SESSION TITLE: Cardiovascular Student/Resident Case Report Posters II
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: Hiatal hernia can rarely present with cardiac symptoms mostly due to regional tamponade.Here we describe a case of large hiatal hernia presenting with symptomatic atrial flutter and echocardiographic left atrial mass.
CASE PRESENTATION: A 88 year old woman with diabetes mellitus, hypertension, paroxysmal atrial fibrillation presented with history of recurrent falls. Her blood pressure was 111/54, heart rate 97, respiratory rate 16, saturating 97% on 1L oxygen. Physical examination was unremarkable. Labs revealed normal serial cardiac enzymes and acute on chronic kidney injury. Telemetry during hospitalization revealed paroxysmal atrial flutter, variable rapid ventricular rates of 150 to 200 which corresponded with symptoms of pre syncope and syncope. Her systolic blood pressure during these episodes was 60s-70s. Echocardiography revealed ejection fraction 50-55%, left atrial mass which appeared to increase in sitting & standing position, decrease during valsalva maneuver. CT chest revealed large hiatal hernia compressing on the left atrium. She was offered surgery for correction of the hernia but opted for conservative management. Her dose of b-blocker was titrated to achieve ventricular response of less than 120 during activity. She didn’t have recurrent symptoms.
DISCUSSION: Cardiac tumors are rare- primary, benign or metastatic. However there a number of normal cardiac structures and extra cardiac masses which can mimic intra cardiac tumors including mediastinal tumours, coronary aneursyms and hiatal hernias1. Hiatal hernia, with its anatomical proximity to the left atrium, may simulate a intra cardiac mass.Normal left atrial structures which can simulate echocardiographic pathology include suture line following transplant, fossa ovalis, calcified mitral annulus, coronary sinus, lipomatous hypertrophy of interatrial septum, pectinate muscles and transverse sinus. CT or MR imaging may help differentiate these from true intra cardiac tumors like in our patient. There have been reports of intra cardiac tumors presenting with atrial fibrillation-flutter. Mechanism of atrial flutter is due to a macro reentrant circuit with functional block between the venae cavae2. Our patient likely had symptoms caused by hiatal hernia compressing on the left atrium with the resultant scar(intercaval) altering the substrate of her prior well tolerated paroxysmal atrial fibrillation to flutter with rapid ventricular response and resultant syncope and falls.
CONCLUSIONS: This rare case demonstrates, hiatal hernia can present with cardiac signs, symptoms, imaging and prompt diagnosis is necessary for appropriate management.
Reference #1: 1.The role of echocardiography in diagnosing space-occupying lesions of the heart. Ragland MM et al. Clinical Medicine & Research March 1, 2006 vol. 4 no. 1 22-32
Reference #2: 2.Mechanisms of atrial flutter and atrial fibrillation: distinct entities or two sides of a coin? Albert Waldo. Oxford Journals. Cardiovasc Res (2002) 54 (2): 217-229
DISCLOSURE: The following authors have nothing to disclose: Manju Bengaluru Jayanna, Mark Woodruff, Hussam Abuissa
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