Abstract Hiatal hernias are categorized on a grading scale of Type I through IV with Type I being a mild herniation of the gastroesophageal junction through the diaphragmatic hiatus and Type IV being categorized as having an abdominal organ herniate into the thorax. The left ventricle of the heart rests on the diaphragm in typical anatomy. Severe cases of hiatal hernias can lead to life threatening volvulus formation, and damage structures within the thorax including ischemic insults to the myocardium. Here, we present a case of Type IV hiatal hernia compressing the LAD causing ST segment elevation changes and elevated cardiac biomarkers. An 81-year-old male presented to outpatient thoracic surgery clinic with complaints of abdominal pain, dyspnea, constipation requiring disimpaction, and food aversion. He had a past surgical history of esophagectomy with cervical esophagogastrostomy, pyloromyotomy, feeding jejunostomy, prior Type IV hiatal hernia repair, and colon resection. Recent CT abdomen/pelvis showed a large hiatal and medial diaphragmatic hernia protruding into the left lower chest causing compressive atelectasis of the left lower lobe. His clinical picture was consistent with failure to thrive, and he was admitted to the in-patient internal medicine team for further management and evaluation for possible surgical correction of his hiatal hernia. Soon after he arrived, he elicited new chest pain and shortness of breath. An EKG was obtained, revealed ST-segment elevation in leads V2 and V3. High-sensitivity troponin values revealed an upward trend of 400, 786, and 831. Troponins were noted in the 20s on admission. Interventional cardiology was consulted for ischemic evaluation, and he underwent prompt left heart catheterization which revealed mild non-obstructive coronary artery disease. The patient returned to the floor without cardiac medical therapy. The patient was later treated with aggressive bowel stimulation which relieved his cardiac symptoms. Our case highlights a rare case of hiatal hernia compressing the left ventricle leading to pseudo-ACS. The patient’s chest pain ultimately resolved with an aggressive bowel regimen. Our case proposes recommendations for an aggressive bowel regimen for similar scenarios to minimize exposing patients to unnecessary risks and procedures. Greater awareness of this rare phenomenon in patients with Type IV hiatal hernias can reduce unnecessary cardiac catheterizations and lower healthcare costs for patients and hospitals. This abstract is funded by: None
Bond et al. (Fri,) studied this question.