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Proposed mechanism of ventricular tachycardia (VT) secondary to posterior cardiac compression from a large hiatal hernia (long axis view). A: The mitral annulus is a saddle-shaped continuous fibrous ring that is adjacent to the aortomitral continuity (AMC). B: Direct posterior cardiac compression from the hiatal hernia (black arrows) may have resulted in indirect distortion of the anterior mitral annular annulus and/or the basal left septum (blue arrows), aggravating the propensity to VT.
Context in source publication
Context 1
... implications of HH-induced cardiac distortion on arrhythmia pathogenesis are poorly recognized. Atrial ar- rhythmias have been described, which are likely attributable to LA compression. A large observational study demon- strated that there is a higher prevalence of atrial fibrillation (AF) at all ages with HH compared to the general population, with a higher magnitude of difference in those aged ,55 years despite a reduced prevalence of AF risk factors (17.5- fold higher in men and 19-fold higher in women compared with an age-and gender-matched population). 4 Moreover, patients with more frequent gastroesophageal reflux symp- toms and/or esophagitis seem to have an increased risk of AF. 5 Similarly, there have been case reports of atrial flutter, 6 junctional bradycardias, 7 anterior T-wave inversion, 8 and ST elevation that have resolved post hernia repair or even after initiation of anti-reflux therapy. 9,10 In our case, we postulate that hernia-induced cardiac compression resulted in distortion of the mitral annular ring, which is a continuous fibrous ring adjacent to the basal structures of the left ventricle including the aortomi- tral continuity (Figure 3). This appears to have aggravated the propensity to VT, with the postoperative resolution of this compression correlating with resolution of the VT. While mechanical compression is likely to be the main mechanism of VT, gastroesophageal reflux may also contribute to arrhythmias by releasing local and systemic cytokines and thus resulting in local heat and myocardial inflammation. 5,11 Additionally, there may be associated sympathetic nerve and vagal nerve stimulation through either local heat or compression, which may further induce and perpetuate arrhythmogenesis. We speculate that these factors create a proarrhythmic environment that may induce abnormal automaticity and triggered activity, and thus produce VT. This nonreentrant mechanism is consistent with the initial EPS, in which VT was not induced with programmed stimulation. In particular, triggered activity is likely to be a key process in the VT pathogenesis, as burst right ventricular pacing was able to initiate the ...
Citations
... Our patient is a 92-year-old female who arrived at the hospital with a complaint of syncope for the past four weeks, and her CT scan revealed a large hiatal hernia. Large hiatal hernias can result in significant posterior cardiac compression and atrial arrhythmias have also been described due to impingement on the left atrium [7,8]. The left atrium's anatomical proximity to herniated stomach contents increases the likelihood of mechanical irritation of the atria, autonomic neuronal connections, or inflammation, which may increase the risk of atrial fibrillation (AF) [9]. ...
Patients with syncope often present a diagnostic challenge due to the diverse causes of this condition. While
a careful assessment can identify the underlying cause in many cases, syncope can arise from a variety of
sources, including structural anomalies. Among these, hiatal hernia (HH) is a relatively common yet unusual
condition associated with syncope. HH involves the protrusion of abdominal organs into the mediastinum
through the diaphragmatic esophageal hiatus, with types III and IV being capable of causing cardiac
problems. We report a case of a 92-year-old patient with a known HH history who experienced recurrent
syncope episodes triggered by heavy meals. Extensive evaluation ruled out cardiac and neurological causes.
Imaging revealed a large HH compressing the left atrium. Despite being an infrequent occurrence, such cases
highlight the potential for atrial compression-induced syncope, which can be effectively managed with
proton pump inhibitors and lifestyle modifications, as demonstrated by our patient's positive outcome.
... Left atrial compression from hiatal hernia has also been found to cause "swallow syncope", and reduced exercise capacity. 5,6,7 Clinical evidence of such cardiac compromise or cardiac failure from end-stage hiatal hernia compressing on left atrium would be an indication for acute surgical intervention. ...
