Q. I just had a quick question for you. Our notes say that a ductus arteriosus allows flow from the pulmonary artery to the aorta, which I knew. However, they also say that it’s a left to right shunt, and that it can become right to left. This confuses me, since from what I know, flow would be going from right (pulmonary artery) to left (aorta).

A. When we talk about the ductus allowing flow from the pulmonary artery (right) to aorta (left), we’re talking about intrauterine flow through the ductus. Before birth, the pressure on the right side of the heart is greater than the pressure on the left – so blood flows from pulmonary artery to aorta (through the ductus).

After birth, though, the pressure on the left becomes greater than the pressure on the right. In most babies, the ductus closes (probably in response to the new levels of oxygen in the blood). In some babies it remains patent, in which case flow would now be from the aorta (left; higher pressure) to the pulmonary artery (right; lower pressure).

If the ductus is widely patent, then after a while, that left to right shunt can put enough pressure on the lungs that they react by closing down vessels, effectively making it more difficult to push blood through. Now the right heart has to work really hard to push blood through the lungs – and it can get to the point where the right heart is actually bigger and stronger than the left, making the shunt reverse and go from pulmonary artery (right; higher pressure) to aorta (left; lower pressure).