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Dr. Starzl

In their own words:

The next big practical piece of transplantation is going to be limb, face, that kind of transplantation, which has only just put its head above the horizon. We, the ASTS in particular, should be very aware of what’s going on here. Because as has been the history of transplantation, the cutting edge in this new area has been done by surgeons.

Biography:

Thomas Earl Starzl, MD, PhD is the founding President of the American Society of Transplant Surgeons, 1974-75. Also initiating one of the first clinically relevant kidney transplant programs in 1962, and performing the first human liver transplant in 1963, Dr. Starzl grew these early efforts into a multi-organ transplant program at the University of Colorado through the 1960’s and 70’s. Pioneering work in basic science, particularly topics related to immunosuppression, patient management, rejection, and long-term outcomes, Dr. Starzl ultimately moved to the University of Pittsburg where its transplantation service was renamed Thomas E. Starzl Transplantation Institute in 1996. Dr. Starzl, known as the Father of Transplantation, received the nation’s highest honor for scientific achievement, the Medal of Science in 2005.

Transcript:

Thomas Starzl: Okay. My name is Tom Starzl; I am an antiquated transplant surgeon, now 82-years-old.

Thomas Peters: One of the topics that is of interest for Chronicles is the beginning of the ASTS and you were there. Can you tell us about the beginning of our society?

Thomas Starzl: Well the origins of the society occurred about a dozen years after the birth of the field of organ transplantation and by that I mean right around 1974. Discussions began between a Philadelphia surgeon whose name I can’t remember any longer, but he was a key player at Sinai Hospital in Philadelphia. Fred Merckel, myself and I think Roy Calne was involved in some of these discussions that took place in different cities in Philadelphia. But the one meeting that I remember most distinctly was the one in Miami which took place during the Annual Meeting of the American College of Surgeons. There the idea of formulating a surgical transplant society was discussed explicitly. And also the decision I think was taken by consensus that it would be a surgical society.

Thomas Peters: And who were the first leaders, the first officers, do you recall?

Thomas Starzl: Uh yes I do. I was the Founding President. I think it was understood that John Najarian would be the second President. And it was even hoped that a fellow named Tom Markiero as the third one, and I think that was in fact what happened although it happened in what could easily be defended as a democratic process but I think the pieces were in place right from the beginning. I think the reason for that is that the University of Colorado which is where I was from and Tom Markiero had come from had been a seminal center and the University of Minnesota had been the first of the second wave setters and also had assumed a position of very great importance and influence. So that more or less was the background against which these decisions were made.

Thomas Peters: Tell us your thoughts about how the ASTS has played a role in the development of transplantation. How has the society advanced the field?

Thomas Starzl: Well I think ASTS was the dominant society in the field of transplantation for right around a half-dozen years, right up until the early 1980’s. And there were a number of reasons for that, one of them actually was that the regional or the national societies in general had not yet been formed. That meant that this was one of the first, if not the first. For example, the British Transplant Society enjoyed its 25th anniversary in…Some time in the 1990’s which would have meant that the British Transplant Society and ASTS more or less were founded at the same time. And also the other major European societies were not yet in place. So the International Transplant Society was founded in 1968, we were only ahead of that by 5 or 6 years at the time the ASTS was formed.

So at that time really the dominant society and the only one in which there was broad representation that came together once a year or once every two years was the International Society. So those meeting of the ASTS that took place at one of the hotels in Chicago and it was in a very specific place within that hotel really constituted one of the principal events where information was exchanged, new drugs were discussed and ultimately where proceedings emanated that ended up in journals.

Now the first time the ASTS was, formally met had now been constituted had the proceedings or most of them published in the Journal of Surgery. And some kind of a deal had been constructed with Surgery to take on these proceedings and we thought it was a good idea. The SUS was using the Journal of Surgery as the organ, so we had that privilege for one year. And I recall my inaugural address founding the society was in fact published in the Surgery, immortalized we might say by publication in Surgery.

