LEFT VENTRICULAR DYSFUNCTION SECONDARY TO LARGE HIATAL HERNIA COMPLICATED BY GASTRIC OUTLET OBSTRUCTION

Abstract

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: A hiatal hernia is an anatomical abnormality in which abdominal contents displace into the thoracic cavity through a diaphragmatic defect and can result in GERD, bronchiectasis, and rarely cardiac compression. We describe a case of a large hiatal hernia in an advanced age female in whom the hernia compressed the left ventricle resulting in significant cardiac dysfunction. CASE PRESENTATION: An advanced age female with a past history of diabetes, hypertension, hypothyroidism, and large hiatal hernia repaired in 2017 presented with nausea and bloody/bilious vomiting with food intolerance and was found to have a gastric outlet obstruction. The patient's case was complicated by aspiration pneumonia and cardiac sequelae. Patient exhibited soft pressures and sinus tachycardia in the 120 to 140 range with frequent atrial and ventricular ectopy and a left bundle branch block. Echocardiogram noted that her left ventricle was small and compressed secondary to bowel from the hiatal hernia. Given patient's advanced age, the plan was to treat conservatively with beta blockers. Patient then had rhythmic change to new atrial fibrillation with rapid ventricular response. Ultimately patient had cardiorespiratory compromise secondary to decreased preload from cardiac compression from her large hiatal hernia and expired. DISCUSSION: There are a few case reports of cardiac sequelae such as ST elevation and decreased preload from left atrial and ventricular compression due to large hiatal hernias, especially in the post prandial state in which the mass effect increases. In this patient's case, the patient's mass effect of her large hiatal hernia was exacerbated by her gastric outlet obstruction. She had recurrence of her hiatal hernia despite two repair procedures in the past and given her advanced age, she was a poor surgical candidate for surgery of her hernia. She had conservative management with beta blockers and NG tube placement for gastric decompression, but she ultimately had complicated course with increased ectopy, new arrhythmia, and left ventricular compression caused by mass effect of the massive hernia. CONCLUSIONS: The patient's mass effect of her large hiatal hernia was exacerbated by her gastric outlet obstruction which led to increased ectopy, new arrhythmia, and decreased preload from left ventricular compression. In an advanced age patient with gastric outlet obstruction and a history of large hiatal hernia, the treatment options were limited. In cases of patients who are able to undergo more aggressive management, it is advisable to closely monitor and intervene on large hiatal hernias and relieve the cause of gastric outlet obstructions as they can have significant cardiopulmonary effects secondary to their mass effect as seen in this case. REFERENCE #1: Umemura, A. et al. Cardiopulmonary Impairments Caused by a Large Hiatal Hernia with Organoaxial Gastric Volvulus Showing Upside-Down Stomach: A Case Report. The American journal of case reports, [s. l.], v. 20, p. 1530–1535, 2019. DOI 10.12659/AJCR.918191 REFERENCE #2: Gnanenthiran, S. et al. Feeding Inducses Left Atrial Compression and Impedes Cardiac Filling in Patients with Large Haital Hernia. Journal of the American Society of Echocardiography. V.32, iss. 3, p. 375-384, 2019. DOI 10.1016/j.echo.2018.09.017 REFERENCE #3: Harada, K. et al. Left ventricular obstruction caused by a large hiatal hernia. Echocardiography (Mount Kisco, N.Y.), [s. l.], v. 34, n. 8, p. 1254–1256, 2017. DOI 10.1111/echo.13563. Disponível em: https://search-ebscohost-com.ezproxy.libraries.wright.edu/login.aspx?direct=true&db=mnh&AN=28497506&site=eds-live. Acesso em: 11 set. 2020. DISCLOSURES: No relevant relationships by Anas Ahmed, source=Web Response No relevant relationships by Amie Kim, source=Web Response No relevant relationships by Steven Young, source=Web Response