Hiatal Hernia-Induced Cardiac Dysfunction: Unraveling Its Impact on Myocardial Function and Atrial Strain (QF_FR_088)

A 69-year-old male with a history of essential hypertension, dyslipidemia, and type 2 diabetes presented for routine follow-up. He quit smoking 9 years ago after a 40-year history. The patient reported mild exertional dyspnea, in NYHA class II with close monitoring.

Previous transthoracic echocardiography revealed a mildly dilated left atrium (36 mL/m²) with reduced left ventricular ejection fraction (LVEF 48%) and diffuse hypokinesia. Mild mitral and tricuspid regurgitations were also noted. Myocardial perfusion scintigraphy showed no ischemia. Coronary CT angiography demonstrated extensive coronary calcification with an Agatston score of 2058, though without significant stenosis.

Diagnostic Techniques and Their Most Important Findings:

Cardiac MRI revealed preserved atrial dimensions but significant left ventricular systolic dysfunction (LVEF 33%). Segmental impairment of myocardial relaxation was seen in the inferolateral wall, likely influenced by a large hiatal hernia (Figures 1 and 2). Late gadolinium enhancement revealed mild non-ischemic fibrosis in the basal inferoseptal and inferior walls (Figure 3).

The left atrial strain analysis indicated abnormal values in the reservoir and booster pump phases, which are markers of worsening diastolic function. The LA reservoir strain was reduced to -10.48%, indicating impaired atrial compliance. Additionally, the LA booster pump strain was decreased to -8.63%, reflecting diminished atrial contractility. These findings suggest significant left atrial dysfunction, probably contributing to elevated atrial pressures and impaired filling dynamics.

The right ventricle was normal with preserved systolic function (RVEF 51%), and no pericardial effusion or thrombus was noted.

Learning Points from this Case: Cardiac MRI and strain analysis were critical in identifying left ventricular systolic dysfunction and non-ischemic myocardial fibrosis. The significantly reduced left atrial strain, particularly in the reservoir and booster pump phases, highlights the impact of diastolic dysfunction on atrial function. These findings, combined with mild fibrosis, suggest ongoing myocardial remodeling. The large hiatal hernia likely contributes to the observed relaxation impairment. Early detection and continuous monitoring are essential to prevent further clinical deterioration and guide treatment decisions.