# Letter to the Editor: Pulmonary circulation abnormalities in post-acute COVID-19 syndrome and acute vascular distress syndrome

Vincent Jounieaux, Daniel Rodenstein, Yazine Mahjoub

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Vincent Jounieaux, Daniel Rodenstein, Yazine Mahjoub. Letter to the Editor: Pulmonary circulation abnormalities in post-acute COVID-19 syndrome and acute vascular distress syndrome. European Radiology, 2024, 34 (6), pp.4189-4190. 10.1007/s00330-023-10349-0. hal-04321676

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"Letter to the Editor: Pulmonary circulation abnormalities in post-acute COVID-19 syndrome and acute vascular distress syndrome."

Jounieaux, Vincent ; Rodenstein, Daniel ; Mahjoub, Yazine

ABSTRACT

DEAR EDITOR, We read with interest the recent study by Mohamed I. et al published in European Radiology. In this retrospective, non-interventional observational study, the authors described the morphofunctional changes at the level of the pulmonary circulation in 79 patients who remained symptomatic more than 6 months after hospitalization for SARS-CoV-2 pneumonia. [...]

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Jounieaux, Vincent ; Rodenstein, Daniel ; Mahjoub, Yazine. Letter to the Editor: Pulmonary circulation abnormalities in post-acute COVID-19 syndrome and acute vascular distress syndrome. In: European radiology, Vol. 34, no.6, p. 4189-4190 (2024) http://hdl.handle.net/2078.1/289611 -- DOI : 10.1007/s00330-023-10349-0

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# Letter to the Editor: Pulmonary circulation abnormalities in post-acute COVID-19 syndrome and acute vascular distress syndrome

Vincent Jounieaux<fnref n="1" />* ID, Daniel O. Rodenstein<fnref n="2" /> and Yazine Mahjoub<fnref n="3" />

Dear Editor,

We read with interest the recent study by Mohamed I. et al published in *European Radiology* [1]. In this retrospective, non-interventional observational study, the authors described the morpho-functional changes at the level of the pulmonary circulation in 79 patients who remained symptomatic more than 6 months after hospitalization for SARS-CoV-2 pneumonia. COVID-19 is well known for inducing not only pulmonary alveolar lesions but also pulmonary vascular ones [2]. At the acute phase, the pulmonary perfusion abnormalities are mixed and varied, including areas of hypoperfusion related or not to pulmonary embolism and areas of increased perfusion [3]. At the post-acute phase, it is interesting to note that the most frequent pulmonary perfusion abnormalities observed by Mohamed I. et al were areas of increased perfusion [1]. Such areas were found in 59 patients (74.9%), always superimposed on areas of GGO (58/59), areas of band-like opacities (51/59), and/or areas of vascular tree-in-bud (5/59). Lung vascular impairments

are known to be specific of COVID-19 infection that leads to a typical pulmonary neoangiogenesis [4] with increased pulmonary blood flow [3] and volumes [5]. All these changes result in a characteristic intrapulmonary shunt (as observed in hepatopulmonary syndrome [6]) which explains the singular presentation of the disease (happy hypoxia, preserved pulmonary compliance, efficacy of prone position despite absence of pulmonary recruitment, relative inefficiency of pulmonary vasoelators, efficiency of pulmonary vasoconstrictors, etc.). Thus, as COVID-19 infection appears more a vascular than a pulmonary disease, we proposed the acronym “AVDS” (for acute vascular distress syndrome) to designate the specific increased lung blood flow (arterial and pulmonary) that leads to a symptomatic intrapulmonary shunt [7]. Contrast-enhanced transthoracic echography and/or transcranial Doppler ultrasound is able to detect this specific COVID-19-related intrapulmonary shunt that we found in more than 40% of patients hospitalized for COVID-19 pneumonia in intensive care unit (ICU) (personal data, submitted). COVID-19 symptoms usually persist less than 4 weeks and presumably also the intrapulmonary shunt. In this context, we reported significant PaO₂:FiO₂ ratio improvement in ICU COVID-19 patients despite worsened or stable chest imaging variables [8]. However, in their study, Mohamed I. et al did not found any association between the finding of areas of increased perfusion and quartiles of time elapsed between the date of hospitalization and chest CT examination (p = 0.58) [1]. In a symptomatic 44-year-old patient, a persistent right-to-left shunt has been found 45 days after a COVID-19 infection [9] but, to the best of our knowledge, data from Mohamed I. et al are the first

This is a Letter to the Editor referring to the article that is available at https://link.springer.com/article/10.1007/s00330-023-09618-9.

