Left atrium compression due to oesophageal dilation can induce acute heart failure

Abstract

DESCRIPTIONAn 85-year-old woman reported sudden onset dyspnoea and subsequent vomiting after eating a large meal. She had normal blood pressure (124/ 60 mm Hg) but was tachypnoeic (28/min). Coarse crackles were heard in all the lung fields, and chest radiography showed congestion. ECG showed a non-specific ST-T change, and the brain natriuretic peptide level was 35.2 pg/mL. Transthoracic echocardiography demonstrated extrinsic left atrial (LA) compression (figure 1), and the tricuspid regurgitation pressure gradient was 42 mm Hg. Subsequently, contrast-enhanced CT revealed oesophageal dilation compressing the LA (figure 2).

Left Atrial Compression Secondary to Massive Esophageal Dilatation in a Patient With Idiopathic Achalasia

“… 1 This pattern of esophageal motor disorder is well demonstrated by HREM and classified as type I achalasia. 2 IA rarely presents with symptoms of compression of adjacent mediastinal structures by the dilated esophagus, such as bronchial 3 or cardiac 4 , 5 , 6 , 7 , 8 , 9 , 10 compression. LA extrinsic compression may lead to impaired ventricular filling, elevation of LA and pulmonary venous pressures, clinically manifesting as acute heart failure with signs of pulmonary congestion and low cardiac output.…”

“…As with our case, only four of the cited cases were reported to cause a significant hemodynamic repercussion. 6 , 7 , 9 , 10 Because there is no cure for achalasia, treatment is aimed at relieving symptoms by improvement of LES physiology and reduction of functional obstruction through pharmacologic, endoscopic, and surgical interventions, with the ultimate goal of improving esophageal emptying. In general, the most long-term effective treatments are pneumatic dilatation and surgical myotomy.…”

Syncope Due to Intracavitary Left Ventricular Obstruction Secondary to Giant Esophageal Hiatus Hernia

“…The mechanism for CHF includes external compression of the left atrium, resulting in increased left atrial pressure and subsequent pulmonary venous congestion [1,2,3]. The presence of syncope can be explained by impaired filling of LA (and subsequent impaired LV filling), resulting in decreased cardiac output.…”

“…History was not consistent with vagally mediated swallowing syncope, because syncope occurred after the lunch, not while she was swallowing. In order to prove the direct effect of the size of giant hiatus hernia on dynamic intracavitary obstruction of the LV, we should have done rapid fluid challenge test by infusing normal saline through nasogastric tube under echocardiography or during cardiac catheterization [3]. But it was not possible because she was a traveller and desired to go back to her hometown early.…”

“…Giant esophageal hiatus hernia can cause congestive heart failure (CHF) and syncope [1,2,3,4]. The mechanism for CHF includes external compression of the left atrium, resulting in increased left atrial pressure and subsequent pulmonary venous congestion [1,2,3].…”