Dr. Albert Starr: A Historical Commentary

Fifty years ago, on Sept. 21, 1960, the first successful implantation of a mechanical heart valve in the mitral position was performed by Albert Starr, MD, President of The Society of Thoracic Surgeons, 1985-1986, and his surgical team at the University of Oregon in Portland. This historic event was preceded by extensive laboratory investigation with his collaborator, M. Lowell Edwards, a prolific “retired” hydraulic engineer who held 63 patents and had an interest in fluid dynamics and human circulation.

With open heart surgery in its infancy at the time, and intense and exciting laboratory and clinical investigations underway on a number of conditions potentially amenable to surgical treatment using cardiopulmonary bypass, these two individuals decided to focus their work on the mitral valve. They evaluated a series of valve designs and finally settled on the ball-valve concept. Within three weeks of that decision, Lowell Edwards had designed and constructed an implantable device. Using this device in dogs, they achieved 80 percent long-term survival. They also critically evaluated the complications associated with such a device (thrombosis, dehiscence, hemolytic anemia, and infection). 1A valve design with an acrylic ball was selected for the first clinical implant. Edwards, with three other investors, formed Edwards Laboratories to manufacture artificial heart valves for human use, the first such company of its kind.

With the full support of his department chairman, J. Engelbert Dunphy, MD, and the chief of cardiology at the University of Oregon, Herbert E. Griswold, MD, Dr. Starr identified patients in the terminal stages of heart failure from mitral valve disease as potential candidates for mitral valve replacement.

In August of 1960, the first patient to receive the Starr-Edwards ball valve, as it came to be known, was a woman in her late 40s who was confined to the hospital with endstage mitral valve disease after two attempts to repair her valve. She survived the procedure but subsequently died as the result of a stroke after sustaining a massive air embolus.

The first successful procedure was performed in September of that year on a male truck dispatcher who had previously undergone two closed mitral commissurotomies for calcific mitral stenosis. He lived for more than 10 years after the operation and died from injuries associated with falling off a ladder. Fortunately, other successful procedures were subsequently performed.2 Over the past five decades, more than 250,000 Starr-Edwards valves have been implanted in patients throughout the world.

This momentous accomplishment paved the way for development of other mechanical and bioprosthetic devices to replace diseased heart valves and the formation of a number of companies to manufacture them. Millions of patients have benefitted from implantation of these human valve substitutes.

Dr. Starr also established at the University of Oregon an infrastructure for conducting clinical trials, including an informed consent procedure and longterm tracking of patients. This occurred at a time before the U.S. Food and Drug Administration initiated oversight over medical devices. He also established a multidisciplinary team to provide postoperative care of his patients, creating what currently corresponds to an intensive care unit.

For his accomplishments, Dr. Starr shared the prestigious Lasker Award in 2007 with Alain F. Carpentier, MD, who developed one of the first successful bioprosthetic valve substitutes.

- STS Historian Nicholas T. Kouchoukos, MD

References

1. Starr A, Edwards ML. Mitral replacement: clinical experience with ball valve prosthesis. Annals of Surgery 1961:154:726-740.

2. Grunkemeier Gl, Starr A. Twenty-five year experience with Starr-Edwards heart valves: follow-up methods and results. Canadian Journal of Cardiology 1988;4:381-385.