<footnote>*Correspondence:</footnote>

<footnote>Vincent Jounieaux
jounieaux.vincent@chu-amiens.fr</footnote>

<footnote n="1">¹ Respiratory Department, Amiens University Medical Centre, 1, Rond-point du Pr Cabrol, 80054 Amiens, France</footnote>

<footnote n="2">² Respiratory Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium</footnote>

<footnote n="3">³ Respiratory Department, Cardiac Vascular Thoracic and Respiratory Intensive Care Unit, Department of Anaesthesia and Critical Care, Amiens University Medical Centre, Amiens, France</footnote>
to support the hypothesis that COVID-19-related angio-
genesis can persist for a longer time (16 CT findings of
areas of increased perfusion in quartile 4: 8.8 months) [1].
In these patients, it would be of interest to propose a con-
trast-enhanced transthoracic echocardiography to check
the relationships between the persistent vascular abnor-
malities and the presence of a symptomatic intrapulmo-
nary shunt. If such examinations were not proposed (as
we believe), DLCO can be also useful to answer this point
as DLCO is known to be decreased not only in case of
pulmonary sequelae (fibrosis) but also in case of intrapul-
monary shunt [10]. In their study, the authors found that
49.2% of their cohort had decreased DLCO. The propor-
tion of patients with decreased DLCO appeared greater
among patients with abnormal perfusion (n = 29; 53%)
compared with patients with normal perfusion (n = 1;
14%) [1]. It will also be interesting to compare DLCO
between patients with areas of increased perfusion alone
and patients with normal perfusion.

To conclude, according to the high proportion of increased perfusion areas observed by Mohamed I. et al (> 70%) [1], we propose to perform a contrast-enhanced transthoracic echocardiography in patients who remain symptomatic ≥ 3 months after a COVID-19 infection, even in absence of initial lung infiltration or complete resolution of parenchymal lung lesions. In case of persistent AVDS-related intrapulmonary shunt, the treatment is currently not known (3 months anticoagulation and/or steroids therapy?).

Funding

The authors state that this work has not received any funding.

Declarations

Guarantor

The scientific guarantor of this publication is Vincent Jounieaux.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

**Informed consent**

No informed consent was necessary for this paper.

Ethical approval

No ethical approval was necessary for this paper.

Study subjects or cohorts overlap

Not applicable

Methodology

• Letter to the Editor

Received: 23 May 2023 Revised: 23 May 2023

Accepted: 21 August 2023 Published online: 10 November 2023

References

1. Mohamed I, de Broucker V, Duhamel A et al (2023) Pulmonary circulation abnormalities in post-acute COVID-19 syndrome: dual-energy CT angiographic findings in 79 patients. Eur Radiol; 1-13. https://doi.org/10.1007/s00330-023-09618-9

2. George PM, Desai SR (2021) COVID-19 pneumonia and the pulmonary vasculature: a marriage in hell. Eur Respir J 58:2100811

3. Lang M, Som A, Mendoza DP et al (2020) Hypoxaemia related to COVID-19: vascular and perfusion abnormalities on dual-energy CT. Lancet Infect Dis 20(12):1365–1366

4. Ackermann M, Verleden SE, Kuehnel M et al (2020) Pulmonary vascular endothelialitis, thrombosis, and angiogenesis in COVID-19. N Engl J Med 383(2):120–128

5. Fahrni G, Rocha A-C, Gudmundsson L, Pozzessere C, Qanadli SD, Rotzinger DC (2023) Impact of COVID-19 pneumonia on pulmonary vascular volume. Front Med. 10:1117151

6. Rodríguez-Roisin R, Krowka MJ (2008) Hepatopulmonary syndrome-a liver-induced lung vascular disorder. N Engl J Med 358(22):2378–87

7. Mahjoub Y, Rodenstein DO, Jounieaux V (2020) Severe COVID-19 disease: rather AVDS than ARDS? Crit Care 24(1):327

8. Basille D, Auquier MA, Andréjak C et al (2021) Dissociation between the clinical course and chest imaging in severe COVID-19 pneumonia: a series of five cases. Heart Lung 50(6):818–824

9. Jounieaux V, Basille D, Abou-Arab O et al (2021) Pure SARS-CoV-2 related AVDS (acute vascular distress syndrome). BMC Infect Dis 21(1):122

10. Rodríguez-Roisin R, Krowka MJ, Agustí A (2018) Hepatopulmonary disorders: gas exchange and vascular manifestations in chronic liver disease. Compr Physiol 8(2):711–729

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