Thomas Peters: And it started out with a description of the lady who gives birth not knowing that she was pregnant. Do you remember that thought?

Thomas Starzl: I do, I do. Oh there were a number of other things that were discussed in that original paper, one being the extraordinary numbers, even as of 1975, who had gone already to become Departmental Chairman and the Inaugural Division Chiefs as in this county and of course around the world, transplantation had almost overnight become a very special branch of surgical practice and of medicine.

Thomas Peters: You were a pioneer in so many ways, but most pioneers face a series of defeats as well as victories. Can you tell us about some of each in your life as a transplant surgeon?

Thomas Starzl: Well I think every…It’s interesting you should put together triumphs and defeats because almost always they were one and the same. That is there was something that happened or an assertion or a position or a development that would pop up and would be roundly condemned for three or four or five years and then it turned out to be okay. So that and that happened on multiple locations, so I felt like I was never…It was like going around a track, a racetrack running around a track over and over again and every time the smoke cleared up from all the controversy engendered by the previous circle, there would be a new controversy and a new puff of smoke. And if I forget, the smoke never really quite cleared. So I think the…And a lot of the defeats had to do with that interval between something that came up was denounced and then succeeded. And I suppose the best example of that would be liver transplantation. But that was…I

If you wanted to put those circles or define them solely in terms of organs, I would have to say that you have to go right back to kidney transplantation at the beginning because kidney transplantation, you are way too young to know this, was a violently controversial issue in 1962 and 1963. And bearing in mind that as of the spring of 1963, there had been in the world, only six examples of survival for at least one year of a kidney allograft and those six had come up over a period of right around four years from January 1959 until the spring of 1963. So this was not the kind of a procedure with which you could hope to make a living and practice or build a reputation as being a responsible individual by doing. So I think that was a very explosive and dangerous period. And just to top it off, in 1963 we of course we tried to do liver transplantation. That created a controversy that really didn’t get resolved for about 20 years, so…

And then the next thing that I was involved in was intestinal transplantation, which went through the same virulent period of denunciation until it emerged and it was carried forward by the fellows that I was working with? and Kareem Abu-Elmagd, so now that’s a conventional procedure. But these things…these were tribulations that were strictly organ-related.
But then you could define it in terms of drugs or introduction, introduction of new agents and I think that the first of those controversies was the combination of Imuran which was of course pioneered by Roy Calne with steroids. There was a great deal of debate about whether steroids were an important part of the conversation. Of course steroids were important because Imuran was too weak to allow survival; ALG which we introduced in 1966 was another one. The cyclosporine story you are very familiar with. Cyclosporine was introduced first and then Sandoz had actually made ad decision to take it off the market because of the tremendous toxicity of the drug as it was originally used, was rescued. Tacrolimus was next. And so any change from the pre-existing status quo inevitable created conflict.

I think the only endeavor that I was ever involved in that could not be brought to fruition was xenotransplantation and who knows where that’s going to go. It’s too late for me to have any say in that.

Thomas Peters: When I was your fellow in 1977 we hospitalized, you and I together, Dr. Bill Waddell with a GI bleed, which thankfully cleared up on its own, but I was the fellow on call that night. And he said something to me that was an amazing tribute to you, maybe one of the best that you don’t know about, you and I have never talked about it. And that is when Bill Waddell recruited you to Colorado, you came out, worked very hard and both of you had in his words, “A lot of fun.” Could you tell us a little bit about your early days in Colorado, how you developed a program in kidney transplantation that was really the first along with David Hume’s of a programatic approach to kidney disease by transplantation?

Thomas Starzl: Well…

Thomas Peters: And how was it fun?

Thomas Starzl: Uh well…I, I think it was fun in a way because it didn’t involve money, it was completely non-commercial and we were both still pretty young. Although Bill was quite aged at the time, but he actually was 39 or 40 and I was quite a bit younger, I was about 6 or 7 years younger than that. But the beginning of my arrival in Colorado I think has to be taken all the way back to Chicago.

