Heart under Pressure: Intrathoracic Impact of Large Hiatal Hernia

Large hiatal hernias can have significant implications for perioperative management. The accompanying images display a large hiatal hernia compressing the heart (fig. 1A) and inferior vena cava (fig. 1B). Hiatal hernias are not uncommon, especially in elderly patients. Approximately 25% of people over the age of 50 yr have a hiatal hernia.1Fig. 1.: (A) Computed tomography imaging of intrathoracic stomach exhibiting mass effect upon the heart and lungs. (B) Compression of the inferior vena cava (IVC) by the hiatal hernia.Large hiatal hernias may present without gastroesophageal reflux disease and gastrointestinal obstruction symptoms, and as such may escape notice in a preoperative assessment. These patients are at increased risk of aspiration. Preinduction gastric tube insertion can help decompress the stomach, reducing the risk of aspiration, and improving ventilation. Additionally, rapid sequence induction or awake intubation, depending on the airway examination, is usually indicated. Large hiatal hernias may also exhibit mass effect on the inferior vena cava and heart and cause increased intrathoracic pressures, especially with initiation of positive pressure ventilation2 (see Video, Supplemental Digital Content, https://links.lww.com/ALN/D619, which demonstrates hiatal hernia compressing nearby organs). Compression of the inferior vena cava (fig. 1B) can impair venous return. Cardiac compression from a large hiatal hernia (fig. 1A), a so-called “tension gastrothorax,” may lead to arrhythmias, hemodynamic compromise, and even cardiac arrest.2,3 As such, hiatal hernias should be considered as a possible cause of hemodynamic compromise, especially during anesthetic induction. Timely decompression of the dilated stomach often results in resolution of symptoms and return of hemodynamic stability.3 Competing Interests The authors declare no competing interests. Supplemental Digital Content Video: Hernia compressing nearby organs, https://links.lww.com/ALN/D619