An Interview With Albert Starr, MD
Dr. Albert Starr, inventor of the artificial heart valve, discusses his experiences being a doctor in extraordinary situations, and his passion for everyday life in the OR.
What were your first experiences in medicine? When I finished my internship at Hopkins, I went back to Bellevue as a resident. The chief, Dr. Frank Barry, was also Deputy Secretary of the Army. I told him that my draft board wanted me to join and serve as a doctor in the medical forces in Korea, but I was still in training so I thought I shouldn’t go. Although he told me what a great opportunity this was, he said that he wouldn’t help me get an easier assignment such as Europe. He thought I should instead go to a combat theater. Once I was in Korea, I realized he was right. It was a dangerous place, but it was very exciting. I was a battalion surgeon for a few months before I went to a mobile hospital. Those guys were fearless. It was marvelous to see devoted, well-educated men who took the war seriously and were professionals. The experience was eye-opening and had a great effect on me.
How did serving in the Army shape your impression of practicing medicine? I was a surgeon in a M.A.S.H. unit in Korea, which colored my life enormously by getting me surgical practice time. I did close to 1,000 laparotomies in 1 year, and I was only 23 years old. At that time, I was head of the abdominal team, and that was where the big surgery was. Anyone with a penetrating wound to the abdomen had to be operated on immediately. I was doing so many laparotomies that I developed calluses on my hands from the surgical instruments. It also affected me by giving me more respect for the armed forces, more respect for army officers and how professional and brave they were. If I were killed in Korea, then going to medical school would have been worthwhile, having operated on all those soldiers. It made me feel that I had accomplished something, enough for a lifetime, and anything else was a bonus. I started out feeling like I had done it all. Nothing was in vain. In the early days of surgery there were no vascular grafts in Korea. It was still pretty primitive in 1950-1951. After my tour of duty, my life seemed like bonus time. I felt I had already lived a full life and devoted my skill to the lives of others. I knew then that I wanted to be a pioneer, to do something that would be lasting and make some unique contribution.
Please tell us about your work behind the Iron Curtain in then-Soviet-occupied Eastern Europe. Dr. Jeremy Swan was the president of the American College of Cardiology, and he was responsible for leading some of these trips. He knew me from my work and asked me if I’d like to go. During the Cold War, the American College of Cardiology and a number of other professional organizations were trying to develop links to the Soviet Union and its satellites at the encouragement of the State Department. The State Department sponsored trips for medical doctors to visit various places in Eastern Europe. Some were cardiology groups, which I accompanied frequently, and visited places such as Warsaw, Budapest, Bucharest, and Belgrade.
I remember walking through a park in Yugoslavia with the Minister of Health and talking about various political issues, and we got to the Korean War. He told me that he was a medical officer in the war, and so was I. Then we realized that we were on opposite sides, and there we were, walking together while the Cold War was still on. We realized that we had our political differences, but that we could still interact amicably. During that experience, I had many similar conversations.
Regarding your goal of being a pioneer in medicine, how did you come to develop the first-ever life-sustaining cardiovascular device? A sequence of small steps put us on the path. At the time, there was no suitable replacement for the mitral valve, and we were just beginning to perform valvular heart surgery. If a patient could not have a valve repaired, the chances were that he might not survive the operation. We had access to private funds and we were working with an engineer, Lowell Edwards, so it was multidisciplinary work. We did not think of it so much as a life-sustaining cardiovascular device, although in retrospect it was the first implantable life-sustaining technology. It preceded pacemakers. The way we looked at it was to prevent death at the time of surgery for valves that could not be repaired. Therefore, it was a death-prevention device rather than a life-sustaining device. We weren’t taking healthy patients and implanting the device. We were taking people who were dying and had no other course of treatment or we were operating on them and performing inadequate surgery because the valves could not be repaired and they were dying as a result of the surgery.
After doing considerable experimental work on animals, we finally arrived at a design that allowed 80% survival of experimental animals with mitral valve replacement. We had patients in the university hospital who were in oxygen tents and had mitral valve disease, so we encountered no difficulty whatsoever in having patients referred for this treatment. We had tremendous support from the department of cardiology. We also had a chief of surgery who was an excellent surgeon and was supportive of cardiac surgery. He gave us the go-ahead to use the device. We did have legal advice concerning informed consent. At the time, there was no FDA in devices and there was no such thing as informed consent. Mr. Edwards asked his lawyer about what potential liabilities would be involved in such a device and what would be the obligations for the manufacturer and the surgeon to the patient. We developed an informed consent letter that the patient would sign that closely resembles the current informed consent.
Was there any real precedent for the informed consent document? What steps did you go through to develop it? No, there was no real precedent at that time. It was not the law, but you could be subject to civil suits if you were to damage somebody with an unproven new device. It would be like an assault. At the minimum, you should get the patient to agree to undergo the procedure, and, in the informed consent, you should precisely outline all the different alternatives and what the risks are, and that’s what we did. We figured out that the risks might be thrombosis, embolization, blood clots forming on the valve, which would then break off, and stroke. At that time, renal damage was common after heart surgery, as was congestive heart failure. We explicitly explained the risks, the patients signed the form, and they kept it as part of their medical record.
What are your passions and philosophies in practicing medicine? Our team is very focused on surgical excellence in regard to the technical aspects of surgery. We are performance oriented, so we are always focusing on how the procedure can be done better, faster, more elegantly, and with less trauma. On the other extreme is an intellectual approach to surgery, in which the surgeon dithers around trying different things. We approach surgery like an athlete would a professional sport, we try to keep learning and improving, and we never stop in this pursuit. I feel passionately about that. If you’re not interested in performance, you can still be a great internist, but if you are going to be a surgeon, you should be focused on technique. You should be an absolute nut about how to perform better.
Which physicians have been your main influences? One of them was Dr. Alfred Blalock—the chief at Johns Hopkins University when I was an intern. He was very kind to me and I try to act like he would have in certain instances. For example, when I finished my internship, there were not enough positions to take me at Hopkins. Dr. Blalock called the chief at Presbyterian in New York City and said, ?George, I want you to take this kid,? and I’ve never hesitated to do that for anyone else. He made me aware of what a powerful person could do if they went out of their way for somebody else. Another was Dr. Max Chamberlain, who pioneered segmental resection of the lung. He was a very well-known surgeon and was one of my attendings during my residency. He was an elegant surgeon who emphasized technique in surgery. When we started doing heart surgery, I used the same general principals of being methodical and choreographing the operation to be fast and elegant.
What is the current focus of your research? One of my interests is computer-assisted surgery using robotic enhancement. We have access to the intuitive surgical system, and right now we are constructing an operating room with concomitant cardiac catherization facilities with x-ray imaging and a very sophisticated digitized information system. My current focus is basically working on the design of the operating room of the future where it will be possible for a patient in one location to have a cardiac catherization, a stent, and various surgical procedures, some of them robotically enhanced. They are pounding away at that operating room right now as we speak, and we expect it to be open by the end of this year. It would allow distance surgeries to be performed, but basically our major interest would be using it as an adjunct to minimally invasive surgery, especially in surgery for atrial fibrillation, using it to be able to treat it with external ablation techniques and using the robotically assisted thoroscopic method.