Because in Chicago in the summer of 1958, while I was a fellow in cardiovascular surgery there with John Lewis, I carried on some research that I had actually started in Miami at the University of Miami in 1957, which at first was related solely to physiology. I wanted to learn about the qualities, if there were any, in splenetic venous blood, why the liver had a double blood supply of the portal venous supply and the arterial supply. And it was known that if you did a portacaval shunt, the liver shrank, but I had observed also that if you had diabetes, this was in humans, if you did a portacaval shunt, the diabetes sometimes got better. And so I became very interested in the metabolic axis represented by physiologic or metabolic axis of the liver and the pancreas. And liver transplantation or liver replacement was in that context, an experimental model, one in which you could take a liver out and sew it back in.

Originally I thought that could be done as an isograft and completely denervate no question about it and also eliminate all collaterals by taking the damn thing out and putting it back again. But I had discovered in Miami that you really couldn’t do that very easily because you didn’t really have enough cuff to work with in those close quarters near the diaphragm. And I had tried to take the liver in another dog and do a so-called orthotopic transplantation. So when I went to Chicago, I took that up again and in the summer successfully started doing liver replacements.
And I should say that also that Frannie Moore at the Brigham, I believe at almost exactly on the same day and certainly within the same week or month had started a program at the Brigham to do the same thing but with a quite different objective. He actually had greater vision that I did, he was thinking of liver replacement for therapeutic purposes. And now bear in mind there had…We have already discussed these early kidney successes and I gave you a pretty precise date of the first time that a first time a successful kidney allograft was actually transplanted, the date to be more specific was the 24th of January, 1959. And so in the preceding half-year or more, we had been doing liver replacement and no, Joe Murray did that fraternal twin, not identical, and that was the first time in any species that an organ had been transplanted, so organ transplantation in humans was done by Murray when there was no experimental model. And then the French succeeded in the same way the following June. So it was during touchstone period that I was doing liver replacements for initially for metabolic purposes but suddenly I also became in interested in the application of liver replacement as a therapeutic tool. And I had developed all of the models; they are almost identical to the liver transplant procedure being done in humans today. So it was during that period that I met Frannie Moore at a meeting of the American Surgical Association. I met him for the first time in April of 1960 and I expressed a great interest to come to the Brigham and work with him for what I knew was a necessary step to go forward with livers but which was being worked on there by Joe Murray for kidney transplantation, namely immunosuppression. So Moore rejected my advances and so we went our separate ways.

And at the end of, toward the end of 1961 I went out to Colorado and by that time I had contacted Burroughs-Welcome and gotten my own supply of Imuran took it into the lab on a very intensive basis throughout the late winter and early spring and summer of 1962. I found out how to use it, how to most effectively use it and it couldn’t be used alone. The results were, you could get an average survival of 30 days or so with kidney transplantation and that was an important tactical switch at that time.

I first went to Colorado with the determination to check this drug out with livers because that’s where I was going. But I came to realize and rather quickly I might say that this operation of liver replacement in dogs was much too difficult, too fraught with technical problems to evaluate an immunosuppressive drug. So we switched gears and made a tactical, a strategic determination that we would not attempt liver transplantation without succeeding first with kidney transplantation. And all the time, this was still in audio, 1962, we were watching what was going on in Boston and we were in communication with the people in Boston about what was going on with the clinical, first clinical trials of Imuran, the results from which were very poor.

At the Brigham, I think they did the combination of the Imuran trials at the Brigham and in England by Roy. They did four cases in England, were quite discouraging. There was only a single patient out of the first 14 or 15 that lasted for as long as six months and those were all terminated by death. So it looked like the field was, the kidney field was dead in the water and to put it quaintly, I concluded, we concluded in Colorado, Bill Waddell and I did that any trials with liver transplantation would have to go kidney transplant phase first. And that’s really why the kidney program was started; it was considered a preliminary step to liver transplantation.

