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Reply to Anderson et al.

Reply to Anderson et al. Letters to the Editor / European Journal of Cardio-Thoracic Surgery 613 [5] MacIver DH, Partridge JB, Agger P, Stephenson RS, Boukens BJD, Omann C et al. The end of the unique myocardial band: part II. Clinical and func- tional considerations. Eur J Cardiothorac Surg 2018;53:120–8. Gerald D. Buckberg* [6] Buckberg G. Echogenic zone in mid-septum: its structure/function relation- Department of Cardiothoracic Surgery, David Geffen School of Medicine at ship. Echocardiography 2016;33:1450–6. UCLA, Los Angeles, CA, USA Received 23 February 2018; accepted 26 February 2018 *Corresponding author. Department of Cardiothoracic Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 62-258 CHS, Los Keywords: Helical ventricular myocardial band � Structure/function � Angeles, CA 90095, USA. Tel: +1-310-2061027; e-mail: gbuckberg@mednet. Misconceptions � Cardiac mechanics � Determinism (cause and effect) ucla.edu (G.D. Buckberg). Robert Anderson consistently tries to cast away the helical ventricular myocar- doi:10.1093/ejcts/ezy119 dial band, using terms such as ‘skeletal muscle, inaccurate notion, unique, and Advance Access publication 14 March 2018 oversimplified’ towards this end [1, 2]. My motto is ‘Elegance is Simplicity and Confusion is Complexity’ with 3 monumental truths: E = mc (Einstein), M = fa (Newton) and how the ‘helix and wrap’ (Torrent Guasp) concept solved the age-old dilemma of the cardiac form/function relationship. Masters are identified. Anderson selected Pettigrew, a heralded anatomist. Intraoperative analgesic regimens may Mine was Claude Bernard, a physiologist using vivisection. He believed ‘life is motion’, stating that ‘only groping and empiricism’ would exist without a cause affect postoperative pain: single-port versus and effect approach. To him, biology meant ‘anatomists deduce to explain physiology’, whereas ‘physiologists explain it by anatomy’. multi-port video-assisted thoracic surgery The landmark question, ‘the heart moves, but why?’ must be solved. Torrent Guasp’s anatomy showed that its 6 movements of narrowing, shortening, Mark C. Kendall* lengthening, widening, twisting and uncoiling are caused by just 3 muscles—‘2 Department of Anesthesiology, Rhode Island Hospital, The Warren Alpert helical arms and the surrounding wrap’ [3]. Their interaction is documented Medical School of Brown University, Providence, RI, USA by sono-micrometer crystals, 2-dimensional and 3-dimensional (3D) echo, ventriculogram, magnetic resonance imaging, velocity vector imaging and Received 12 February 2018; accepted 18 March 2018 electrocardiographic recordings-is that an inaccurate notion? This in-depth architectural understanding unhinges several current misconcep- Keywords: Thoracic surgery � Acute pain � Analgesic regimen tions in cardiovascular dynamics, including cardiac topography limitations [the left ventricle and the right ventricle (RV) and septum], isovolumetric relaxation I read with great interest the article by Li et al. [1] in a recent issue of the jour- time, when the mitral valve opens, muscular reasons for torsion (twisting), the nal. The authors performed a retrospective study on 285 patients to compare term untwisting, why longitudinal and circumferential strain happen, resynchroni- single-port video-assisted thoracic surgery with the multi-port variants in zation, the RV function and diastolic dysfunction cause and treatment. terms of short-term perioperative outcomes and concluded that single-port Histological anatomy and autopsy analysis may be deceiving since (i) ‘dead video-assisted thoracic surgery has potential advantages of less postoperative hearts don’t beat’ and (ii) preservation errors occur. Hearts previously thought pain when compared with multi-port techniques. The authors should be con- dead after 6 h of coronary artery occlusion were alive and functioning because gratulated for performing a study on an important topic (e.g. acute pain) in histology—not the heart—was wrong [4]. William Harvey thought boiled hearts patients undergoing thoracic surgery [2,3]. The current emphases on the need looked circular, mirroring those in Anderson’s report. Harvey’s circulation discovery to improve postsurgical pain and reduce opioid intake