The knowledge is the circle, surrounded by ignorance. The bigger the circle - the wider the frontier towards the unknown.

This wisdom helped me a lot, not to be afraid of ignorance. I was happy once being able to ask questions.

One of these questions bothered me since 1997, and was related to reasons of better ventricular performance after mitral valve replacement with preserved annulo-papillary continuity. Since the earliest observations by Walton Lillehei, a lot has been written and said about this phenomenon, but underlying mechanism remained controversial.

It took me four years to think about it, although, I was almost sure that the answer is hidden inside the natural masterpiece of ventricular myocardial architecture. Unfortunately, I did not keep a record of papers I've read during these four years, but all in vain. Each time I thought the answer is close - I realized there was a missing link, which I could not find in classical literature.

My ideas about the functional importance of annulo-papillary continuity and possible anatomical explanations were not accepted by my colleagues, although, they did not provide me any alternative explanation. This kind of situation (I believe known to many people) gave me additional strength to keep on searching.

Until the October 2001, my concept was based on comparisons with elbow biomechanics.
 

Elbow biomechanics and mitral complex.

In brief - if we cut-off the ulnar insertion of the biceps brachii muscle, we would not be able to hold any weight in our hand, in spite of the fact that this muscle can contract, whenever it is excited. Therefore, this muscle can perform intrinsic work - but without preserved insertions on the opposite arms of the elbow lever - it can not do any extrinsic work. For the persons with this problem - this means a great loss of arm function – almost invalidity.
I've always kept in my mind the figure from the textbook of anatomy I have used as the medical student. The figure was by Jane Sands Robb from 1942. At this moment, I tried to compare the effects of chordal resection with the resection of biceps’ ulnar insertion. The only thing that was clear to me, was the fact - that chordal resection leaves not only papillary muscle unsupported - but also produces a similar effect to certain adjacent (and remote) parts of the ventricular myocardium. I could not know exactly the extent of this effect.
My erroneous conception was that closed loop - formed by the papillary muscles, myocardium, mitral annulus, mitral leaflets and chordae tendineae – has the same functional explanation as the loop (or triangle) formed by biceps brachii, radius and ulna. The concepts of the fibrous skeleton of the heart and the architecture of the ventricular fibers - had different meaning for me.

I was desperate, because (being a cardiac surgeon) I could not organize any kind of anatomical research at our Medical School. I had an idea to build up a wire frame with 1x1cm windows and then to start peeling off myocardial fibers (starting form the epicardium) - making a photographs from time to time - in order to produce 3D reconstruction of fiber architecture. My friends Ivan and Dejan, who are "PC magicians", encouraged me with information that they will be able to render such 3D object. I knew that this kind of job is almost impossible and I started to lose my enthusiasm.

Miracles do not happen in contradiction to nature, but only in contradiction to what is known to us of nature.

Saint Augustin

And then came a miracle. I had very old PC (486, 100MHz, 1Gb) and funny Internet connection of 9.4 Kbps. I spent a nights trying to find something interesting and related to my "problem" on the Web. You can imagine my reaction (Figure 2), when I saw the link for the JTCVS paper:

• Torrent-Guasp F, Ballester M, Buckberg GD, Carreras F, Flotats A, Carrio I, Ferreira A, Samuels LE, Narula J.
  Spatial orientation of the ventricular muscle band: physiologic contribution and surgical implications.
  J Thorac Cardiovasc Surg. 2001 Aug;122(2):389-92.

The Gospel of Matthew (7:7) - "Ask, and it shall be given you; seek, and you shall find..."

Of course, I did not wasted my time, and I sent a mail to corresponding author (i.e. Dr. Manel Ballester-Rodés) exposing him my problems and asking for his opinion. I did not have an idea about Francisco Torrent-Guasp, although he was signed as the firs author of this paper.

Soon after this, came the first reply from Francisco Torrent-Guasp (Paco). That was the beginning of the most beautiful period in my career. I felt like "Alice in Wonderland", confused and delighted at the same time. I have realized the meaning of freedom and the magnitude of nature, which were put together in perfect harmony in every single aspect of Paco's life. It was apparent simplicity in everything he did - not the primary but the ultimate simplicity - being the language by which the nature reveals its secret to very few people.
 

Here follows the initial correspondence between Paco and me.
 