Thomas Peters: You were at the time the leader of the only other transplant service that really did have a clinically important view, viewpoint in terms of kidney. . .

Thomas Starzl: Well there were three, there were three. The Brigham was the original one and the Brigham program in one form or another had already been there for eight years.

Thomas Peters: Right.

Thomas Starzl: And they had generated an enormous number of cases actually, enormous by the standards of the day, something in the range of 25 or 30 cases all together, first with total body radiation and then their initial trials with 12 or 13 patients with Imuran. The second program that was started was our and Dave Hume’s program started just a few weeks later and Dave Hume and I were in day-to-day contact. Dave was in on these steroids-plus-Imuran secret from the beginning, although he used it in, he used that combination in a different way and it could be used in different ways. What I mean by that is that we reserved the use of steroids for rejection that almost always happened if you treated with Imuran out to that point, so you always had to intervene with steroids. Hume used the steroids from the time of operations, but that was the introduction of double-drug therapy, Imuran and prednisone.

Just because he was such a grand person, I think it would be unjust not to point out the role that Will Goodman played because there had been a fourth program and that was at UCLA attempted by Goodman ion 1960 and 1961. They had generated six cases and all had failed. Five of the six failed abjectly, I mean by that really just a human tragedy, a disaster. But one case had yielded some extremely important information about which I was unaware, which was not public at all and that was the reversal of rejection in the fifth case or the single case with a decent, with an encouraging result.

This was the recipient of a kidney of a young woman from her mother and the kidney functioned for about 139 days and had been prepared unlike any previous case, without irradiation. The patient had been given non-myelotoxic doses of, less than you would do if you were substitution irradiation with Cytoxan. The patient had been given lower doses than that and then given a kidney and then treated with steroids with rejection. On four or five separate occasions, rejection had occurred they had been reversed with steroids. The problem is that case was not reported until 1963, so nobody actually knew about it, although I found out from Goodman about it at the American Surgical Association in April of 1963. But that was really a tragedy because Goodman, Goodman was way ahead of the game but because the program had been just squashed, it didn’t get going again until 1964. So in a sense, there were really four programs.

Thomas Peters: There is a personal vignette that I think might be of interest to people who see this and that is actually where you come from and what your high school class was like. Probably not many members of the ASTS know about a remarkable class, four individuals of which became prominent physicians. Can you just talk a little bit about where you came from in Iowa and what your early education was and who some of your classmates turned out to be?

Thomas Starzl: Well um, Le Mars, Iowa is the city where I was born and raised and almost never left until I joined the navy when I was seventeen years old, that was in 1944. The city had a population right around 5,000. It had a small college, a pretty good one, an evangelical-based college; maybe I should say an Episcopalian-based college. And my father had a newspaper that put out an edition twice, every Monday and Thursday. There was another paper there, an arch-rival and so I grew up in a newspaper family. My father’s brother was, became a famous journalist and the CEO of the Associate Press. So he was a big star, always out there in Rockefeller Plaza in New York City, running around the world and my father was back home running the local newspaper. That probably was an incentive to escape from this small Iowa town.

Now the classes were small and right around 45 or 50 and for some reason, our class had these four guys you mentioned. One of them went on to, Warren Stant went on to be the Chairman of Surgery at the University of Virginia, it was thought to be one of the best orthopedic programs in the country. A guy by the name of Mauer Elvin, Mauer went down to St. Jude’s and was the Hospital Director, Chief Medical Officer there having previously been a professor of pediatrics at the University of indiana. And then Bobby Joint had gone to the University of Rochester as Chairman of Neurosciences, then Dean and then Chancellor, I believe out there. And then I was the black sheep, I was the fourth member. So there, I don’t know that there had up to that point been any physicians produced from Le Mars, Iowa over the preceding 40 years and I doubt if very many afterwards, the supply had been exhausted and that was that.

