Syncope due to Right Atrial Compression From Hiatal Hernia: A Rare Case With Literature Review of Cardiac Manifestation Managed With Dual‐Chamber Pacing

Syncope in elderly individuals is a common yet diagnostically challenging presentation. Although hiatal hernias are prevalent in this population, their cardiovascular implications were rarely explored beyond left atrial compression. We reported the case of an 85‐year‐old female with a history of hypothyroidism and hiatal hernia who presented with recurrent exertional syncope resulting in trauma. Electrocardiography demonstrated bifascicular block, raising concern for high‐grade atrioventricular block; however, telemetry and exertional monitoring failed to reveal conduction pauses. Bedside transthoracic echocardiography suggested a right atrial mass, and subsequent thoracic CT confirmed a large paraoesophageal hiatal hernia exerting significant right atrial compression. This mechanical obstruction was presumed to have reduced venous return during exertion, compromising preload and cardiac output. In the context of syncope and bifascicular block, and given the patient′s poor surgical candidacy, a dual‐chamber permanent pacemaker was implanted. The patient remained asymptomatic during follow‐up, with no recurrence of syncope. This report describes the first known case of exertional syncope due to right atrial compression by a hiatal hernia, successfully managed with pacemaker therapy. It highlighted the importance of integrating imaging into the diagnostic workup for unexplained syncope and broadened the known cardiovascular consequences of hiatal hernia.