocardiogram tests made it appear that the left and right ventricle and septum (the muscular curtain between the right and left ventricles) all squeezed at once. But this portrayal became dramatically challenged following the development of three-dimensional echo studies that showed the heart twisting. The twisting’s natural sequential motions (different parts of the heart contracting one after another) were confirmed during our initial ultrasonic crystal probe study to validate Paco’s model of the heart’s helix and wrap.142
Pacemaker Perils
Pacemakers are a remarkable invention. Starting with the first implantable version invented in 1958, these medical devices are now used by over 5 million people in the United States alone. If a patient’s heart is not beating sufficiently fast, or if there is a block, a pacemaker delivers electrical impulses to stimulate and maintain a normal heart rate. It is a truly a miraculous, wonderful device. But as I would find out, it’s not as miraculously wonderful as commonly believed.
Though pacemakers are nearly always put in now by cardiologists, I used to put them in all the time, and as far as I knew, they worked perfectly fine. As a cardiac surgeon, I did not perform the long-term follow-up of these patients. I just believed pacemakers improved lives and returned patients to normalcy.
That is why I was shocked during my research to learn that 30% of patients who get pacemakers do not obtain the expected improvement.143
Equally unsettling was that no one knew why.
How can this be? How could these marvelous devices that successfully delivered minute electrical currents to stimulate the heart’s contractions… not deliver the promised results?
Suddenly, my looking into the relationship between the EKG and the helical heart would launch a whole new, compelling investigation.
Following the Leads
In designing treatments, devices are created to reproduce nature. But it is humans, not nature, that must determine the actions performed by these devices. How well they work will reveal if our belief about the true nature of the heart is correct.
As I looked deeper into the problem, my first clues revolved around where the leads (wires) are connected to the heart, as they carry the electrical impulses from pacemakers. Our choice of the stimulation site reveals an enlightening story… but only if we listen.
When a person has a slow heart rate because the atrium is slow to contract (the ventricles are fine), the atrium can be stimulated by a pacemaker (without placing any additional leads to stimulate a ventricle). This approach is very successful, as the natural sequence of ventricular twisting is maintained in these patients.
However, when the pacemaker lead is directly placed in ventricular muscle to stimulate that ventricle — then problems may occur.
I began to wonder if directly exciting the ventricles with an electric current might cause an irregularity in their contraction, so that twisting might disappear. If that were the case, would the heart then contract like a fist (as conventional medicine believes it only does)… or might it develop an irregular beat?
I knew that without twisting, the heart will not function as it normally should. Might this account for why the pacemaker does not satisfactorily correct their problem in almost a third of these patients?
Of course, this possibility would not be considered by physicians who do not accept that the heart twists in the first place. In fact, cardiac resynchronization therapy (CRT) began as a means to recreate what they believed to be normality — by simultaneously pacing (stimulating) the septum and left ventricle — to make them squeeze at the same time (synchronously). This approach was based upon recognizing that irregular ventricular contractions caused damage in patients… since mortality rises if different parts of their hearts beat at different times.144 This delay in stimulation makes one part of the ventricle contract — while the other part stretches — a combination that makes the mitral valve leak and impairs the heart’s efficiency.
It is true that CRT’s simultaneous pacing can counteract this problem by making the septum and the left ventricle wall contract at the same time. All seems to look good as the septum bulging disappears and the mitral valve stops leaking. A serious condition appears avoided.
Unfortunately, 30 to 40% of patients receiving CRT have no improvement.145 Why not? Stimulating the muscles to make them squeeze simultaneously is not the ideal objective. The correct goal is to make the helix twist as it squeezes — the link to restoring normality.
CRT’s “biventricular pacing” highlights an “all at once stimulation” approach that fails to reproduce normal heart function. The natural twisting motion of the left ventricle, septum, and right ventricle requires a sequential pattern of stimulation to function normally.
At this point, I still had more questions than answers. Yet I could not imagine that I was the first person to make these connections.
Not surprisingly, I wasn’t. Not even close.
Searching Forward by Looking Backward
I recognized the focus of my search would be to understand the heart’s wiring conduction system, the heart’s helical design, and the natural twisting motion that occurs during each heartbeat. Curiously, though much of this knowledge was not available in 1925, I found that Carl Wiggers, a famed physiologist, addressed the same questions back then.146
He described a cardiac muscle dysfunction that he called “asynergic beats” (meaning “not organized,” since “synergy” means cooperative interaction). This occurred when an electrical stimulus, like that generated by a pacemaker, was placed at the right ventricular (RV) apex — instead of through the heart’s natural conduction system. While we’ve had this knowledge of asynergic beats for over 90 years (since 1925), pacemaker leads are still being placed at the same RV apex spot that creates the uncoordinated beats. There has simply been little consideration given to Wiggers’ work, and nothing has changed.
