Massive hiatus hernia impeding transoesophageal echocardiography in a patient with swallow-syncope syndrome.

A n 82-year-old lady, with a long history of syncopal spells that were occasionally associated with meals, was referred for transÔesophageal echocardiography (T√E) because of a large left atrial mass identified on transthoracic echocardiography (Figure 1A). T√E was able to visualise only a part of the left atrium and the ascending aorta (Figure 1B & C), and when the probe was further advanced, it was not possible to obtain any cardiac images because of air artefact. A hiatus hernia was suspected and the T√E was abandoned. The patient was then referred for a cardiovascular magnetic resonance (CMR) scan for further investigation of the left atrial mass. This revealed a giant hiatus hernia, with most of the stomach positioned within the thoracic cavity (Figure 2A & B). The hiatus hernia extended up to the level of the great vessels, and this explained why TOE was only able to image the great vessels. There was no evidence of any other intraor extra-cardiac masses. The presence of the hiatus hernia was not known before the T√E and CMR examinations. A large hiatus hernia constitutes a form of posterior mediastinal mass that may encroach on the posterior aspects of the heart, particularly the left atrium, mimicking a left atrial mass on transthoracic echocardiography. Hiatal hernias have been implicated in causing dyspnoea, postprandial syncope, and electrocardiographic abnormalities. Several features may help differentiate between a large hiatus hernia and a left atrial mass on transthoracic echocardiography. With angulation of the transducer, the echo density of the hiatal hernia will extend beyond the margins of the atrium. Furthermore, the oral ingestion of a carbonated beverage may result in the appearance of swirling echo densities in the mass. TOE has been reported to occasionally help in the diagnosis of a hiatus hernia, though in the majority of cases, and particularly when the hernia is large, it fails to obtain meaningful cardiac images. Frans et al have suggested that the diagnosis of hiatus hernia may be made on TOE if the mass-like lesion has a thick inner lining resembling the stomach mucosa and contains microbubbles. This technique can make the diagnosis, but it is not always successful. Smelley and Lang have recently suggested that the use of echocardiographic contrast mixed with a carbonated beverage can further aid in clarifying the nature of a mass abutting the left atrium. Nevertheless, if a hiatus hernia is suspected, it is probably wiser to avoid further manipulation of the probe, as the possibility of causing oesophageal or gastric damage is high. A hiatus hernia may be suspected from chest X-ray. Nevertheless, the diagMassive Hiatus Hernia Impeding Transoesophageal Echocardiography in a Patient with SwallowSyncope Syndrome