Myocardial Infarction Associated with a Giant Hiatal Hernia

An 81-year-old woman was admitted to our hospital due to dyspnea on exertion, attributed to severe aortic stenosis, and was scheduled for transcatheter aortic valve implantation (TAVI). The day before the procedure, she experienced chest pain radiating to the left shoulder after consuming a hospital meal that was large compared to her usual meal size. An electrocardiogram (ECG) in the supine position showed ST-segment elevation in leads II, III, aVF, and reciprocal ST-segment depression in leads V1-V4. Interestingly, these changes resolved when she was in the sitting position. Chest computed tomography (CT) revealed a giant hiatal hernia slipping under the heart, with no other abnormal findings. During the TAVI procedure, the supine position again triggered chest symptoms, and subsequent coronary angiography demonstrated disruption of the left circumflex coronary artery (LCx) in the middle portion. Following drainage of the gastric contents, the coronary flow in the LCx improved to normal levels. Cardiac enzymes, including CK-MB, were elevated after TAVI. These findings suggest that the giant hiatal hernia directly compressed the coronary artery, leading to LCx flow disturbance and myocardial infarction. This case report highlights that a hiatal hernia is a common condition in the elderly and can be a potential cause of ischemic heart disease. It underscores the importance of recognizing that the cardiac effects of a hiatal hernia can vary significantly depending on the morphology of the hernia and the position of the patient.