But people were at various levels of sociology or psychology have from time to time considered doing some little study to see what the hell was going on in Le Mars, Iowa in 1944. But there were other members of the class, there was a young woman named Marian Reese who became the founder and owner of Marian Reese production, which was a Hollywood motion picture group. There was a family, a classmate of mine who formed a company that froze meat from the farmers that were around that part of the country and they were…They were eventually bought up by Bird’s Eye for a couple hundred million dollars. And also members of the Wells family, Wells Ice Cream now it’s marketed as Blue Bunny Ice Cream. Wells Ice Cream to this day makes about 25% of all the ice cream sold in the United States. All of those people were together in a single class, it was an extraordinary class.

Thomas Peters: It must have been something in the water in Le Mars then.

Thomas Starzl: Cyanide

Thomas Peters: Perfect

Thomas Peters: We have talked a little bit about the past of ASTS and of your past and some history of transplantation. Tell us what you think about the future of transplantation and surgery?

Thomas Starzl: Well I think it has a, a bright future. Right now it’s in a…It’s in a troubled period because there is a tremendous transition going on as you and I have, Tom, have been discussing at least briefly in the way that medicine is practiced in that it has become a business. Maybe it’s been forced into that position, but the way in which it’s practiced is so different than, than existed in the ‘60’s which is that formative period. I don’t think that transplantation could have vaulted to the position that it did under today’s circumstances. And if it hadn’t happened in the states, I don’t think it would have happened worldwide, so the United States took a big lead and part of the reason was the way that medicine existed in the ‘60’s. And that’s not a criticism, it’s not a whine, I think it’s a realistic view of things and I think I have heard that analysis by other, particularly Frannie Moore on more than one occasion.

But now we’ve got something that works, it works very well and it has evolved into a business and that, too, is a necessity because nothing can be woven into the fabric of medicine unless it can sustain itself economically. But that aspect of it, I think puts some limitations on what will be accomplished next. The ceiling on transplantation is currently imposed on organ supply and that can be relieved in only two or three self-evident ways, greater use of live donation which carries its own liability and artificial organs, maybe stem-cell research. So in some respects, we’re at a stage in which, a stage or Brownian movement in which the meetings get bigger but the substance of genuine innovation and advancement has declined to the point that people might tend to get discouraged.

However I see a bright future, I already said that because I think certain kinds of transplantations will be done in large numbers down the line and those are the somatic transplants, the so-called composite transplant procedures. I think they will be done in larger numbers if immunosuppression protocols are applied that abstemiously avoid heavy multiple-drug immunosuppression. And with the insight that we now have about what are the mechanisms of alloengraftment and with the recognition that alloengraftment as we can do it is a form of tolerance.

I think it will be possible to do these somatic transplant procedures in large numbers and if so, the next big practical piece of transplantation is going to be limb, face, that kind of transplantation which has only just put its head above the horizon. The number of limb transplants for example that have been done up to the present time, worldwide, even including China, is only right around I think about 50. And as far as I know, the number of face transplants and these I think are limited to France are only two or three. But we, the ASTS in particular, should be very aware of what’s going on here. Because as has been the past history of transplantation, the cutting edge in this new area has been done by surgeons. And one of the most prominent of those surgeons is Max Dubernard, whose got trails running all the way back to a fellowship with Joe Murray and not a small one, a three-year fellowship with Joe Murray back in the mid-1960’s.

So that is a practical piece of transplantation that is still waiting to be developed and it’s development is going to depend upon exploitation of the insight that we now have about what actually are the mechanisms of alloengraftment. You and I…When I was and now that you still are in practice, most people at least during all of the time I was in practice had no idea at all why transplantation worked. You did it; it was pretty obvious your enemy was rejection. You attacked the enemy with the bullets you had, those were the immunosuppressive drugs. You learned empirically how to do that and you were off and running.

That wasn’t good enough to take the next step but we do, I believe, understand what the mechanisms are, those are pretty thoroughly explained in a little paper that I published in a January article this year of the New England Journal of Medicine. And all you have to do is to exploit those mechanisms and I think you can greatly reduce the amount of immunosuppression that you have to give. That is where transplantation will go and if it goes that way it will have a big effect in other somatic areas such as skin replacement for otherwise lethal burns.

