P687 Left atrial mass - a potential pitfall

Abstract

Abstract Background. Echocardiography is an important diagnostic tool in differential diagnosis of retrosternal pain. Despite the high prevalence of hiatus hernia, a relatively small number of echocardiographically manifested cases have been reported. Case summary. A 75 y old female patient with rheumatic polymialgia and diabetes was admitted for progressive weakness, retrosternal pain and dyspnoea. Due to elevated levels of D-dimer and troponin I an urgent CT angiography was performed and a diagnosis of pulmonary embolism was confirmed in the ER. Echocardiography showed a mildly hypertrophied left ventricle with normal EF, a mildly dilated right ventricle, moderate pulmonary hypertension 45 mmHg, and an apparent mass in the left atrium (picture). To further characterize the left atrial mass a cardiac MR angiography was made, that excluded potential cardiac tumor and confirmed that the suspected mass was a large hiatus hernia impressing the left atrium. Patient was treated with anticoagulant therapy due to PE and corticosteroids due to polymialgia and was discharged in improved condition. We also consulted thoracic surgeons regarding hernia and did not decide to operate on the hernia urgently but opted for conservative reflux measures and an outpatient follow up with barium contrast oesophagus imaging. Discussion. Hiatal hernia may exert a wide spectrum of manifestations mimicking acute cardiovascular events, from ECG changes to angina, dyspnoea and even syncope as a consequence of total compression of the left atrium. A history of known hiatus hernia and aforementioned clinical correlates postprandially may shed some clues. Echocardiographic features that may suggest a hiatus hernia include: 1. A large ill-defined mass filling the left atrial chamber from posteriorly, with its maximal size seen when imaged in a posterior plane. 2. Respiratory variation in the degree of encroachment of the mass on the left atrium. 3. Loss of the normal sharply defined sonolucency of the descending thoracic aorta in the apical 4-chamber and long-axis views due to superimposition of the hiatus hernia. 4. A swirling motion seen within the mass after consumption of effervescent fluids. 5. Occasionaly, identification of an inner lining reminiscent of gastric mucosa is possible. Various intracardiac or extrinsic lesions can resemble the echocardiographic appearance of hiatus hernia. Other potential causes of extracardiac masses that could encroach on the left atrium include structures such as aneurysm or dissection of the aorta, dilation of coronary sinus, abcesses, oesophageal carcinoma and other mediastinal space occupying structures. Conclusion. Hiatus hernia can simulate clinical and sonographic characteristics of cardiac disorders. Its echocardiographic manifestation may mimic a left atrial mass and must therefore be differentiated from such lesions. Abstract P687 Figure. Hiatal hernia mimicking LA mass(PLAX)