Christopher E.

Hekelnkaemper
BMED 213

Reflections: The History and Future of Heart Valve Prosthetics

Introduction and Problem Statement

One of the most prevalent medical issues affecting hundreds of thousands of people today is
heart valve disease. The mitral valve replacement surgery is among the most common types of
open-heart surgeries performed. However, in today’s health care market there are nearly 80
different models of prostheses that patients can choose from for this type of procedure. This can
be daunting for many patients who have little to no knowledge of how these prosthetic
components work within their bodies. This paper seeks to explore the history and world of heart
valve prosthetics as well as the causes and mechanisms of the diseases that may cause mitral
valve issues. (Bloomfield).

There are many different reasons for why

prosthetic heart valve replacement is a growing
issue. Mitral valve issues may arise from many
different sources. Acute rheumatic fever and
chronic rheumatic heart disease, the mechanism
of which remains elusive to this day, are the
most common causes of valve failure. This
disease leads to valvulitis, which in turn leads to
thickening, adhesion, and stenosis of the aortic
and mitral valves within the heart. Symptoms of
which include shortness of breath and
incapacitation (Harrison).

Mitral valvotomy, a term coined by Elliot Cutler

and Samuel Levine, was a procedure for treating
mitral valve issues. The first patient received this
procedure in September of 1923. The procedure
involved using Knife-hook, called a valvotome, to scrape and remove parts of the valve cusps.
This procedure was performed six times and predates the introduction of the heart valve. The
procedure has now been replaced with balloon dilation, while other procedures have been
introduced to the market with better results. Although these procedures could help reduce the
symptoms of these mitral valve issues, the problem remained that some valves were so badly
stenosed that the only solution would be to replace the entire valve itself (Mathews).
Heart Valve Types and History
The early 1950s was an opportune time for scientific discovery and collaboration. The end of
World War II in 1945, resulted in an influx of civilian engineers and scientists with an immense
amount of knowledge. As a result, industrial science during World war II encouraged
partnerships among scientists in different fields (Mathews).

In 1968, in an effort to improve prosthetic valves, scientists decided to describe what they called
the “Nine Commandments,” which was essentially an organized list of design choices involved
in making a better prosthetic valve. The first “commandment” was “embolism protection.” In
other words, the heart valves must not obstruct blood in the bloodstream. Second is the valve
must be made of durable materials, like stainless steel. The third is described as the “Ease and
Security of attachment.” In other words, the valve shape must conform with the annulus. Fourth
is the “preservation of the surrounding tissue function.” The fifth is the “reduction of
turbulence.” This could be done by increasing the size of the valve. Sixth is the “Reduction of
noise.” Mechanical valves may make loud noises that are audible to patients and the people
around them. Seventh is the use of materials that are bio-compatible with blood and tissue.
These materials may include stellite 21 (a mix of cobalt, chromium, molybdenum, and nickel),
Teflon, plexiglass, stainless steel, silicon, or rubber. Lastly is the ability to store and sterilize the
valve before implanting it (Mathews).

The types of prosthesis available today can be

boiled down into two main groups, mechanical
valves, and biological valves. The first
mechanical valves were ball-and-cage valves.
Although the ball-and-cage valve is different
they are mechanically equivalent to the
ball-and-cage bottle stopper, patented in 1858.
Although the design is crude and archaic, it
works.

Albert Starr, a revered and respected surgeon

at Columbia University, and Lowell Edwards,
a successful engineer with over 63 patents for
his own inventions, collaborated to develop a
safe production level ball-and-cage valve. Many
of these valves are still inside patients alive to
this day (Bloomfield).
The duo was very thorough in their design and was criticized for departing heavily from the idea
of artificially imitating nature, which was the widely accepted view for many of the leading
scientists in this area. Starr defended himself stating, “Our job is not to design a valve identical
to nature’s, not to see how close we can come to duplicating a natural phenomenon, but to
overcome the clinical problems of the diseased heart valve.” (Mathews) This is crucial as it leads
to a different perspective on the role of prosthesis within the human body.

Other prostheses appeared after the success of the Starr-Edwards Prosthesis. Bjork-Shiley’s
prosthesis used graphite discs coated with pyrolite carbon which tilts between two struts of the
housing which is made of stainless steel. This prosthesis was prone to cracking and is no longer
in production. Bileaflet valves became the most common mechanical prosthesis with more than
600,000 implants since its introduction in 1977 (Bloomfield).

With our current state of knowledge on

biocompatible materials Starr’s departure
from the common idea of artificially imitating
nature has disappeared. Current technology
has enabled scientists to develop biologically
suitable valves that can nearly mimic nature.
Tissue valves can be drawn from a variety of
different sources. The most common today are
porcine valves, which are valves extracted
from the heart of a pig. They are treated with
glutaraldehyde to both sterilize it and make it
biologically acceptable. The biggest
disadvantage for tissue based valves is the
durability of the valves which is caused by
calcification. To overcome this calcification,
scientists are working to develop synthetic or
grafted tissues treated with aldehyde capping
chemistry and glycerolization (Shang).

My father was born on thanksgiving day in 1945. He had me when he was 50 years old and he is
now 74 years old. With old age comes increasingly more hardships with everyday life. My father
works hard and stresses his body more and more every day. Unfortunately, his father, my
grandfather died from a complication with an aortic valve. Heart valve disease is not going to
disappear. Heart disease kills hundreds of thousands of people every year and is the leading
cause of death amongst men. However, an encouraged partnership amongst engineers, biologists,
doctors, and other fields has pushed the boundaries of science and knowledge. This is an exciting
time to be in the sciences.
 Works Cited

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doi:10.1136/heart.87.6.583.

Harrison, Tinsley R. “Principles of Internal Medicine.” ​Southern Medical Journal,​ vol. 44, no. 1,

1951, p.

79., doi:10.1097/00007611-195101000-00027.

Mathews, Annette M. “The Development of the Starr-Edwards Heart Valve.” ​Texas Heart

Institute

Journal​, 1998.

Shang, Hao, et al. “Aldehyde Reduction in a Novel Pericardial Tissue Reduces Calcification

Using Rabbit

Intramuscular Model.” ​Journal of Materials Science: Materials in Medicine,​ vol. 28, no.

1, 2016, doi:10.1007/s10856-016-5829-8.