Cardiac Tamponade as a Complication of Hiatal Hernia

Abstract

Hiatal hernia is frequently encountered by gastroenterologists, typically as an incidental finding. Associated gastroesophageal reflux disease may be managed with proton pump inhibitor therapy, although resistant cases may require fundoplication repair of the hernia. We present an unusual case of a patient with paraesophageal hiatal hernia presenting with recurrent NSTEMI and cardiac tamponade secondary to extrinsic cardiac compression by the hernia. Following comprehensive clinical and radiologic evaluation, she underwent nasogastric tube (NGT) decompression of the stomach, which resolved the tamponade. The hernia was subsequently surgically repaired. An 87-year-old female with a history of paraesophageal hiatal hernia, gastroesophageal reflux disease, and coronary artery disease presented to our hospital with severe substernal chest pain. Two years previously, she was hospitalized with an episode of chest pain and elevated troponin caused by cardiac compression secondary to a large paraesophageal hiatal hernia. Vitals were within normal limits on admission. Examination showed a soft, non-distended, non-tender abdomen, with active bowel sounds. A systolic murmur was auscultated throughout the precordium, loudest at the right upper sternal border. Chest computed tomography revealed a large hiatal hernia containing nearly the entire stomach with mass effect on the heart. Echocardiography revealed a large hernia partially effacing the left atrium and left ventricular free wall, compressing the heart, and causing tamponade physiology. Electrocardiogram showed ST segment depression in leads V5 and V6. Relevant initial labs included troponin 2 ng/mL. Shortly after admission, the patient underwent NGT placement with two days of continuous wall suction, which resolved her troponin elevation and ST segment depression, and alleviated her symptoms. She was referred to general surgery and, three days later, underwent a paraesophageal hernia repair with mesh and Toupet fundoplication. She was discharged with cardiology follow up two days later. There are few prior reports of hiatal hernia causing tamponade post coronary bypass surgery or failed hernia repair. To our knowledge, this is the first case reported without preceding surgery. We recommend that extrapericardial pathology be considered in tamponade patients with coexistent hiatal hernia, and that cardiac risk be accounted for in the decision whether or not to surgically repair a large or expanding hiatal hernia. 2636 Figure 1. Chest CT scan obtained prior to nasogastric tube decompression shows dilation of the stomach with compression of the heart.2636 Figure 1. Chest CT scan obtained prior to nasogastric tube decompression shows dilation of the stomach with compression of the heart.