Albert Starr and the

Starr-Edwards heart Valve

AFTER GRADUATING FROM /\ Columbia College of Physicians J. V. and Surgeons in 1949, Dr. Albert Starr served a one-year internship at Johns Hopkins Hospital. There, he worked under the world famous surgeon Dr. Alfred Blalock, who had pioneered the Blalock-Taussig operation for children with cyanotic heart disease.

When his internship was completed, Starr returned to New York but was soon drafted into the U.S. Army Medical Corps to serve first as a battalion surgeon in the First Cavalry Division in Korea, then as a surgeon for a Mobile Army Surgical Hospital (MASH) unit. In a single year, he performed more than one thousand major operations.

"Korea was the first war in which you had an almost unlimited backup system to a limited war," Starr said in a recent interview. "It was a war in which there was almost an unlimited supply of human blood available for transfusion on the battlefield. There was also the beginning of antibiotics, and helicopter evacuation so that someone wounded in a firefight in Korea would be back in a MASH within minutes of being wounded, rather than hours or days. The survival rate, if you made it back to the MASH hospital, was about 95 percent."

After his tour of duty, he returned to complete his surgical training at Bellevue and Presbyterian hospitals in New York. By 1957, Starr had finished his thoracic surgery residency and moved to the University of Oregon, Portland, to start

Albert Starr an open heart program. This is where Starr was first exposed to heart valve surgery and the problems surgeons were having repairing diseased valves. After experimenting with all sorts of valve prostheses, Starr became convinced that valve replacement was necessary to save many patients with diseased mitral valves because there was no way to repair badly deformed and diseased mitral valves.

Enter a retired engineer named M. Lowell Edwards. A successful and independently wealthy engineer, Edwards had several important inventions to his credit and originally approached Starr to help him develop an artificial heart.

"I thought he was overreaching, to put it mildly," Starr said. "What I discovered was that he was a very suc cessful engineer, and although he was wearing the typical Oregon golfer's dress, he was very accomplished and had numerous inventions to his credit. One of them was a fuel injection system for rapidly climbing aircraft during World War II. The P-38 and many of our fighter aircraft had his fuel injection system, and a good part of the successful war effort, at least as far as the air war is concerned, is credited to his fuel injection system. In the Battle of Britain, the Spitfires had his fuel injection system, and that enabled them to get up to very high altitudes very rapidly without the system failing."

When Starr pointed out that medicine didn't even have artificial valves yet, much less an artificial heart, the two decided to begin one valve at a time and invent prostheses. They started with the mitral valve and considered every kind of valve known. After drifting from valve to valve, they finally hit upon the ball valve, which showed early promise because it was not as easily occluded by the blood clots that quickly formed around the sutures of more conventional leaflet-type valves.

They quickly learned, however, that blood clots did form in the ball valves — it just took longer before the clot was large enough to block up the free-moving ball. At the time, they were performing their early experimentation in dogs, many of whom were dying from thrombosis months after their valves were implanted. This challenge led Starr and Edwards to the silastic shield, which was basically a retractable diaphragm that covered the sutures and prevented blood clots from forming. This shield created long-term survivors, and soon Starr had a kennel full of active dogs that had undergone mitral valve replacement.

"The chief of cardiology, Dr. Herbert Griswold, knew we had a kennel full of active dogs and came to visit us In August 1960. He looked at all these dogs and said, 'Starr, we have to do this clinically.' That was the first time we began to think about that seriously because I thought it would be a couple years' project at least."

Interestingly, the first valve implanted in a human did not use the silastic shield. Starr, knowing that dog's blood clots very aggressively, figured he wanted the simplest procedure possible and, if the patient's blood clotted, they could always administer anticoagulant medication. This first operation was done in September 1960 on a young woman in her mid-twenties. The Starr-Edwards cage-ball valve prosthesis quickly became established as the gold standard in mechanical heart valve prostheses.

"This generated tremendous excitement and put the Oregon Health Sciences University on the map," Starr said. "We had visitors from all over the world."

Starr-Edwards cage-ball heart valve

Homograft:

A donor graft, or portion of tissue, taken from a donor and placed into a recipient of the same species.

Dr. Donald Ross was the first to successfully replace an aortic valve with a tissue valve from another human. He also invented the Ross Procedure, which is still in use today to replace a malfunctioning aortic valve.

erated Intense excitement and become established as the gold standard for mechanical heart valve prostheses. The valves maintained this status for many years, although today newer, low-profile valves are commonly used. There are, however, still some surgeons implanting the original Starr-Edwards cage-ball valve.

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