An Ode to the Herculean Heart

As a medical student interested in internal medicine, it is somehow natural to gravitate first to understand the heart; now, a few years later, my fascination has become a deep respect. As a fan of the writing of Sandeep Jauhar, MD, (“Intern” and “Doctored” are two of my favorite books), Jauhar’s most recent book, “Heart: A History,” was the ideal medium to learn more about how the heart became the most revered organ.

From the heart’s significance in medieval times, to a timeline of breakthroughs in the field of cardiology, interspersed with personal anecdotes from Jauhar’s life – it was a riveting read. When I came to the end of the book, sitting beside my living room window overlooking a basilica drenched by early winter rain in Baltimore on a Sunday morning, I was just so moved by the author’s story. It has truly stuck with me, and in retrospect it was not just the content, but also the manner in which Jauhar distills it.

I had the good fortune of interviewing the author to discuss a few facets of his book:

Me: What inspired you to write the book?

SJ: I was inspired to write the book for three reasons. One is that I have a malignant family history for heart disease. My mother would say, “You should listen to your dad and do your chores, or your dad will develop heart failure!”

I was absolutely fascinated by the heart, primarily because it affected my family so much. Both my grandfathers, paternal and maternal, and my mother, died of sudden heart attacks.

The second reason is that I am fascinated by the heart as a machine. I trained in physics in college and I know a little bit about machines and engines. The heart is an amazing machine – it beats three billion times in an average person’s lifetime. The amount of work it does without stopping – it is hard to fathom. If you connected an adult heart through a tube to a swimming pool, it would empty that pool within a week. Our lives depend on the heart more than any other organ. The heart can function without a functioning brain, but not vice versa.

The third reason, and probably the preeminent one, is that the history of discoveries related to the heart is fascinating. The heart was not operated on until the late nineteenth century – all other major organs, including the brain, were operated on before the heart. It is challenging to operate on an organ constantly moving and full of blood, and the history surrounding the efforts to overcome this challenge is fascinating.

Me: What are some of the surprising pieces of information that you learned while doing research for the book?

SJ: In the pre-scientific age, philosophers were focused on the heart’s metaphorical properties – it was thought to be the seat of the soul since it is in the center of the body. It sped up during stress, and due to various reasons that I elucidate in the book, it was also thought to be center of our emotional lives. Then there is the concept of the biochemical pump that science and medicine have focused on for a century.

What is the intersection between the metaphorical and biological hearts? This is what I explored in the book. The purest example of that is the takotsubo cardiomyopathy or the “broken-heart syndrome,” wherein the heart weakens in response to acute stress. I found that there were so many examples where our emotions effected our hearts in multifarious ways. What I found interesting was, even though the heart doesn’t contain the emotions per se (as the ancient philosophers had previously thought), our emotional lives are deeply connected to heart health and we need to pay attention to that if we want to live well, both by and with our hearts.

Me: You have mentioned many breakthroughs that modern medicine now looks at as ordinary. But few know that the endeavors that led to these important breakthroughs such as Lillehei with the open heart surgery and Forssmann with cardiac catheterization, were laden with initial ridicule and dismissal. Do you think that the medical community has become more receptive to new approaches in light of these previous experiences?

SJ: Lillehei was a cardiac surgeon in the mid-20^th century, a golden era for cardiac medicine. He came up with an outlandish, yet amazing, scheme called cross circulation where he connected an adult to his/her child to serve as a “human heart-lung machine” while he operated on the latter’s heart. You’re right – that was first met with disbelief and censure – people said that this would be the first operation in human history that could have a 200% mortality. A lot of the book describes how the innovators overcame those kind of obstacles – the rebuke, censure, skepticism, and also the marginalization.

Forssmann, as you mentioned, did the first cardiac catheterization on himself. He sacrificed his body in ways that is hard to fathom – he ended scarring veins in his arms, legs, and groin by doing all of these procedures on himself. He would go to conferences to present his findings and find no interest. As a result, he grew increasingly disillusioned and turned to urology.