makes the topic very changed Galen’s (180 AD) observation of twisting (ebb and flow) to the traditional relevant in perioperative medicine [4,5]. ‘all at once’ or clenched and open fist concept of compression and dilation. This Although the study by Li et al. was well conducted, there are some ques- misconception lasted 400 years, until 3D imaging reconfirmed twisting. tions regarding the study that need to be clarified. First, it is not clear whether Anderson’s profound misunderstanding of structure/function evolves from the intraoperative analgesic regimens were standardized for all patients as this the MacIver’s 2018 ‘The end of the myocardial band’ paper [5]. Thinking that can substantially affect the study outcomes. Second, it is unclear whether any twisting is a relatively minor motion versus longitudinal shortening and cir- patient received a thoracic epidural as part of their analgesic management, cumferential strain promotes a position that clashes against its causing 80% of which is regarded as the standard of care for postoperative pain control in the RV function, tricuspid annular plane systolic excursion (TAPSE) [2] and the these types of surgical cases. Finally, although the patients were recruited con- left ventricular failure development after its loss. They fail to understand that secutively, it is not clear how each patient was allocated to the study groups the right sided helix’s inner spiral arm contraction causes longitudinal shorten- (e.g. surgeon’s preference and disease extension) as this can result in a signifi- ing.. . and diastolic dysfunction; the wrap compresses. In response to their cant selection bias for the study outcomes. question about RV anatomy, no helix exists in its free wall, but it contains left I would welcome some comments by the authors as this would help to helical arm fibres: Can Anderson’s team’s proposed anatomy have merit, if its further substantiate the findings of this important clinical study. function relationships are impossible? [6] Anderson and MacIver’s ‘end of the myocardial band’ edict cannot be achieved. As Svetlana Alexievich, the 2015 Nobel Laureate in Literature said, ‘History records the lives of ideas. People don’t write it, time does’. They should listen. REFERENCES [1] Li Q, Sihoe A, Wang H, Gonzalez-Rivas D, Zhu Y, Xie D et al.Short-term REFERENCES outcomes of single- versus multi-port video-assisted thoracic surgery in mediastinal diseases. Eur J Cardiothorac Surg 2018;53:216–20. [2] Niraj G, Kelkar A, Kaushik V, Tang Y, Fleet D, Tait F et al. Audit of postoper- [1] Anderson RH, Agger P, Stephenson RS. The incorrect notion of the ‘unique ative pain management after open thoracotomy and the incidence of myocardial band’. Eur J Cardiothorac Surg 2018;54:612. chronic postthoracotomy pain in more than 500 patients at a tertiary cen- [2] Buckberg GD. Right ventricular failure after surgical ventricular restoration: ter. J Clin Anesth 2017;36:174–7. operation or myocardial protection problem? Eur J Cardiothorac Surg [3] Fiorelli A, Santini M. Total intravenous anaesthesia with local anaesthesia 2017;52:1018–21. for controlling pain after spontaneous ventilation video-assisted thoracic [3] Buckberg GD, Hoffman JI, Coghlan HC, Nanda NC. Ventricular structure- surgery: is it a viable strategy? Eur J Cardiothorac Surg 2017;52:200. function relations in health and disease: part I. The normal heart. Eur J [4] Kıtlık A, Erdogan MA, Ozgul U, Aydogan MS, Ucar M, Toprak HI et al. Cardiothorac Surg 2015;47:587–601. Ultrasound-guided transversus abdominis plane block for postoperative [4] Sjostrand F, Allen BS, Buckberg GD, Okamato F, Young H, Bugyi HI et al. analgesia in living liver donors: a prospective, randomized, double-blinded Studies of controlled reperfusion after ischemia: IV. Electron microscopic clinical trial. J Clin Anesth 2017;37:103–7. studies: importance of embedding techniques in quantitative evaluation of [5] Chong MA, Wang Y, Dhir S, Lin C. Programmed intermittent peripheral cardiac mitochondrial structure during regional ischemia and reperfusion. nerve local anesthetic bolus compared with continuous infusions for J Thorac Cardiovasc Surg 1986;92:512–24. LETTERS TO THE EDITOR http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Journal of Cardio-Thoracic Surgery Oxford University Press

