Carreras-Costa, Francesc

Corno, Antonio F.

Kocica, Mladen J.

Torrent-Guasp, Francisco

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before referring to our more experienced radiologistcolleagues for FNA. It is my firm belief that our specialtyis evolving fast, and the future generation of thoracicsurgeons may be expected to use portable ultrasound (forexample, to accurately locate pleural effusions beforedrainage) as an extension of their bedside clinical skills.* Tel.: þ852-2632-2629; fax: þ852-2647-8273.E-mail address: yimap@cuhk.edu.hk (A.P.C. Yim).doi:10.1016/j.ejcts.2004.04.026Letter to the EditorSystolic ventricular fillingRobert H. Anderson*Cardiac Unit, Institute of Child Health,University College London,30 Guilford Street, London WC1N 1EH, UKReceived 14 April 2004; accepted 27 April 2004; Available online28 May 2004Keywords: Ventricle; Anatomy; Myocardium; PhysiologyIt is disappointing to see yet another review appearing inthe surgical literature promoting a physiological concept onthe anatomic basis of the ‘ventricular myocardial band’ [1].It is well known that disputation is the lifeblood of science,but it is equally accepted that those promoting a newconcept should first examine, and refute, any evidence thatmight invalidate it. As far as I am aware, neither Dr Torrent-Guasp, nor his co-workers, have offered any explanation asto why previous accounts of the architecture of theventricular mass are deficient. In fact, there is a wealth ofanatomic evidence [2–4] to show that, rather than beingarranged in the form of a skeletal muscle, with an originfrom one arterial root, and an insertion at the other, asclaimed by Dr Torrent-Guasp and his supporters [1], theventricular mass is arranged in the form of a modified bloodvessel, with each myocyte anchored to its neighbour withina supporting fibro-collagenous matrix.If the ventricular mass were truly arranged in the form ofthe ‘ventricular myocardial band’, then the structure of thefibrous matrix determining this arrangement would bedemonstrated by techniques such as serial histologicalsectioning or magnetic resonance imaging. In reality, thesetechniques show the ventricular myocardium to be arrangedin a complex three-dimensional meshwork of tangential andintruding fibres [2,3]. Dissection techniques have been usedto confirm this arrangement [4], but those using thedestructive approach of dissection recognise that thismethodology unequivocally produces artefacts,since the technique, of necessity, interrupts the integrity ofthe supporting fibro-collagenous matrix. For this reason,the investigation of Jouk and colleagues [5] is key in theongoing debate, since these workers have confirmed thebasic arrangement of intermingling tangential and intrudingfibres, but without needing artefactually to take apart themusculature making up the ventricular mass.I recognise, of course, the prerogative of Torrent-Guasp toquestion the currently accepted arrangement of the ventri-cular mass, with its physiological and clinical correlates.When questioning this generally accepted hypothesis,nonetheless, I emphasise again that it is incumbent uponTorrent-Guasp, and those who now support him [1], todemonstrate its deficiencies. This they have singularly failedto do. Those who seek to interpret the known physiologicalfacts in the fashion suggested by Torrent-Guasp and hiscolleagues, therefore, should be aware of the major short-comings of their anatomical analysis.References[1] Torrent Guasp F, Kocica MJ, Corno A, Komeda M, Cox J, Flotats A,Ballester-Rodes M, Carreras-Costa F. Systolic ventricular filling. Eur JCardio-Thorac Surg 2004;25:376–86.[2] Streeter JrDD. Gross morphology and fiber geometry of the heart. In:Berne RM, Sperelakis N, editors. Handbook of physiology section 2.The Heart (American Physiology Society), vol. 1. Baltimore: Williamsand Wilkins; 1979. p. 61–112.[3] Greenbaum RA, Ho SY, Gibson DG, Becker AE, Anderson RH. Leftventricular fibre architecture in man. Br Heart J 1981;45:248–63.[4] Sanchez-Quintana D, Garcia-Martinez V, Hurle JM. Myocardial fiberarchitecture in the human heart. Acta Anatom 1990;138:352–8.[5] Jouk PS, Usson Y, Michalowicz B, Grossi L. Three-dimensionalcartography of the pattern of the myofibres in the second trimester fetalhuman heart. Anat Embyrol 2000;202:103–18.