Retrograde lower body arterial reservoir discharge underlies rapid reversal of ductus arteriosus shunting after early cord clamping at birth in preterm lambs

Arterial reservoir (windkessel) function, whereby a part of left ventricular (LV) output is stored in elastic arteries during systole and discharged in diastole, is a well-established physiological phenomenon. However, its role in rapid reversal (to left-to-right) and a systolic-to-diastolic shift of shunting across the ductus arteriosus after birth is unknown. To address this question, ductal and aortic isthmus flows were measured with high-fidelity transit-time probes in six anesthetized preterm fetal lambs before and after cord clamping and subsequent early mechanical ventilation and for 30 min postbirth. Descending aortic flow was calculated as the sum of isthmus and ductal flows. Left-to-right ductal flow profiles were related to those of the isthmus and descending aorta, with upper body arterial reservoir discharge indicated by forward diastolic isthmus flow, and retrograde lower body arterial reservoir discharge by negative diastolic descending aortic flow. Left-to-right ductal shunting appeared immediately after cord clamping (P < 0.001), due entirely to newly emergent retrograde lower body reservoir discharge, and rose with ventilation via increased lower body reservoir discharge (P < 0.005), supplemented by upper body reservoir discharge after 45 s (P < 0.025) and LV systolic flow after 3 min (P = 0.025). The contribution of lower body reservoir discharge to left-to-right ductal shunting fell to 55 +/- 8% at >= 15 min (P < 0.001) but remained higher (P < 0.002) than LV systolic flow (33 +/- 8%) or upper body reservoir discharge (12 +/- 5%). These results suggest that retrograde lower body arterial reservoir discharge plays a key role in rapid reversal and a systolic-to-diastolic shift of ductal shunting after cord clamping and early ventilation at birth.