Reply to Anderson et al.

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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1010-7940
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10.1093/ejcts/ezy119
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Abstract

Letters to the Editor / European Journal of Cardio-Thoracic Surgery 613 [5] MacIver DH, Partridge JB, Agger P, Stephenson RS, Boukens BJD, Omann C et al. The end of the unique myocardial band: part II. Clinical and func- tional considerations. Eur J Cardiothorac Surg 2018;53:120–8. Gerald D. Buckberg* [6] Buckberg G. Echogenic zone in mid-septum: its structure/function relation- Department of Cardiothoracic Surgery, David Geffen School of Medicine at ship. Echocardiography 2016;33:1450–6. UCLA, Los Angeles, CA, USA Received 23 February 2018; accepted 26 February 2018 *Corresponding author. Department of Cardiothoracic Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 62-258 CHS, Los Keywords: Helical ventricular myocardial band � Structure/function � Angeles, CA 90095, USA. Tel: +1-310-2061027; e-mail: gbuckberg@mednet. Misconceptions � Cardiac mechanics � Determinism (cause and effect) ucla.edu (G.D. Buckberg). Robert Anderson consistently tries to cast away the helical ventricular myocar- doi:10.1093/ejcts/ezy119 dial band, using terms such as ‘skeletal muscle, inaccurate notion, unique, and Advance Access publication 14 March 2018 oversimplified’ towards this end [1, 2]. My motto is ‘Elegance is Simplicity and Confusion is Complexity’ with 3 monumental truths: E = mc (Einstein), M = fa (Newton) and how the ‘helix and wrap’ (Torrent Guasp) concept solved the age-old dilemma of the cardiac form/function relationship. Masters are identified. Anderson selected Pettigrew, a heralded anatomist. Intraoperative analgesic regimens may Mine was Claude Bernard, a physiologist using vivisection. He believed ‘life is motion’, stating that ‘only groping and empiricism’ would exist without a cause affect postoperative pain: single-port versus and effect approach. To him, biology meant ‘anatomists deduce to explain physiology’, whereas ‘physiologists explain it by anatomy’. multi-port video-assisted thoracic surgery The landmark question, ‘the heart moves, but why?’ must be solved. Torrent Guasp’s anatomy showed that its 6 movements of narrowing, shortening, Mark C. Kendall* lengthening, widening, twisting and uncoiling are caused by just 3 muscles—‘2 Department of Anesthesiology, Rhode Island Hospital, The Warren Alpert helical arms and the surrounding wrap’ [3]. Their interaction is documented Medical School of Brown University, Providence, RI, USA by sono-micrometer crystals, 2-dimensional and 3-dimensional (3D) echo, ventriculogram, magnetic resonance imaging, velocity vector imaging and Received 12 February 2018; accepted 18 March 2018 electrocardiographic recordings-is that an inaccurate notion? This in-depth architectural understanding unhinges several current misconcep- Keywords: Thoracic surgery � Acute pain � Analgesic regimen tions in cardiovascular dynamics, including cardiac topography limitations [the left ventricle and the right ventricle (RV) and septum], isovolumetric relaxation I read with great interest the article by Li et al. [1] in a recent issue of the jour- time, when the mitral valve opens, muscular reasons for torsion (twisting), the nal. The authors performed a retrospective study on 285 patients to compare term untwisting, why longitudinal and circumferential strain happen, resynchroni- single-port video-assisted thoracic surgery with the multi-port variants in zation, the RV function and diastolic dysfunction cause and treatment. terms of short-term perioperative outcomes and concluded that single-port Histological anatomy and autopsy analysis may be deceiving since (i) ‘dead video-assisted thoracic surgery has potential advantages of less postoperative hearts don’t beat’ and (ii) preservation errors occur. Hearts previously thought pain when compared with multi-port techniques. The authors should be con- dead after 6 h of coronary artery occlusion were alive and functioning because gratulated for performing a study on an important topic (e.g. acute pain) in histology—not the heart—was wrong [4]. William Harvey thought boiled hearts patients undergoing thoracic surgery [2,3]. The current emphases on the need looked circular, mirroring those in Anderson’s report. Harvey’s circulation discovery to improve postsurgical pain and reduce opioid intake makes the topic very changed Galen’s (180 AD) observation of twisting (ebb and flow) to the traditional relevant in perioperative medicine [4,5]. ‘all at once’ or clenched and open fist concept of compression and dilation. This Although the study by Li et al. was well