... Large hiatal hernias (HH) are infrequent but can cause atypical symptoms such as chest pain and dyspnoea, and rare complications such as pulmonary oedema and even ventricular tachycardia due to the extent of the hernia and compression of the heart and pulmonary veins by organs protruding into thoracic cavity [1][2][3] . HH may appear as an extracardiac posterior mass encroaching on the left atrial cavity, mimicking a left atrial mass [4] . We describe two older patients with an apparent left atrial mass on transthoracic echocardiography, which was subsequently identified as HH by other imaging modalities. ...
Unlabelled:
Chest pain and dyspnoea are among the most common complaints seen in the emergency room and each symptom calls for a broad differential diagnosis. Large hiatal hernias are infrequent, but they can lead to atypical symptoms mimicking different cardiovascular, pulmonary and neoplastic diseases. We present two cases of older patients with an apparent left atrial mass on transthoracic echocardiography, which was subsequently identified as hiatal hernia by other imaging modalities. A multidisciplinary team with multimodality imaging is necessary for diagnostic work-up of chest pain and dyspnoea of non-cardiac origin and especially for a suspected mass compressing the heart, causing chest discomfort.
Learning points:
Hiatal hernia (HH) can mimic different cardiovascular, pulmonary and neoplastic diseases.HH has a typical echocardiographic (2DE) presentation as an amorphous, echolucent mass with the appearance of a left atrial space-occupying lesion.Oral ingestion of a carbonated drink may help to distinguish between a large HH and an atrial mass by 2DE.
... Type II-IV hiatal hernias involve displacement of stomach contents and other organs into the thoracic cavity (also known as para-esophageal hernias) and can cause a wide variety of symptoms at time of presentation [3]. In more sizable hernias, there can be evidence of posterior cardiac compression, especially of the inferior and inferolateral left ventricular wall segments, which may cause significant arrhythmia [4]. Hernias with >30% of the stomach protruding into the thoracic cavity are more commonly associated with cardiac complications [5] such as chest pain [6] and dyspnea on exertion [7] secondary to left atrial compression an compression of cardiac inflow structures such as pulmonary veins and coronary sinus. ...
The above computed tomography scans in the axial and sagittal planes reveal the stomach within the chest cavity impinging on the lungs and heart due to a large hiatal hernia. The 2-D parasternal echocardiography images reveal the stomach adjacent to the inferolateral wall of the heart and causing flattening of the inferolateral wall during diastole, also known as pseudodyskinesis. The EKG reveals atrial fibrillation, a potential result of a large hiatal hernia.
... The prevalence of atrial fibrillation has been shown to be higher in patients with HH compared to the general population [6]. Paroxysmal ventricular tachycardia has also been reported as rare cases of ST-segment elevation acute coronary syndrome [7,8]. One case of cardiac arrest has even been described [9]. ...
Symptomatic hiatal hernia (HH) is most often revealed by gastroesophageal reflux disease, but there are atypical presentations some of which are life-threatening. We report the case of a 57-year-old woman brought to the emergency department with isolated shortness of breath for 24 h. Initial explorations revealed unexplained hyperlactatemia (6.4 mmol/L) without clinical or biological evidence of hypovolemia, distributive, obstructive or cardiogenic shock. Two hours after admission, we observed a decreased of blood pressure and an increase of lactate level to 7.9 mmol/L. A bedside echocardiography revealed an extra-cardiac left atrial compression and thoracoabdominal computed tomography showed a large sliding HH compressing the left atrium. After an upper gastrointestinal endoscopy permitting the aspiration of gastric contents, a repair surgery was performed without complications and patient was discharge three days later. Emergency physicians should be aware that HH can be a rare cause of cardiac symptoms by heart compression and certainly use echocardiography for unexplained hemodynamic failure.
... Hiatal hernia and changes in electrocardiogram. Changes in the electrocardiogram pattern and rhythm have been observed in patients with hiatal hernias [17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35]. However, the linkage between these conditions has not been fully elucidated. ...