* Tel.: þ 44-207-905-2295.E-mail address: r.anderson@ich.ucl.ac.ukdoi:10.1016/j.ejcts.2004.04.034Reply to the Letter to the EditorReply to AndersonFrancisco Torrent-Guaspa, Mladen J. Kocicab,*,1,Antonio F. Cornoc, Francesc Carreras-CostadaDenia, Alicante, SpainbClinic for Cardiac Surgery,Institute for Cardiovascular Diseases,UC Clinical Centre of Serbia,8th Kosta Todorovic St., 11000 Belgrade,Serbia and MontenegrocDepartment of Cardiovascular Surgery,Letters to the Editor / European Journal of Cardio-thoracic Surgery 26 (2004) 459–462 461Centre Hospitalier Universitaire Vaudois (CHUV),Lausanne, SwitzerlanddDepartment of Cardiology, Cardiac Imaging Unit,Hospital Sant Pau, Barcelona, SpainReceived 26 April 2004; accepted 27 April 2004; Available online28 May 2004Keywords: Ventricle; Anatomy; Myocardium; PhysiologyWe are delighted that our article [1] attracted the interestof a world-wide expert of cardiac morphology like youProf. Anderson and, despite your evident nihilism, weappreciate your input. We also totally agree with you thatthe readers should be protected from unproven statements,and therefore we take this opportunity to provide furtherarguments in favor of our hypothesis.In support of this, we will cite a sentence from, so oftenmentioned, Streeter’s seminal work [2]: “It was not until themiddle of this century that two researches,separately established valid, reliable methods. They wereTorrent-Guasp, with his principal ‘fiber path’ method ofblunt dissection, and Hort, with his micrometric methodtrough wall blocks.” As the first author (Torrent-Guasp) washis personal friend and close associate, having publishedseveral papers together, we feel obliged to say that DanielStreeter was the brightest example of integrative person,capable to unify (not to confront) different approaches, asthose of classical and contemporary anatomists, thuscreating a valuable mainstream in exploring the ‘Grossmorphology and fiber architecture of the heart’ [2].An independent empirical testability is the hallmark ofscience. Again, it was just Dainel Streeter who haddescribed the techniuqe of unraveling ventricularmyocardial band ‘reliable and reproducible’ stating thataccepting ‘statistical criterion of the principal fiber directionat given point’ may accomodate factual difficulties, arisingfrom complex and anisotropic myocardial architecturaldesign [2]. Whether we like it or not, from Vesalius tonowadays, the ‘destructive approach of dissection’ has beenthe one used by all the anatomists born in this world, duringthe last five centuries. But, should our minds be asdestructive as our fingers? Classical anatomists, weresimply unable to find any architectural plan able to join,in a coherent whole, all fibers comprising the ventricularmass. Therefore ‘the previous accounts of the architectureof the ventricular mass’ are not deficient — they just do notexist as such. In spite of that, without extensiveknowledge of the work of classical anatomists, we surelywouldn’t be able to realize the architectural plan of theventricular myocardium.Unavoidable coherence and mutual coupling of form andfunction exist in the entire ventricular myocardium. In orderto emphasize the importance of structure-functionrelationships of the intact ventricles, National Heart,Lung, and Blood Institute convened a workshop entitled‘Form and Function: New Views on Development, Diseasesand Therapies for the Heart’, which was promoted anddeveloped around the anatomical concept of the ventricularmyocardial band [1].From this point, further, there were many scientificalpapers published, confirming the validity of ventricularmyocardial band concept [3–5]. Diffusion Tensor MRI, asrapid, highly resolutive, non-destructive methodology,has confirmed both histological structure [3] andmacroscopical design of the ventricular myocardium [4,5].Moreover, those analyses have also confirmed some crucialfunctional correlates [3–5], derived from the specificalspatial organization of the ventricular myocardium, asdescribed in our article [1].Even if we understand that, in your view, we moved theSun at the center of the Universe, instead of the Earth, timewill tell.References[1] Torrent Guasp F, Kocica MJ, Corno A, Komeda M, Cox J, Flotats A,Ballester-Rhodes M, Carreras-Costa F. Systolic ventricular filling. EurJ Cardio-Thorac Surg 2004;25:376–86.[2] Streeter Jr DD. Gross morphology and fiber geometry of the heart. In:Berne RM, Sperelakis N, editors. Handbook of physiology section 2.The Heart (American Physiology Society), vol. 1. Baltimore: Williamsand Wilkins; 1979. p. 61–112.[3] Scollan DF, Holmes A, Winslow R, Forder J. Histological validation ofmyocardial microstructure obtained from diffusion tensormagnetic resonance imaging. Am J Physiol 1998;275:H2308–18.(Heart Circ Physiol 44).[4] Saber NR, Gharib M, Wen H, Buckberg GD, Ross BD. Interpreting-myocardial morphology and function from DENSE MRI data based onfluid mechanics concepts. J Cardiovasc Magn Res 2004;6:365–6.[5] Schmid P, Gamper U, Jaermann T, Kozerke S, Boesiger P.Three-dimensional reconstruction of cardiac fiber structure usingdiffusion tensor MRI. J Cardiovasc Magn Res 2004;6:90–1.* Corresponding author. Tel.: þ381-11-367-0609; fax: þ381-11-361-0880.E-mail address: kocica@sezampro.yu (M.J. Kocica).1 URL: www.ctsnet.org/home/mkocicadoi:10.1016/j.ejcts.2004.04.033Letters to the Editor / European Journal of Cardio-thoracic Surgery 26 (2004) 459–462462

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