No 1 - Paco:

Dear Dr. Kocica,

 

Dr. Ballester Rodés has sent to me your message, with the doubts and questions related with heart structure and mechanics. I must tell you that I have been working on these themes during half a century and now, after those 50 years, I have been able to describe the ventricular macroscopic structure (by means of the anatomical definition of the ventricular myocardial band) and the ventricular mechanics (explaining the way the ventricles decrease and increase their volume by means of respective muscular contractions). Therefore it seems (that is what what general opinion says) that I have been able to solve the old problem, stated first time by Erasistratus 2300 years ago, to show which is the mechanical trick used by the ventricles to increase their volume by means of a contraction, apparent incoherent fact since any contraction usually implicates decrease of dimensions, retractions, shortening, etc.
Recently, last month of September, has appeared an article of mine in the REVISTA ESPAÑOLA DE CARDIOLOGIA (Rev Esp Cardiol 2001 ; 54 : 1091-1102). This article has been summarized in the JTCVS article that you have read, in which appears as coauthors Dr. Ballester and some others. I will send you the translation, into my very bad English, of this article.
If you want to go further you could come to Dénia and I will give you any kind of details at the same time that you will learn to dissect the ventricular myocardium to evidence the ventricular myocardial band; I did show it in many places of Europe, USA, Japan, etc., and soon I am going to do it in Mexico, Brazil, Uruguay and Argentina. Next March-April the NIH of USA has organized a Workshop on my work that will take place in Washington attending about 30 basic heart research authors.
And now let me try to answer to your questions, as Dr. Ballester asked me to do.
FIRST QUESTION :
It seems your are worried about the connections of the ventricular myocardial band with the fibrous skeleton. First I must tell you that such concept, fibrous skeleton, was a very unfortunate idea inserted by the classic anatomists in the mind of people. Only the aortic and pulmonary artery rings and the two trigons, are consistent anatomical entities.
The mitral and tricuspid rings are just a line along which the atria are stuck to the ventricles. It is more ; most of the ventricular muscular fibers are not inserted in these two A-V rings, as the classic anatomists say. The ventricular myocardial band is inserted, in one end, in the pulmonary artery ring and, in the other end, in the aortic ring; nothing more. Not even the trigones or used as a fixed point by the ventricular fibers. You write in you letter, that "there is not efficient contraction if muscle is not attached (supported) somewhere". That is true on respect the skeletal muscles, as the biceps, but it does not applies to the circular muscles. The circular muscles rest, when they contract, on the contents of the tubular cavity they delimitate, i.e., the circular muscles of the vessels rest on the blood, the circular muscles of the bowels rest on the food that has been eaten, the circular muscles of the bronchia on the air, the circular muscles of the sphincters on what is defined by the short tube they define, etc. Therefore the fulcrum of the circular muscles is a mobile point (the blood, the food, the air, etc., are running), not a skeletal fixed point as the one represented by the insertions of any skeletal muscle in a bone (as the biceps, triceps, and so on). The circular muscles do not need any fixed point to perform their activity. And it happens that the ventricular muscle band describe two spirals (loops) in the space, a fact by means of which it can be stated that the heart (the ventricles) act as a circular muscle when it squeezes (torsion) and increases (untorsion or untwist) its ventricular cavities. This concept can not be found (at my knowledge) in classic books of physiology neither you will never find the explanation of the ventricular increase of volume by means of a contraction (on this respect I have made a dynamic model that looking to it working during one minute, even a boy 10 years old will understand, for ever, the heart mechanics; this model has been presented last month of September by Prof. Gharib - Director of the Department of Aeronautics of the California Institute of Technology and Director of the Department of Bioengineering for the Exploration of the Space of the NASA- in a Congress on Bioengineering in Helsinki; last May I did present such model in Pasadena to him and to more than one hundred engineers of such Institute).
SECOND QUESTION :
You say "where are the fibers that make the papillary muscles attached to the fibrous skeleton?". The papillary muscles are not attached, at all, at the fibrous skeleton, not even to the phantom anatomical entities called A-V rings. They are the valvular leaflets who are attached to such so called rings; the papillary muscle only are attached to the chordae tendineae.
THIRD QUESTION :
You say "I'd like to know whether you have already done some research regarding microstructure of the papillary muscles". Time ago, when I started this work being an student of Medicine, I did a lot of histological work on the ventricular myocardium looking for an anatomical entity that I did not find because of a simple fact: it does not exist. My starting hypothesis was wrong and that is why, when I realized, I started making an anatomical macroscopic (no microscopic) approach that after 25 years let me to evidence the ventricular myocardial band (I needed another 25 years to understand how the heart performs, by means of such ventricular myocardial band, its double action -ejecting and sucking blood- thanks to the two loops that this band describes in the space).
I will send you, by mail, a heart model (static one, not the dynamic one) and that translation of my article appeared last moth of September in the REVISTA ESPAÑOLA DE CARDIOLOGIA.

