Palliative operation for malformations of the heart, commonly used for children born with Fallot's tetralogy - «blue baby» syndrome. It consists of anastomosis of the subclavian artery to the pulmonary artery, bypassing the pulmonary stenosis so that a part of the hypoxemic aorta blood is supplied to the heart.
The operation was first successfully performed on November 29, 1944: anastomosis between arteria subclavia and arteria pulmonalis in a case of Fallot's tetralogy.
Alfred Blalock's report:
Nov. 29, 1944.
Dr. Alfred Blalock
Ether – Oxygen – Dr. Harmel
ANASTOMOSIS OF LEFT PULMONAL ARTERY TO LEFT SUBCLAVIAN ARTERY
This patient was an undernourished child who had cyanosis on frequent occasions. The diagnosis was pulmonary stenosis.
Under ether and oxygen, administered by the open method, an incision was made in the left chest extending from the edge of the sternum to the axillary line in the third interspace. The second and third costal cartilages were divided. The pleural cavity was entered. The left lung looked normal. No thrill was felt in palpating the heart and pulmonary artery. The left pulmonary artery was identified and was dissected free of the neighboring tissues. The left pulmonary artery seemed to be of normal size. The superior pulmonary vein, on the other hand, seemed considerably smaller than normal to me. I had hoped that the artery to the left upper lobe might be sufficiently long to allow an anastomosis, but this did not appear to be the case. The left subclavian artery was then identified and was dissected free of the neighboring tissues. The vertebral artery and the branches of the thyrocervical axis were doubly ligated and divided. The subclavian was so short that there would not have been sufficient length for our purpose, had this not been done. The subclavian artery was then ligated distal to the thyrocervical trunk. A bulldog clip was placed on the subclavian artery at a point just distal to its origin from the aorta. The subclavian artery was then divided just proximal to the ligature. Two bulldog clips were then placed on the left pulmonary artery, the first clip being placed at the origin of the left pulmonary artery, and the second clip being placed just proximal to the point where the artery entered the lung. There was ample space between these two clips for our purpose. A small transverse incision was then made in the wall of the pulmonary artery. By the use of china beaded silk on fine needles, an anastomosis was then performed between the end of the left subclavian artery and the side of the left pulmonary artery. A posterior row of sutures was placed first. There was practically no bleeding g following the removal of the bulldog clips.
The anastomosis seemed to be a satisfactory one, and the main point of worry comes from the small size of the left subclavian artery. I was disturbed because I could not feel a thrill in the pulmonary artery after the clips were removed. I do not believe this was due to any clot in the subclavian artery, because it seemed to pulsate vigorously. It is possible that it was due to a low pressure in the systemic circulation. I do not actually know what the systemic pressure was. Another possibility was that it might have been due to spasm of the subclavian artery. My only regret was that the subclavian artery was not bigger. It is possible that the increased red cell count in this patient may have predisposed to thrombosis.
– 2 –
Sulfanilamide was placed in the left pleural cavity. This was followed by closure of the incision in the chest wall. The third and fourth ribs were approximated by two encircling sutures of braided silk. The soft tissues of the wall were closed in layers with silk sutures.
The patient stood the procedure better than I had anticipated. It is interesting that the cyanosis did not appear to increase very greatly from the temporary occlusion of the left pulmonary artery. It is also of interest that the circulation in the nail beds of the left hand appeared to be fairly good at the completion of the operation.
I did not attempt to visualize the left common carotid artery. It is possible that this would have been bigger than the left subclavian. This child was very small and I am confident that the subclavian artery would be more easily dealt with in a larger child.
- A. Blalock, H. B. Taussig:
The surgical treatment of malformations of the heart in which there is pulmonary stenosis or pulmonary atresia.
The Journal of the American Medical Association, Chicago, 1945, 128: 189-202.