Hiatal hernia is a not uncommon anatomic disorder resulting in portions of the bowel occupying space in the thoracic cavity. There are a number of antecedent risk factors including obesity but not hiatal hernias resulting in symptoms. When symptoms do occur, they can include chest pain, nausea, abdominal pain, and gastroesophageal reflux. Cardiac arrhythmias have also been reported as associated conditions resulting from a hiatal hernia. To date, however, a complete heart block secondary to a hiatal hernia has not been reported. An 88-year-old female with a history of GERD (gastroesophageal reflux disease) was found to have a large hiatal hernia at endoscopy after she presented to the emergency department with nausea and abdominal pain. Prior to her scheduled surgical repair, she developed symptomatic third degree heart block which resolved with nasogastric tube deflation of the gastric contents. After surgical repair of the hiatal hernia, she developed episodes of atrial fibrillation with rapid ventricular response and was started on diltiazem. She eventually converted back to normal sinus rhythm and remained dysrhythmia free. In addition to other known arrhythmias associated with hiatal hernia, a complete heart block can also be seen. Acute management requires deflation of the chest occupying hernia. This appears to be the one of the first reported cases of complete heart block caused by hiatal hernia.

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Background: Pulmonary artery intimal sarcoma (PAIS) is a rare malignancy of vasculature that carries a very poor prognosis that is often misdiagnosed as a pulmonary embolism due to overlapping clinical and radiological features. It is a very aggressive malignancy with surgery the mainstay of initial management. Chemotherapy is normally given postoperatively, although it is not clear if chemo and radiotherapy bring any improvement, some data report an increase in survival in patients who received multimodality therapy vs single therapy. Case: A 48 year-old female was initially diagnosed with a pulmonary embolism based on clinical presentation and imaging. She was treated vigorously but continued to show no improvement after two weeks. She underwent an open thrombectomy and a large concurrent pulmonary artery intimal sarcoma (PAIS) was found. The mass was adherent to the intima and extended into the left and right pulmonary arteries. The tumor was not fully resected and tissue results showed poorly differentiated sarcoma. A treatment plan was then initiated to include systemic chemotherapy. She developed metastatic disease despite receiving multimodal therapy and died with within 2 years from the initial diagnosis. Conclusion: Persistent symptoms in patients diagnosed and treated adequately for pulmonary artery thrombosis should indicate a possible comorbid condition including sarcoma. This is particularly the case in the older age group with imaging that suggests central embolism despite treatment.