Two- and Three-Dimensional Transthoracic Echocardiographic Assessment of Hiatal Hernia

Left atrial compression and right ventricular outflow tract diameter on echocardiography are independently associated with exercise capacity in patients with large hiatal hernia

INTRODUCTION

Large hiatal hernia (HH) is often associated with left atrial (LA) compression, anteroposterior cardiac compression (manifesting as reduced right ventricular outflow tract (RVOT) diameter), and left ventricular (LV) compression (manifesting as systolic paradoxical outward motion (LV-PM) of the posterobasal LV segment). Exercise impairment, also common in this population, improves following HH surgery. We aimed to identify echocardiographic parameters independently associated with exercise impairment due to HH-mediated cardiogenic compression.

METHODS

Patients with a large HH (>30% intra-thoracic stomach, n = 163) referred for cardiac evaluation were included. Echocardiographic parameters were retrospectively analyzed in relation to HH-related LA compression severity and the presence of LV-PM. Echocardiographic parameters independently associated with exercise capacity were identified by multivariable analysis.

RESULTS

Mean baseline metabolic equivalents were reduced (70 ± 28% predicted). Moderate-severe LA compression and LV-PM were present in 91 of 163 (56%) and 65 of 162 (40%) patients, respectively. Patients with moderate-severe LA compression and LV-PM had decreased LA and LV dimensions. Moderate-severe LA compression was also associated with reduced RVOT diameter while LV-PM predicted a greater reduction in LV volumes. LA compression and RVOT diameter were independently associated with baseline exercise capacity and increased following HH surgery performed in a subgroup (n = 72, LA diameter: 14 ± 5 vs 20 ± 4 mm/m² ; RVOT diameter: 17 ± 3 vs 19 ± 3 mm/m² , P < .001 for both). Conversely, LV-PM was not independently associated with exercise capacity.

CONCLUSION

Hiatal hernia-related cardiac compression reduces LA and RVOT dimensions. These parameters are independently associated with baseline exercise capacity and improve following HH surgery. LV-PM is associated with decreased LV volumes but not exercise capacity in this population.

How to misuse echo contrast

Background

Primary intracardiac tumours are rare, there are however several entities that can mimic tumours. Contrast echocardiography has been suggested to aid the differentiation of various suspected masses. We present a case where transthoracic echocardiography completely misdiagnosed a left atrial mass, partly due to use of echo contrast.

Case presentation

An 80 year-old woman was referred for transthoracic echocardiography because of one-month duration of worsening of dyspnoea. Transthoracic echocardiography displayed a large echodense mass in the left atrium. Intravenous injection of contrast (SonoVue, Bracco Inc., It) indicated contrast-enhancement of the structure, suggesting tumour. Transesophageal echocardiography revealed, however, a completely normal finding in the left atrium. Subsequent gastroscopy examination showed a hiatal hernia.

Conclusion

It is noteworthy that the transthoracic echocardiographic exam completely misdiagnosed what seemed like a left atrial mass, which in part was an effect of the use of echo contrast. This example highlights that liberal use of transoesophageal echocardiography is often warranted if optimal display of cardiac structures is desired.