Best regards from F. Torrent-Guasp

No 2 - Mladen:

Dear Dr Torrent-Guasp:

 

I'm delighted with your kind and extensive reply. I'm also looking forward to read your original article.
To make my standpoint clearer, I have to underline that all of my observations were based on available literature (mostly classical) data and some personal speculations and difficulties, that I've met, trying to understand some traditional, often misleading, concepts (which are, as You said, based upon many uncertainties, like - "fibrous skeleton" concept, "AV valvular ring" concept etc.). Working only 6 years in Cardiac Surgery, I didn't have so much opportunities to explore on living human heart (it wouldn't be appropriate, either). Unfortunately, our anatomical Institute (as you've noticed about "classical anatomists") mostly deal with basic teaching courses, having firmly accepted the traditional concepts.
Basically, I do think that Your concept offers the most understandable answers (although, I also think that it would take me a considerable time to understand it in details, unless I find a way to learn it from the very source).
I just need to clear up some of my doubts:
1) Regarding all aspects (embryology, structure, biochemistry, function...) the myocardium is specific kind of muscle, different from both skeletal and smooth muscle. I'd like to "defend" a little bit, my idea about "anchoring points" for muscle contraction. In all examples, You've mentioned, the working muscle is smooth muscle of an hollow (tube) organs - organized in either circular, spiral or longitudinal manner. The stimulus for their action may be intraluminal (producing distension of the tube wall) or intramural (e.g. reflex/neuronal, humoral..). I agree with You, and it's quite understandable, that circularly shaped muscle (closed loop), can produce an obvious work (content propulsion - himus, air, blood...) without having any static (or relatively static - made of different kind of tissue) fulcrum. Everything I said, so far, is in fact consistent with "loop concept" - geometrically. But, if you try to consider the structure of the loops (roughly) - we come to the main point of my interest. Circular fibers of the blood vessels, gut, trachea etc. are basically made of the same tissue (smooth muscle circles). Ventricular loops are not homologous, regarding the tissue composition (PA and Ao at the both sides of the loop, and - possibly - trigones at the border-zone. I'm not taking the heart interstitium in consideration, because I'm thinking only on structural features of the "beginning" of the loop, "crossing points" and the "end" of the loop. May I realize (in a simplified manner), that ventricular myocardium is in fact a "single muscle band", spatially twisted - to form 2 distinctly oriented loops, starting in the vicinity of pulmonary trunk and ending in the vicinity of the aortic bulb. If so, more precisely, if the "beginning" and the "end" of the ventricular band are in fact separated, and not continuous with each other, than they have to be anchored to some structure (different tissue - AP and Ao if I understand it well). Streeter, Backer, Caruso and many others, have analyzed the spatial orientation of the ventricular myocardial fibers. Until I haven't read Your paper, I couldn't imagine where does this "myocardial mass "begins" or "ends". Why do I insist on defining the beginning and the end of the band as an anchoring points? Well, that brings us to the second thing regarding my abstract supposes.
2) Papillary muscles. I wasn't interesting in their a microscopic structure, but in almost macroscopic one. In your model, both LV-PM rise from the apical loop (anterior - from descending segment, and posterior - from ascending segment). Wondering about their "attachment for the fibrous skeleton" (or something), I didn't mean on papillary muscle's head(s). Their obvious connection with valve leaflets, via chordae tendineae is out of discussion. I don't know if I could formulate my thoughts exactly, but, I was thinking about myocardial fascicles (bundles) that form papillary muscle. Do they form an inversed "U" turn - at the apex (head) of the papillary muscle, or do they end there. This was one question (I couldn't find any article about this). Another question that bothers me was about proximal and/or distal end of those bundles. In Your muscle band model - this question may be formulated as: Which myocardial fascicles (bundles) form the LV papillary muscles and where are they distributed in the remaining of ventricular band (out of papillary muscles)? In fact, I don't know whether it is possible to examine this (is there any methodology which can allow "following up" a special group of fibers within mass of ventricular band).
3) Putting all this together (1 and 2), I've tried to answer myself - precisely which myocardial bundles are "excluded" from work, by cutting off PM from their continuity with mitral valve (during MV replacement surgery). Current literature can't explain the exact detrimental mechanism of valvulo-ventricular discontinuity, produced by surgery, as well as the beneficial effect of preserving this continuity wasn't explained. Some articles have found the correlation between cutting the papillary muscles off and poor RV function. This, and many other things, make my "sweet troubles". For the moment, I thought that it's maybe possible that majority of bundles, forming PM, in fact come from the RV, or septum, and that this could explain disarrangements after MV replacement surgery. My simplified thoughts were that "dividing the PM from the valve, leaves a part of myocardium without one of two necessary anchoring points, needed for efficient contraction."
At last, I'd like to excuse myself for this extremely long mail, and I won't bother You in a future with similar mails (Promise!). I would be, also, extremely happy, if I could visit your laboratory, and finally learn something consistent about heart structure. Unfortunately, I'm not able to do so until February 2002, and even than, It depends a on many non-medical things.
Finally, You may consider to have one great admirer of Your work, here in Yugoslavia, and I'm very proud having an opportunity to communicate with You.

