Pulmonary Plethora: Excess Lung Blood Volume from Heart Failure, Stenosis, COPD, or Embolism
Pulmonary plethora (pulmonary vascular congestion) is an abnormal increase in pulmonary blood volume, visible on imaging as prominent pulmonary arteries and plethoric lung fields.
Causes
- Left heart failure: Elevated left atrial pressure → pulmonary venous hypertension → capillary engorgement.
- Pulmonary valve stenosis: RV outflow obstruction → RV hypertrophy; post-stenotic dilation of PA.
- COPD: Hypoxic pulmonary vasoconstriction → pulmonary hypertension → vascular remodeling.
- Pulmonary embolism: Acute obstruction → regional plethora (Westermark sign: oligemia distal to clot; plethora proximal).
- Left-to-right shunts: ASD, VSD, PDA → increased pulmonary flow.
Symptoms
Dyspnea, orthopnea, wheezing, cough, fatigue, chest discomfort, syncope (if severe).
Management
Target underlying etiology: diuresis/afterload reduction for heart failure; balloon valvuloplasty/TAVR for stenosis; bronchodilators/oxygen for COPD; anticoagulation/thrombolysis for PE; device closure for shunts.
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