Vasculopathy and Increased Vascular Congestion in Fatal COVID-19 and Acute Respiratory Distress Syndrome

The leading cause of death in coronavirus disease 2019 (COVID-19) is severe pneumonia, with many patients developing acute respiratory distress syndrome (ARDS) and diffuse alveolar damage (DAD). Whether DAD in fatal COVID-19 is distinct from other causes of DAD remains unknown. To compare lung paren...

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Published in:	American journal of respiratory and critical care medicine Vol. 206; no. 7; pp. 857 - 873
Main Authors:	Villalba, Julian A, Hilburn, Caroline F, Garlin, Michelle A, Elliott, Grant A, Li, Yijia, Kunitoki, Keiko, Poli, Sergio, Alba, George A, Madrigal, Emilio, Taso, Manuel, Price, Melissa C, Aviles, Alexis J, Araujo-Medina, Milagros, Bonanno, Liana, Boyraz, Baris, Champion, Samantha N, Harris, Cynthia K, Helland, Timothy L, Hutchison, Bailey, Jobbagy, Soma, Marshall, Michael S, Shepherd, Daniel J, Barth, Jaimie L, Hung, Yin P, Ly, Amy, Hariri, Lida P, Turbett, Sarah E, Pierce, Virginia M, Branda, John A, Rosenberg, Eric S, Mendez-Pena, Javier, Chebib, Ivan, Rosales, Ivy A, Smith, Rex N, Miller, Miles A, Rosas, Ivan O, Hardin, Charles C, Baden, Lindsey R, Medoff, Benjamin D, Colvin, Robert B, Little, Brent P, Stone, James R, Mino-Kenudson, Mari, Shih, Angela R
Format:	Journal Article
Language:	English
Published:	United States American Thoracic Society 01-10-2022
Subjects:	COVID-19 COVID-19 - complications Humans Lung - diagnostic imaging Lung - pathology Pandemics Pneumonia Pulmonary Alveoli - pathology Respiratory diseases Respiratory distress syndrome Respiratory Distress Syndrome - etiology Severe acute respiratory syndrome coronavirus 2 Vascular Diseases Vein & artery diseases COVID-19 vasculopathy vascular congestion ARDS ventilatory ratio
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Summary:	The leading cause of death in coronavirus disease 2019 (COVID-19) is severe pneumonia, with many patients developing acute respiratory distress syndrome (ARDS) and diffuse alveolar damage (DAD). Whether DAD in fatal COVID-19 is distinct from other causes of DAD remains unknown. To compare lung parenchymal and vascular alterations between patients with fatal COVID-19 pneumonia and other DAD-causing etiologies using a multidimensional approach. This autopsy cohort consisted of consecutive patients with COVID-19 pneumonia ( = 20) and with respiratory failure and histologic DAD ( = 21; non-COVID-19 viral and nonviral etiologies). Premortem chest computed tomography (CT) scans were evaluated for vascular changes. Postmortem lung tissues were compared using histopathological and computational analyses. Machine-learning-derived morphometric analysis of the microvasculature was performed, with a random forest classifier quantifying vascular congestion (C ) in different microscopic compartments. Respiratory mechanics and gas-exchange parameters were evaluated longitudinally in patients with ARDS. In premortem CT, patients with COVID-19 showed more dilated vasculature when all lung segments were evaluated ( = 0.001) compared with controls with DAD. Histopathology revealed vasculopathic changes, including hemangiomatosis-like changes ( = 0.043), thromboemboli ( = 0.0038), pulmonary infarcts ( = 0.047), and perivascular inflammation ( < 0.001). Generalized estimating equations revealed significant regional differences in the lung microarchitecture among all DAD-causing entities. COVID-19 showed a larger overall C range ( = 0.002). Alveolar-septal congestion was associated with a significantly shorter time to death from symptom onset ( = 0.03), length of hospital stay ( = 0.02), and increased ventilatory ratio [an estimate for pulmonary dead space fraction ( ); = 0.043] in all cases of ARDS. Severe COVID-19 pneumonia is characterized by significant vasculopathy and aberrant alveolar-septal congestion. Our findings also highlight the role that vascular alterations may play in and clinical outcomes in ARDS in general.
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ISSN:	1073-449X 1535-4970
DOI:	10.1164/rccm.202109-2150OC