... In most cases, electrocardiographic alternation disappeared after initial stomach decompression or surgical correction of the hiatal hernia [18,20,21,[30][31][32][33][34][35], or after successful conservative management with dietary control and proton pump inhibitor [29]. Resolution of abnormal findings in ECG after management of hiatal hernia may imply a causal relationship between the hiatal hernia and changes in the electrocardiogram pattern and rhythm. ...
Introduction:
Hiatal hernia (HH) is a condition which refers to the protrusion of an intraabdominal organ in the thorax cavity throughan oesophageal hiatus of the diaphragm. Sliding HH is usually associated with non-specific symptoms, including heartburn, regurgitation or epigastric pain. Importantly, true paraesophageal hernia may lead to cardiac compression. Knowledge of cardiac manifestations of HH is limited.
Objective:
The main aim of the study is to present the rare case of a patient with gastrothorax due to hiatal hernia which caused cardiac arrest, and to provide a literature-based review of the cardiac aspects of hiatal hernia.
Brief description of the state of knowledge:
Patients with paraesophageal hernia may experience arrhythmia, including sinus tachycardia, atrial flutter, atrial fibrillation, supraventricular extrasystole and ventricular tachycardia, as well as left bundle branch block, atrioventricular conduction block and electrocardiographic changes in the ST-segment and T-wave. In echocardiograph, HH may appear as an extracardiac posterior mass encroaching on the left atrial cavity, mimicking the left atrial mass. Rarel, HH may be manifested as tension gastrothorax leading cardiac arrest. In such a case, timely diagnosis and instant adequate treatment of the underlying condition are crucial.
Conclusions:
Hiatal hernia should be considered as a possible cause of arrhythmia and changes in ST-T pattern, particularly if symptoms occurred after a meal. Differential diagnosis of the posterior mediastinal mass or intracardiac mass should include hiatal hernia. Gastrothorax is a rare condition associated with hiatal hernia which may lead to cardiac arrest. However, even timely recognition and therapy of gastrothorax does not ensure a positive clinical outcome.
... Hiatal hernia is known to cause difficulty in TTE and TEE imaging by altering the normal intrathoracic geometry and has, in certain cases, been shown to displace both the right and left heart chambers. 3,4 Even though MitraClip procedures in patients with large hiatal hernias are uncommon, Kataoka et al. 5 recently published a case in which the authors placed a bronchial blocker in order to displace the heart leftwards and to improve visualization of the posterior part of the interatrial septum, thus overcoming a vertebral body beam artifact. ...
A 78-year-old man was admitted to our hospital with obstructive shock caused by a large hiatal hernia that occupied the posterior mediastinum. Tension gastro-duodenothorax was detected in his stomach and duodenum, and we performed urgent endoscopy to relieve shock. Large hiatal hernia occasionally leads to cardiac failure. This is the first reported use of urgent endoscopy to treat a large hiatal hernia.
Unlabelled:
Most patients with hiatal hernia (HH) are asymptomatic; however, common symptoms include gastroesophageal reflux disease (GERD) and heart burn. Larger hernia can cause obstruction, ischemia of the bowel, volvulus of the contents of the hernial sac, respiratory distress, and rarely, cardiac abnormalities are also noted. Most reported cardiac abnormalities associated with HH include atrial fibrillation, atrial flutter, supraventricular tachycardia, and bradycardia. We present a rare case of a large HH causing frequent premature ventricular contractions in bigeminy form that resolved with surgical correction of HH and did not recur on subsequent Holter monitoring. We highlight the potential association between HH/GERD and cardiac arrhythmias and reinforce the need to keep HH/GERD as one of the working diagnoses in a patient with cardiac arrhythmia.
Learning objective:
•Large hiatal hernia can cause several arrhythmias such as atrial fibrillation, atrial flutter, supraventricular tachycardia, bradycardia, and premature ventricular contractions (PVCs).•It is essential to consider hiatal hernia and gastroesophageal reflux disease as one of the differentials in the work up of cardiac arrhythmias including PVCs.
