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You Be the Surgeon

On November 29, 1944, a gravely ill baby named Eileen Saxon was wheeled into an operating room at Johns Hopkins Hospital. She was to become the first recipient of the Blalock-Taussig shunt, a new operation designed to save "blue babies." Eileen's blue complexion and severe weakness came from a congenital, fatal heart malformation called Tetralogy of Fallot.

In these blue babies, not enough blood was getting to the lungs. The pulmonary artery, which directs blood there, was exceptionally narrow where it connected to the heart, a condition known as pulmonary stenosis. The victims of this ailment rarely lived more than a few years.

A pediatrician at Johns Hopkins, Dr. Helen Taussig, approached Dr. Alfred Blalock to suggest a surgical remedy for the condition. They came up with a radical idea -- to bypass the malformation altogether. Vivien Thomas set up experiments in the lab to develop the procedure before it was first performed on nine-pound Eileen Saxon.

Now you can enter the operating room and don the surgeon's scrubs. You'll have the same set of tools used by the original Hopkins surgical team.

A Normal Heart
In a normal heart, the blood circulates through the right ventricle and into the pulmonary artery, which then directs the blood to the lungs to get oxygen. After passing through the lungs, the blood re-enters the heart, goes through the left ventricle to the aorta, and then circulates through the body. This process is what makes the heart one of the most complicated and remarkable organs in the body.

A Blue Baby Heart
In a Blue Baby heart, there are four defects that usually occur simultaneously as Tetralogy of Fallot (Blue Baby syndrome). They are:

  1. pulmonary stenosis, a narrowing at the opening of the pulmonary artery that constricts the flow of blood to the lungs.
  2. ventricular septal defect (VSD), a hole in the septum or wall between the ventricles that allows mixing of the blood between the two chambers which causes de-oxygenated blood to be sent into the body.
  3. right ventricular hypertrophy, an overdevelopment of the right ventricle as it works harder to overcome the handicaps of stenosis and VSD.
  4. an overriding aorta, which exacerbates the VSD, causing more mixing of blood between the ventricles.

The victims of this condition, called "blue babies," are cyanotic, often tired and listless, and capable of only limited physical activity. Before 1944, there was no way to help victims of this malformation, and they rarely lived more than a few years.

Groundbreaking Surgery
Alfred Blalock, Helen Taussig, and Vivien Thomas found a solution to Tetralogy of Fallot -- bypassing the defect altogether. Their procedure involved cutting the subclavian artery and attaching it to the pulmonary artery. Blood would travel along this new pipeline into the lungs, become oxygenated, and then continue into the rest of the body. The shunt saved many thousands of lives, but it was only a temporary fix. Not until the advent of open heart surgery in the 1950s was a total correction possible.

Your Turn to Operate
Now get ready to perform the Blalock-Taussig Shunt just as Dr. Blalock and his team did on November 29, 1944. Good luck!

  • Use the scalpel to make an incision underneath the fourth rib.

  • Use the rib spreader to retract the ribs.

  • You cannot cut through the ribcage to reach the heart. However, the ribs are very flexible and can spread up to four inches in an infant. This will be plenty of room to complete the operation. Once the rib spreader is in place, you will see the left lung. You will have to move the lung out of the way to get to the next step.

  • Once the lung is out of the way, you will see the mediastinal pleura. To get to the heart and the greater vessels, you have to cut through the pleura. Use the scissors to make an incision in the mediastinal pleura.

  • Clamp the subclavian artery.

  • Now that you have a clear view of what you are operating on, you will want to occlude, or clamp, the subclavian artery. This is necessary to impede the flow of blood through the vessel so that little blood is lost when you cut through the artery in the next step. Take the small clamp from the instrument panel and place it where the subclavian joins with the aorta and the heart.

  • Divide the subclavian artery with the scissors.

  • Follow the subclavian artery as far distally as you can see. This is where you will want to cut the artery, giving you the required length to attach it to the pulmonary artery later in the operation. Notice that the adventitia will be pulled back around where you cut. The adventitia can cause clotting and might make it difficult to attach the subclavian to the pulmonary artery later in the operation.

  • Clamp the pulmonary artery with two clamps, isolating a segment.

  • Use the two remaining clamps to occlude a section of the pulmonary artery. This will isolate a small segment of the pulmonary artery for your incision.

  • Make an incision in the pulmonary artery.

  • Take a scalpel and make a four to five millimeter incision in the pulmonary artery.

  • Suture the subclavian artery into the pulmonary artery. This is the most important part of the operation -- the anastomosis of the subclavian artery to the pulmonary artery. Using your sutures, sew the severed end of the subclavian into the incision you made in the pulmonary artery.

  • Remove the clamps and watch as the child turns pink.

  • Once the sutures are tight, remove the clamps. Blood from the subclavian artery will flow freely into the pulmonary artery, and from there into the lungs. The patient should react almost immediately as fully oxygenated blood moves through her body for the first time.

  • The operation has worked! Detach the rib spreader.

  • Suture the incision made in the child's chest.

Congratulations!
You have successfully performed the Blalock-Taussig Shunt.



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