conducted, there are some ques- misconception lasted 400 years, until 3D imaging reconfirmed twisting. tions regarding the study that need to be clarified. First, it is not clear whether Anderson’s profound misunderstanding of structure/function evolves from the intraoperative analgesic regimens were standardized for all patients as this the MacIver’s 2018 ‘The end of the myocardial band’ paper [5]. Thinking that can substantially affect the study outcomes. Second, it is unclear whether any twisting is a relatively minor motion versus longitudinal shortening and cir- patient received a thoracic epidural as part of their analgesic management, cumferential strain promotes a position that clashes against its causing 80% of which is regarded as the standard of care for postoperative pain control in the RV function, tricuspid annular plane systolic excursion (TAPSE) [2] and the these types of surgical cases. Finally, although the patients were recruited con- left ventricular failure development after its loss. They fail to understand that secutively, it is not clear how each patient was allocated to the study groups the right sided helix’s inner spiral arm contraction causes longitudinal shorten- (e.g. surgeon’s preference and disease extension) as this can result in a signifi- ing.. . and diastolic dysfunction; the wrap compresses. In response to their cant selection bias for the study outcomes. question about RV anatomy, no helix exists in its free wall, but it contains left I would welcome some comments by the authors as this would help to helical arm fibres: Can Anderson’s team’s proposed anatomy have merit, if its further substantiate the findings of this important clinical study. function relationships are impossible? [6] Anderson and MacIver’s ‘end of the myocardial band’ edict cannot be achieved. As Svetlana Alexievich, the 2015 Nobel Laureate in Literature said, ‘History records the lives of ideas. People don’t write it, time does’. They should listen. REFERENCES [1] Li Q, Sihoe A, Wang H, Gonzalez-Rivas D, Zhu Y, Xie D et al.Short-term REFERENCES outcomes of single- versus multi-port video-assisted thoracic surgery in mediastinal diseases. Eur J Cardiothorac Surg 2018;53:216–20. [2] Niraj G, Kelkar A, Kaushik V, Tang Y, Fleet D, Tait F et al. Audit of postoper- [1] Anderson RH, Agger P, Stephenson RS. The incorrect notion of the ‘unique ative pain management after open thoracotomy and the incidence of myocardial band’. Eur J Cardiothorac Surg 2018;54:612. chronic postthoracotomy pain in more than 500 patients at a tertiary cen- [2] Buckberg GD. Right ventricular failure after surgical ventricular restoration: ter. J Clin Anesth 2017;36:174–7. operation or myocardial protection problem? Eur J Cardiothorac Surg [3] Fiorelli A, Santini M. Total intravenous anaesthesia with local anaesthesia 2017;52:1018–21. for controlling pain after spontaneous ventilation video-assisted thoracic [3] Buckberg GD, Hoffman JI, Coghlan HC, Nanda NC. Ventricular structure- surgery: is it a viable strategy? Eur J Cardiothorac Surg 2017;52:200. function relations in health and disease: part I. The normal heart. Eur J [4] Kıtlık A, Erdogan MA, Ozgul U, Aydogan MS, Ucar M, Toprak HI et al. Cardiothorac Surg 2015;47:587–601. Ultrasound-guided transversus abdominis plane block for postoperative [4] Sjostrand F, Allen BS, Buckberg GD, Okamato F, Young H, Bugyi HI et al. analgesia in living liver donors: a prospective, randomized, double-blinded Studies of controlled reperfusion after ischemia: IV. Electron microscopic clinical trial. J Clin Anesth 2017;37:103–7. studies: importance of embedding techniques in quantitative evaluation of [5] Chong MA, Wang Y, Dhir S, Lin C. Programmed intermittent peripheral cardiac mitochondrial structure during regional ischemia and reperfusion. nerve local anesthetic bolus compared with continuous infusions for J Thorac Cardiovasc Surg 1986;92:512–24. LETTERS TO THE EDITOR

Journal

European Journal of Cardio-Thoracic Surgery – Oxford University Press

Published: Sep 1, 2018

References

  • The incorrect notion of the ‘unique myocardial band’
    Anderson
  • Right ventricular failure after surgical ventricular restoration: operation or myocardial protection problem?
    Buckberg
  • Ventricular structure-function relations in health and disease: part I. The normal heart
    Buckberg
  • Studies of controlled reperfusion after ischemia: IV. Electron microscopic studies: importance of embedding techniques in quantitative evaluation of cardiac mitochondrial structure during regional ischemia and reperfusion
    Sjostrand
  • The end of the unique myocardial band: part II. Clinical and functional considerations
    MacIver
  • Echogenic zone in mid-septum: its structure/function relationship
    Buckberg