Natural Conduction System
I started looking closer into how the heart normally begins to ignite ventricular contractions. The answers are well-established.
Impulses are initiated within a clump of muscle tissue
cells that reside on the top of the septum. Called the AV node (atrioventricular node), this clump functions like a generator. Jim Cox explained to me that from here, these generated electrical impulses travel over a collection of nerve fibers called the bundle of His (pronounced “Hiss”). This moves down the heart along the septum, where the bundle then separates into two branches — called, appropriately enough, the left and right bundle branches. (Figure 2)
Figure 2: Electrical circuitry of heart, showing artio-ventricular (A-V) bundle on top of septum, branching into left and right bundle branches, and penetration into muscle by Purkinje fibers.
From there, many smaller “twigs,” called “Purkinje fibers,” divert off these two branches. These fibers are part of the Purkinje system (discovered by Czech anatomist and physiologist Jan Evangelista Purkinje in 1839). They conduct the electrical impulses to the left and right ventricles.
I wondered: could studying this natural conduction system provide a solution to the pacemaker issues?
Though this system was recognized in the medical community, it too had its own mystery. You can actually see this natural wiring (these nerves are visible to an anatomist), but just after the Purkinje fibers touch the surface of each ventricle — their visible nerve connections with muscle suddenly stop. They only go into 15% of the muscles. There is nothing perceptible that connects these nerves to allow them to stimulate the remaining 85% of the heart muscle! With no evidence of any other internal wiring system, we simply do not know how electrical impulses reach the muscles that must contract.
Once more, I was running into a brick wall. This was not my area of expertise, and I knew I needed help.
And again, I knew the right person.
Cecil Coghlan
Good fortune fell upon me, as Cecil Coghlan, a remarkable cardiologist, became another mentor as I explored the wondrous scheme of natural electrical design.
I first met Cecil after my presentation about Paco’s helical heart at a Birmingham conference, and we became good friends. Yet this comradery started after he told me that our team had created the wrong ventricular shapes — after I showed him examples of hearts that retained a circular form instead of an ellipse — following our early ventricular restoration procedures. Our initial concentration was on exclusion of the scar, as we had not yet focused upon the importance of ventricular shape.
My learning credo is that opposition requires responses, not reaction. I asked Cecil to meet with us the next day to further explain his thoughts. His knowledge of the heart was extraordinary. He showed me my error — and my critic eventually became my mentor. So now, while investigating the relationship between electrical excitation and heart function, I visited him again at his home and at his University of Alabama office. I brought up my concerns about electricity and the helical heart… and the puzzle of why pacemakers were not satisfactorily helping patients in nearly a third of cases.
Cecil wasted no time in providing me a definitive answer. “It is simply not possible for the heart to maintain its twisting motion when a pacemaker stimulates the ventricles directly.”
The conviction of his statement was somewhat startling, but as I would find, his reasoning was sound. And very revealing.
He continued, “You know the heart has its own electrical conductive system, starting with the bundle of His and continuing into the Purkinje system. If a pacemaker is only stimulating the atrium, the heart’s own system is still utilized and twisting can be maintained and the heart can function well. But if the ventricles are stimulated directly — using a method that bypasses the heart’s natural system — it then replaces normality with one not nearly as effective.”
I interjected, “This is despite their successfully pacing the heart to beat at a higher rate?”
“Exactly,” Cecil confirmed. “Here’s the problem. When they directly stimulate the ventricles, the electrical impulses now travel much more slowly through the ventricle — muscle cell by muscle cell. This only happens at one-tenth of the speed that impulses normally travel by the heart’s natural circuitry [actual numbers being 0.3 mm vs. 3.0 mm/millisecond]. That’s not fast enough to preserve the heart’s sequential motions [one part after the next] that create twisting and uncoiling.”147
“So now the spiral motion is replaced by an irregular, uncoordinated contraction,” I surmised, “which perhaps explains why 30% of patients report unsatisfactory improvement following use of a pacemaker.”143
“It very well could,” Cecil agreed. “But there’s more, too.”
Cecil continued. “This slower distribution of impulses can cause worse issues. If an electrical impulse to a region is delayed by 120 milliseconds — while an adjacent region is contracting — this non-stimulated region won’t contract as it suddenly bulges like an aneurysm, and the ventricle’s overall efficiency is impaired. This disharmony happens when pacemakers fail to stimulate a region of heart muscle via the natural conduction of the bundle of His and Purkinje pathways.”