These example shows that science, and in particular medicine, are conservative fields. We are careful in our approach, and a lot of good comes out of that. We don’t want people to do dangerous things – the most recent example being that of the gene-edited babies.

It’s true, sometimes the conservatism can appear to retard scientific progress. It is hard to say that we have learned as a field to more easily accept breakthroughs. Thomas Kuhn wrote the “Structure of Scientific Revolutions” in the 1960s – he described that for innovations to take place and for a whole field to get upended really requires stupendous effort. In some sense, what Lillehei and Forssmann did are examples of that. They really did start a scientific revolution. Science is inherently a conservative field of inquiry and we need to continue to bring new ideas, which ought to be subjected to criticism and skepticism. Ultimately if the foundation of the idea is good, however, it will be accepted, such as Forssmann’s, who was ultimately awarded the Nobel Prize 30 years after his heart research.

Me: Clinicians sometimes ignore the psychosocial aspects of patients, which is now shown to be linked to their disease, as you have mentioned in multiple parts of the book. I liked how you mentioned “the metaphorical heart is inextricably linked to the biological heart.” Can you talk about these psychosocial aspects with respect to heart disease?

SJ: Acute emotional stress can alter the heart’s shape (as in broken-heart syndrome or takotsubo cardiomyopathy) and we don’t know why it disproportionally affects women. What is interesting is that even happy events, like surprise birthday parties, can alter the heart in a different shape distinct from takotsubo, though we don’t know why that happens.

We know that chronic stress can affect the heart as well – Karl Pearson studied gravestones, and found that spouses tend to die within one year of the death of their loved one. At this point, we accept that chronic emotional stress, depression, and anxiety can increase the risk of coronary disease.

Me: There is a great point you made about sometimes treatment outpacing understanding of disease in medicine. We have invented some great life-saving therapies, but an immense physical and psychological burden, mostly borne by patients, can accompany them. Case in point being left ventricular assist devices (LVADs) and defibrillators – what do you think about this and what are the major challenges that modern medicine faces today?

SJ: There are trade-offs with these great inventions. Both these devices that you mentioned are associated with a number of complications – LVADs can put you at risk of increased gastrointestinal bleeding, and patients recurrently shocked by defibrillators can develop post-traumatic stress disorder. We have to appreciate what the technology offers, but also what it is taking away.

Defibrillators do an admirable task of preventing sudden death by delivering shocks. But preventing sudden death also begs the question: Is sudden death the worst outcome for the patient? Sudden death has so much fear associated with it, but at the same time, it is also in some ways the most desirable way to die. With the defibrillator, the latter option is taken away. For example, my maternal grandfather died due to sudden heart attack – a day after his 83^rd birthday, and he celebrated it probably eating too much along with a good amount of scotch. I’m sure he would have loved to have lived longer, but when I talk to my mother about his death, he was sad that he died suddenly, but she was also grateful that it was a peaceful way for him to pass away.

Seeing my mother suffering from Parkinson’s disease, my brother once said, “I hope she dies suddenly, because she is suffering so much.” He and I got into a disagreement over that statement. It became clear to me, as time went on, that she was deteriorating neurologically and then when she did eventually die from sudden cardiac death in her sleep; I did appreciate that even though the heart can extinguish your life, and it can be a great tragedy, in some ways it is a blessing as well.

Me: Can you tell us how researching and writing the book has improved your connection with patients, or in other ways helped your clinical practice?

SJ: I have become more aware and sympathetic to the psychosocial aspects of heart disease. Like many doctors, I previously tried to direct patients into algorithmic questioning that we are prone to do, “Did you have chest pain?” “What was the quality of it?” I have become more patient when someone comes in and wants to talk about what is important to them. This helps me to understand how psychosocial aspects are linked to their heart disease.