Sincerely Yours,
Mladen J. Kocica, MD

No 3 - Paco:

Dear Drs. Kocica:

 

I think it is clear that the e-mail has not enough possibilities to communicate on all the problems about which you are asking me, mainly if you realize that it is difficult for me to express my ideas in English. Therefore it is better to wait until we can talk directly.
But nevertheless I will tell you that the ventricular myocardial band does not start, neither ends, at "the vicinity of the pulmonary artery and aorta" respectively; its fibers start and finish directly inserted at the pulmonary artery and aortic roots, respectively. In this way the circumference defined by the basal loop is firmly closed since, as you know, the pulmonary artery and aortic rings are joined very tied by fibrous tissue. It seems you are very worried to find a fixed point for any ventricular fibers but you will never find them. And it is so because the ventricular myocardial fibers does not need, to perform their work, to be anchored at any fixed point and it is so because such fibers belong to a band that describes to circles (loops) in the space.
To answer the questions you have on the papillary muscles you should know the ontological significance of these structures. The knowledge of such significance has given rise to a philosophical work I am developing since about 40 years ago. Do you really want me to explain you such work by e-mail ?.
Besides your acute thoughts, I see in you a very positive quality: you are restless about knowing more and more things. That is the most important fact for any scientist.
Best regards for both of you (I imagine, because your names sound me so, you are two ladies, Tina and Mladen)

F. Torrent Guasp

No 4 - Mladen:

Dear Paco:

 

Having red your papers, its hard to stay calm! You can't imagine the confusion that you've made here. Well, I'd lie if I say that was not enjoying seeing all my colleagues stunned ;) Many of them have a remarkable working and teaching experience (>30 years) but they were looking at your model and schemata, as if it is a Chinese alphabet. At least, I could fell a little bit of what you're experiencing each day ever since you've published your work. I have almost learn by heart Dr Cox's beautiful preface in Seminars, and I'm feeling proud to know you. Really.
And now, lets get to more official part. I have understood it well, from your first mail, there is a possibility to visit your laboratory, and to learn those miracles from its very source. I'll be extremely happy if I could spend some time in your lab, on educational basis. I'd like to learn Guasp's dissection technique and I'd like to see your famous dynamic model of ventricular contraction, hoping it would cure my ignorance. Also, I would be very glad if I could develop some ideas for my PhD thesis with you. If you find it worth, please give me some additional details (i.e. your suggestions about the duration of my eventual visit, literature which I'll have to read before entering your lab etc). I have made a preliminary talks with my professors, and I think they will allow me some time to be off-duty for educational purposes. How noble:) Well, I wont bother you any further until I hear your answer. After that, we could discuss about practical issues (we have very difficult work to obtain the Spanish visas, so I'll need an official invitation to apply in Embassy ...).
At last - we have founded The Serbian Society for Cardiovascular Surgery recently, and it was officially recognized by our Ministry of Health few days ago. As we are planning to cooperate with distinguished investigators in a field of Cardiovascular medicine, we have established An Honorary Membership in our Statute. The Society Board meeting (the first one) will be held by the end of the April, and we (Board members) have all agreed to propose you for the nomination. Of course, if you agree with this. It would be a great pleasure to have you in our Society. I hope (and I'll work hard on this) that this Society will be a respectable one in a future.
Once again, thanks for all goodness.