Thomas Peters: Finally from us, there was not much regulation in transplantation when it began in your hands. Can you comment on some regulatory matters that you see as important and in particular, the evolving issue and changing minds as related to financial incentives in both cadaveric and living donor transplantation, living donation?

Thomas Starzl: Well my answers are always way too long and they’ll have to be thoroughly edited. But to get to the first issue, that is regulation. I think the regulation has become deadly, it’s stifling. The assumption when the field was developing that just about everybody that, the people doing this original work were highly ethical people. I don’t know of a single scoundrel that I worked with or knew that was in the field and there were pretty good reasons for that. In order to even work in the field, to work in the field when you got into it, you had to pay a price, commit yourself to poverty so there was no financial gain. But I still think there is a high-level of ethics in transplantation and to have repullulations in place and then being manipulated by various people creates an unnecessary burden. I don’t know if we can do anything about it because it’s so hard to get consensus about just about anything.

I’m not going to mention what center was involved or the surgeons or even what the circumstance are, but there was a newspaper article yesterday, you probably saw it about a liver Transplantation being carried out in “mafia” members in another country. You can, the people involved and the center involved is a high-class center and certainly had no idea of who they were treating. In the defense of what was done, treatment of those patients is that we do not make moral judgements on our patients, an absolutely correct way of addressing that problem. But it does make it tough to do anything or to make any change or further step to have that much, to have that much in the way of regulatory oversight.
So now the second…?

Thomas Peters: The Society as well as other interested in organ donation and transplantation…

Thomas Starzl: Well I have actually never had anything to say about that publicly because again, it’s one of those things that automatically generate attack and it doesn’t matter which side you’re on. But this is such an important issue that I’ll tell you what my position has been all along. I think that the idea that, that when a scare resource becomes available and is freely given by a family, by bereaved family members when somebody is killed under the circumstances that generate good organs, that precious resource generates a business in which everybody down the line profits, that’s really not the right word. That everyone down the line has to be paid in order for the whole enterprise to go forward. And it has always seemed to me…Not entirely logical to believe that the only persons that can’t derive some economic support from the process are the people that have suffered the most or have been the most virtuous or the most community-minded, namely the donor or donor family.

So great empires have been built out here based on this resource and the idea that you shouldn’t allow some kind of a remuneration, even for paying the cost of a funeral as a reward for that generosity just seems to me to be preposterous. So that’s just an example of course, there are all kinds of ways that you could twist organ donation in a way that would be construed as brokering or buying of organs. But as a simple principle, I think that people are the origins of the resource should be allowed to have some remuneration.

Thomas Peters: Is there anything you want to include in this tape that we have not talked about? Have you brought a topic to the morning session that you want to just say a few words about?

Thomas Starzl: Well I always had a fiery agenda up until I was 80 and now I think it would be the height of folly to bring something to your attention that you might feast on, so the answer is no.

Thomas Peters: I was just wondering if Dr. McCabe had any questions?
Robert McCabe: Well I want to ask Tom to tell us about the future of xenotransplantation.

Thomas Starzl: Well…I don’t know what the future of xenotransplantation is going to be, but my view of it is much less optimistic than it was ten years ago. Ten years ago, by ten years ago it had been identified, it had been learned what the seminal barrier was to xenotransplantation from lower mammals to humans and that’s the alpha-gal epitope, a small oligosaccharide that’s got a peptide hooked onto it. And it also was discovered exactly what the nucleotide sequence was and also how to knock it out and so a combined small biotech company called, now called Revivicor in collaboration with our group in Pittsburgh knocked out the gene on the eve of the Miami meeting of 2002.