It was all finally making sense to me. I offered, “Then perhaps a solution would be to find a way to take advantage of the natural conduction system that’s already in the ventricles.”
Cecil nodded, thoughtfully. “That could be true… if anyone understood what that system was.”
Cecil was referring to the fact that the Purkinje fibers only penetrated 15% of the ventricle muscles. How the electrical impulses then get to the other 85% to stimulate the ventricles’ movement — was still not understood.
“But here’s what we do know,” countered Cecil. “There has to be another system that we cannot yet detect, over which the electrical impulses travel rapidly through the ventricles. How do we know this? Since the heart naturally twists, the impulses must somehow quickly get to all muscle areas.”
Cecil’s point was that if pacemaker electrical signals going to this other 85% of the ventricle muscles only traveled at the very slow one-tenth of normal speed (as exists when they only stimulate muscle cells)… the impulse would not get to the areas where it was needed in time to generate twisting. Thus, a dilemma might arise as contraction occurs when a pacemaker lead stimulates only one area… while non-stimulated regions bulge or billow during each heartbeat. Cecil was fascinated by the magic of the unique natural system that ignites the entire heart muscle to produce sequential twisting. His enthrallment was not hampered by our failure to understand this process.
Then Cecil added optimistically, “I have been working on a theory about what this could be… but I still don’t know yet.”
I smiled and told Cecil that what he had just revealed to me was remarkable. The key to healthy and vigorous heart function seemed to be its ability to efficiently conduct electric impulses through the ventricles.
“More than you might realize,” Cecil said with a gleam in his eyes. “Let me tell you something that is every bit as remarkable as what I’ve already said.”
I eagerly listened. He was right. What he revealed next was truly stunning.
Ontogeny and Phylogeny: Phenomenal Lessons from Nature
Cecil proceeded to explain this importance of electrical conduction through the ventricles by comparing how it functioned in the anatomy of different species — an intriguing theme that addressed both “ontogeny” and “phylogeny” relationships.
Ontogeny describes the origin of an organism and how it originally developed, while phylogeny describes how it evolved over time. The dramatic variations of the excitation-contraction relationship in different animals demonstrate why vigorous conduction in the ventricles is vital to every species. Cecil’s idea was that the way in which the impulses travel through a ventricle muscle exerts a striking effect on the animal’s ability to function in its world.
Paco had unfolded hearts across a broad spectrum of species, ranging from birds to mammals, and found that the helical ventricular band exists in each of them. In every case, the beginning of the bundle of His/Purkinje system is always positioned on top of the septum. While that was consisten
t, the hearts of different species had vastly different capabilities, and different rates at which they beat. Cecil now offered me the alluring theory about this connection: that these diverse capabilities in different species were due to how deeply the wiring system had penetrated into their ventricular muscles.
I knew that the human heart rate rarely exceeds 180 beats per minute, even during severe physical or emotional stress. As Cecil pointed out, that is dramatically different from hummingbirds, whose hearts beat nearly 1,500 times per minute in order to maintain their incredibly rapid wing motion during flight. A similarly high rate occurs in canaries, at around 1,000 beats per minute. Cecil learned that each of these species has a specialized type of Purkinje system penetration — one that touches every heart muscle fiber within their ventricles. Rather than the conduction system in humans that only penetrates 15% of the ventricle muscle… in hummingbirds, it touches 100%. This direct connection of the wiring system to the working muscle explains the never-ending speed of their wing motion. Nature avoided the 85% gap between the Purkinje system and muscle that exists in humans.
On the other hand, the wild boar has Purkinje fibers that almost reach the outer ventricular wall (extending through two-thirds of the ventricle). This explains why boars are able to escape from a lion or cheetah. The boars do not run out of gas, while the lion or cheetah will tire after an intense, but short chase.
In dogs, the Purkinje system fibers extend halfway through the ventricular muscular wall. While they have the same resting heart rate as humans of about 80 beats per minute, they can achieve higher heart rates than us, and have increased endurance. This may draw from the dog having descended from the hardy wolf, and account for the wolf’s capacity to roam over great expanses of terrain in search of food.
The fact that the human heart’s conductive nerves barely penetrate the inner muscle of the ventricles may explain why our heart rates never exceed about 180 beats / minute despite urgent needs from exercise or fright. This inherently limits both our speed and our stamina.
Solving the Mysteries of Heart Disease Page 47