The warmest regards from Mladen.

No 5 - Paco:

Dear Mladen:

 

I realized, reading your message, you must believe that I am a very serious and austere fellow, i.e., a classic scientist with long bear, dark dress and bow tie. No, that is very far away from me. My laboratory is a very small room of my home and I am not a genius. Destiny has offered me ( I will explain you why, later on) to board a problem, set before the medical scientific world since 500 years ago, about which, more or less Vesalius, the father of the Anatomy, said (and after him many other anatomists): "I confess my inability to unravel the ventricular myocardium". In Anatomy there are three chronological stages: Macroscopic anatomy, microscopic anatomy and ultramicroscopic anatomy. We are, at present, in the last one, a fact because of which my contributions, on the knowledge of the macroscopic structure of the heart (a macroscopic problem that was necessary to solve to achieve the understanding of heart mechanics), represents such a big impact on the cardiology world of nowadays. Present scientist have been now stop in their hunt searching race for more and more ultramicroscopic (molecular levels) findings and now they are obliged to turn back their faces to the macroscopic anatomy to understand a problem that could be solved 500 years ago, since to clarify it only are needed the fingers of the hands, no any kind of instrument.
And then it happens that you believe that I am a genius but it is not so. If I have made those contributions to Cardiology, it has been because of three reasons .
1) Thanks to my ignorance (I was a fourth year Medicine student of 20 years old when started my research work) I did board the problem from a point of view quite different to the classic one (it was an erroneous hypothesis what pushed me); therefore, thanks to the fact that I did not know what was made by my anatomist predecessors, I could see new unknown anatomical landscapes.
2) Since it was a macroscopic problem and I could buy animal hearts in the slaughter house, the work could be made in my own home.
3) The passion that provoked in me the problem, since I realize that could be solved, and the frustration (I could say another word) that aroused in me because of the indifferent attitude of my colleagues, were the two motors that have pushed me to persevere in my work along fifty years, just half a century.
I am sorry if have disappointed you. I am not any genius neither any serious and austere classic professor. I am just Paco.
a) Of course you can come to Dénia and I will be very pleased to show you the way to evidence the ventricular myocardial band (it will not take a long time; the dissection of the band can be made in five minutes), to show you the mechanical trick used by the heart to enlarge its ventricular cavities by means of a contraction, and so on.
b) I will write any letter you need for the visa, for the Spanish Embassy in Belgrade, but it will not be any official one; it will be just the letter of a normal person, since I do not belong to any institution.
c) I will be very pleased to help you in your thesis.
d) I will be very proud with the membership of your Society.

Best regards, Paco.

To those involved in science, I dedicate the message from Paco:

Comprehend normality to understand pathology.

Finally

I went to Denia in June 2002. Valencia Airport 23.30h - the first time I met Tere and Paco. Soon after, I met the rest of the family. The very next day - we made our first dissection of the HVMB. During the rest of the month - I was able to see the world with different pair of eyes. Each year, until sad event, I spent a month in Denia working on HVMB concept and enjoying the life. Each day, during these past years, we exchanged a thousands of mails, ideas, plans.

The mitral valve and annulo-papillary continuity?

I could not resist to test my "hypothesis" on papillary muscle connection with ventricular myocardium. Figure below roughly depicts the "amount" of ventricular mass involved in papillary muscle function.

Posterior papillary muscle's continuity with adjacent ventricular mass.

During our last days working together, Paco made a drawing (below) which explains the functional significance of the Mitral valve - papillary muscle complex. This was meant to be one of our future research projects - and it will be so.

Mitral valve - papillary muscle complex during the cardiac cycle.