In fact, on the 25th of July, 2002, the first batch of alpha-gal negative pigs was born and everybody could hardly wait ‘til they would grow up and could be tested by putting their kidneys into sub-human primates. It was predicted and it came true that the hyperacute rejection of pig kidneys in baboon or monkey recipients did not occur. But down the line about a week later, there was a rejection that was just as bad, although it was a slow-motion variant and is just as uncontrollable by back-up sugar nucleotides, now not alpha-gal but something else, all-sugar nucleotides that precluded the use of these organs. So instead of being on the doorstep of xenotransplantation, it seemed just as far away as ever, perhaps more.

So what we did was to develop a strategy of determination in evolution, determining in evolution when the alpha-gal gene responsible for this gene product, this alpha-gal gene product, when in the course of evolution it was knocked out. And it was knocked out about 25 million years ago, it was inactivated. But we also learned that there were many other gene mutations that occurred at that time and of course that means that a lot of things would have to be changed over and beyond simply knocking out the alpha-gal. And when you start adding on other modifications, you sooner or later get to the point where you have a mutant lethal mutation and then you’re stopped.

So I think the long and short of it is that kind of research has created a whole new field of molecular evolution that can be looked at which tells us how it is we humans got to be how we are by virtue of mutation that include perhaps maybe above all, this alpha-gal mutation. But that would seem to me to put the prospects of actually duplicating this feat that occurred in nature in our own hands farther away. So do answer your question, Bob, I think that the prospects of xenotransplantation are probably inferior to some kind of relief of the organ shortage by some development in stem cell biology. But I think we are looking down the pipe a long distance before anything like that can come forward, especially because of the regulatory restrictions that we face, where any little step, no matter how small, has got to. . . Forces us to jump through multiple regulatory hoops. So I think for the time being, I see the grand vision of much more along the lines of what I told you of before of getting into new areas of transplantation, exploiting what we now know to be the mechanisms of alloengraftment rather than any immediate payoff from xeno or stem cell biology.

Thomas Peters: The only thing I was wondering was sort of…I mean you have been in it for such a long time, is there ever any like, well I guess a particular surgery or something that you kind of wished you had been part of and that you weren’t? Like I don’ know, the first heart transplant of you know is there any like particular achievement in the field where you are like, “Wow, I wish I had been there when they did that”?

Thomas Starzl: Well I think I had…Well Tom knows better than most people that I was involved in…
Thomas Starzl: Oh yes, the saying Tom knows better than most people because he was there in the ‘70’s that I actually was involved in so many things that some kind of disappointment about missing something would be kind of unrealistic. You probably know that when heart transplantation was being done, heart transplantation was the natural successor that came along and was really made possible by liver transplantation. Liver transplantation was first unsuccessfully over the 4th of July week of 1997 and there were…

And at our place, we had recruited George Pappas, you recall specifically to go forward with the next organ of hearts. And Norm Shumway was poised in Palo Alto while they were all looking not only at the results with liver transplants, but how the liver transplant had been made to work. And above all, that had included the development of ALG to be added to Imuran and prednisone. So in the meantime, Chris had come over here from South Africa and now there were three groups that were sitting there and I did…And also there was a group in New York perched there all at the starting line and I really never thought it was important who did the first one. What was really important was who stayed with the heart transplants and that was Norm.

So now the question you asked me was I sorry that I missed out on anything? Christ, you’d have to be some kind of a megalomaniac to get involved in more things. I think I was involved in too many things perhaps.

Thomas Peters: I think you did just fine. (Laughs) Anything else? Just so the room knows, I met Dr. Starzl when I was a junior medical student in 1968 in Cincinnati in a room with two or three other surgeons. They were doing that heterotopic transplant on a little girl and you were in Cincinnati for the American College of Surgeons meeting and came up to Children’s Hospital and you watched Les Martin do that, arguing he ought to do an orthotopic transplant, he did not. The donor was my first experience scrubbing on any transplant, it was an anencephalic. The recipient lived for about two months. Thank you very much.

Thomas Starzl: You’re welcome.

End of Starzl]