Type 4 hiatal hernia causing haemodynamic compromise by compression of the left atria

Abstract

An 83-year-old male patient, with history of non-small cell lung carcinoma, left lower lobectomy, and subsequent development of a hiatal hernia, presented with 2 days of worsening exertional dyspnoea and was found to be haemodynamically compromised, with symptomatic hypotension on minimal exertion. Computed tomography pulmonary angiogram confirmed a bowel-containing hiatal hernia with the heart laterally displaced. Echocardiogram was performed, showing a large (∼8 cm in diameter) extracardiac mass, compressing the left atrium (LA), and significantly compromising LA filling. Otherwise, there was no other significant cardiac pathology contributing to the patient’s symptoms—only moderate left ventricular hypertrophy with normal systolic function of the left and right ventricles (left ventricular ejection fraction 70%); and trace aortic, pulmonary, and tricuspid regurgitation ( Figures 1 and 2 ). The patient underwent successful emergent hiatal hernia repair 4 days post-admission. This was complicated post-operatively by development of pleural effusion, hospital-acquired pneumonia, reflux, atrial fibrillation, and low mood. After a 1-month long rehabilitation, he returned home with improved exercise tolerance compared to admission and no subsequent inpatient admissions at 6 months. Figure 1 Two-dimensional transthoracic echocardiogram showing compression effects of hiatal hernia on left atrium in four chamber systole. Figure 2 Two-dimensional transthoracic echocardiogram showing compression effects of hiatal hernia on left atrium in parasternal long-axis systole. Large hiatal herniae are increasingly recognized as a cause of dyspnoea through effects on cardiac filling by extrinsic cardiac and pulmonary vein compression. In one study of patients with large hiatal herniae preoperatively, 66% had moderate or severe LA compression and greater than 40% had pulmonary vein compression that improved post-operatively correlating with dyspnoea symptoms. 1 Post-operative change in LA size was an independent predictor of improved exercise capacity. 1 Other studies further demonstrated improvement in dyspnoea scores and quality of life post-hiatal hernia repair. 2 , 3 This case demonstrates classical features of LA compression on echocardiogram, which denoted the cause of his dyspnoea. With no indication of compression on computer tomography, it further highlights the importance of echocardiogram as a definitive imaging modality to determine LA compromise in cases of suspected hiatal hernia-mediated compression. Consent: The authors confirm that written consent for submission and publication of this case report including images and associated text has been obtained from the patient in line with COPE guidance. Conflict of interest: none declared.