Pulmonary veno-occlusive disease: An important consideration in patients with pulmonary hypertension

Diagnostic enigma of pulmonary hypertension: Tale from a series of three patients

Pulmonary hypertension (PH) is a complex condition with multiple etiological factors. The ability to identify a potential underlying cause is crucial for accurate diagnosis, patient management, and prognostication. This article presents a series of three patient cases to illustrate the enigmatic nature of PH diagnosis. Understanding the enigmatic nature of PH and implementing focused clinical evaluation and protocol-driven management are crucial in deciphering this complex condition. By unraveling the mysteries surrounding PH, we can pave the way for effective interventions and better patient care.

Occurrence and role of lung megakaryocytes in infection and inflammation

Megakaryocytes (MKs) are large cells giving rise to platelets. It is well established that in adults, MKs develop from hematopoietic stem cells and reside in the bone marrow. MKs are also rare but normal constituents of the venous blood returning to the lungs, and MKs are found in the lung vasculature (MK_circ), suggesting that these cells are migrants from the bone marrow and get trapped in lung capillaries where the final steps of platelet production can occur. An unprecedented increase in the number of lung and circulating MKs was described in coronavirus disease 2019 (COVID-19) patients, suggesting that lung thrombopoiesis may be increased during lung infection and/or thromboinflammation. In addition to the population of platelet-producing intravascular MKs in the lung, a population of lung-resident megakaryocytes (MK_L) has been identified and presents a specific immune signature compared to its bone marrow counterparts. Recent single-cell analysis and intravital imaging have helped us gain a better understanding of these populations in mouse and human. This review aims at summarizing the recent data on increased occurrence of lung MKs and discusses their origin, specificities, and potential role in homeostasis and inflammatory and infectious lung diseases. Here, we address remaining questions, controversies, and methodologic challenges for further studies of both MK_circ and MK_L.

Paravasal Connective Tissue Parameters Vs. Morpho-Functional Indicators In The Intraorgan Blood Vessels Of The Younger Men Lungs

Objective — The objective of this research was to identify correlations between the paravasal components connective tissue of the blood vessels of lungs and their morpho-functional parameters. Material and Methods — In order to determine the structure of the paravasal connective tissue, the histotopographic and histological examination of lung preparations of 20 men corpses of the first mature age period was held, to determine the capacity and capacitive characteristics of the vascular bed, the determination of the Kernogan index (IK) and the veno-arterial index (VAI) were carried out. Results — It was ascertained that in the structure of the paravasal connective tissue two layers could be conditionally distinguished – the "central" and "peripheral", differing in the architectonics of the fibrous component, the nature of interaction with nearby anatomical structures. It was also revealed that infrared venous vessels IK was expressed in a greater degree in comparison with arterial. When determining VAI vascular, the channel revealed that the area of venous vessels prevailed over the arterial area. Besides, the clear correlation relationships of the structural elements of the paravasal connective tissues were investigated with arterial and venous vessel capacity values and their capacitive characteristics. Conclusion — The presence of correlation relationships confirmed a clear interaction between structural organization of the paravasal connective tissue and the functional activity of the blood vessels, providing optimal hemodynamic conditions in the organ.

Anesthesia for pulmonary veno-occlusive disease: the dilemma and what we should know as anesthesiologists: A case report

INTRODUCTION

Pulmonary veno-occlusive disease (PVOD) is a rare form of pulmonary hypertension. It is often underdiagnosed or misdiagnosed as idiopathic pulmonary arterial hypertension (PAH). Inappropriate treatment may cause worsening of symptoms which may lead to fatal outcomes. Anesthetic considerations and management for pulmonary hypertension are well described, but few anesthesiologists are aware of the entity of PVOD and its management.

PATIENT CONCERNS

We report a case of PVOD in a 73-year-old female who was on concurrent aspirin and anagrelide, requiring emergent open femoral hernia repair.

DIAGNOSIS

PVOD and incarcerated femoral hernia INTERVENTION:: Combined spinal-epidural (CSE) was performed to enable the surgery.

OUTCOME

Surgery was completed successfully under central neuraxial anesthesia and the patient remained stable and comfortable throughout, avoiding the need for general anesthesia. Due to the concurrent aspirin and anagrelide therapy, significant bleeding from the CSE puncture site was observed immediately post-operatively. This was resolved with external manual compression and withholding the aspirin and anagrelide. Patient remained well without neurological deficit and was discharged postoperative day seven.

LESSONS

It is important to differentiate PVOD from PAH due to the controversial use of pulmonary vasodilators in PVOD. Pulmonary vasodilator is commonly used to treat acute pulmonary hypertension in PAH but its usage may lead to pulmonary edema in patients with PVOD. Hence, with no ideal treatment available, the avoidance of general anesthesia is crucial to prevent acute pulmonary hypertensive crisis in patient with PVOD. However, this needs to be weighed against the elevated risk of central neuraxial bleeding when performing a CSE in a patient on concurrent aspirin and anagrelide therapy. Calculated decision-making considering the risks and benefits of all alternatives should be carried out in such a scenario, and measures should be taken in anticipation of the potential consequences of the eventual decision.

CONCLUSION

It is important to differentiate PVOD from PAH. PVOD has unique anesthetic considerations due to the controversial use of pulmonary vasodilators. This case also emphasizes the importance of active anticipation of potential issues and adequate follow up.

Cross-sectional imaging of congenital pulmonary artery anomalies

Congenital pulmonary artery (PA) anomalies comprise a rare and heterogeneous spectrum of disease, ranging from abnormal origins to complete atresia. They may present in early infancy or more insidiously in adulthood, often in association with congenital heart disease such as tetralogy of Fallot or other syndromes. In recent years, cross-sectional imaging, including computed tomography (CT) and magnetic resonance imaging (MRI), has become widely utilized for the noninvasive assessment of congenital PA diseases, supplementing echocardiography and at times supplanting invasive angiography. In this article, modern CT and MRI techniques for imaging congenital PA disorders are summarized. The key clinical features, cross-sectional imaging findings, and treatment options for the most commonly encountered entities are then reviewed. Emphasis is placed on the ever-growing role of cross-sectional imaging options in facilitating early and accurate diagnosis and tailored treatment.