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Postoperative Chest Pain

Accidental Discovery of a Hiatal Hernia While Using Transthoracic Echocardiography to Detect Myocardial Ischemia

Berger, Jeffrey S., MD, MBA; Goldstein, Michael, MD; Dangerfield, Paul, MD; Perry, Jonathan, MD; Boyd, Kendra N., MD

doi: 10.1213/ANE.0b013e3182135a1f
Cardiovascular Anesthesiology: Echo Rounds

Published ahead of print March 3, 2011

From the Department of Anesthesiology, The George Washington University Medical Center, Washington, DC.

Funding: Internally funded.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Jonathan Perry, MD, is currently affiliated with The Baltimore Washington Medical Center.

Reprints will not be available from the authors.

Address correspondence to Jeffrey S. Berger, MD, MBA, Department of Anesthesiology, The George Washington University Medical Center, 900 23rd St., NW Suite G-2092, Washington, DC 20037. Address e-mail to

Accepted December 20, 2010

Published ahead of print March 3, 2011

Written, informed patient consent for publication was obtained to report this case. An 82-year-old man with osteoarthritis presented for elective right knee arthroplasty. The patient had a history of sick sinus syndrome with a permanent pacemaker. An electrocardiogram (ECG) taken preoperatively showed a paced rhythm at 70 beats per minute.

Shortly after an uneventful operation under spinal anesthesia, while under the care of an anesthesiologist covering the postanesthesia care unit, the patient developed severe, intermittent chest pain. The rest of the examination remained unchanged with stable hemodynamics and a paced heart rhythm. An ECG and chest radiograph revealed no changes from baseline. Because the paced-ECG was not useful in diagnosing an acute coronary syndrome, a cardiologist was consulted to perform an emergent transthoracic echocardiogram (TTE).

The patient was positioned left lateral decubitus for examination. Absent chest pain, the TTE was normal; during chest pain, left ventricular function remained normal without regional wall motion abnormalities. However, a 3 × 3.5 cm hyperechoic mass was seen posterior to the left atrium in both the parasternal, long-axis view, with the probe along the left sternal border in the third–fifth intercostal space, and the apical, 5-chamber view, with the probe over the apical impulse (Figs. 1 and 2). Further examination with color flow Doppler failed to demonstrate vascular flow within the mass (Video 1; see Supplemental Digital Content 1,; see Appendix for video legend). Additionally, although the mass appeared to compress the left atrium, there was no flow acceleration across the mitral valve suggesting no obstruction or functional stenosis attributable to the mass. IV perflutren contrast given during the echocardiogram demonstrated complete left atrial opacification without opacification of the mass and without filling defect within the left atrium, further suggesting an extracardiac and avascular mass (Video 2; see Supplemental Digital Content 2,; see Appendix for video legend).

Figure 1

Figure 1

Figure 2

Figure 2

Because hiatal hernia was suspected, the patient was instructed to ingest a carbonated beverage. TTE visualization of microbubbles in the cavity of the mass strongly suggested the diagnosis of hiatal hernia, although this clip was unavailable for publication because of poor image quality. A computed tomographic scan was performed that confirmed the presence of a hiatal hernia (Fig. 3). Appropriate management of the hiatal hernia was pursued with successful resolution of the patient's symptoms.

Figure 3

Figure 3

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We report the unusual finding of a hiatal hernia during TTE evaluation of postoperative chest pain. As a diagnostic aid, TTE is readily available, portable, and noninvasive. The role of TTE for patients with ongoing chest discomfort and a nondiagnostic ECG due to ventricular pacing has been well established to help diagnose acute myocardial infarction.1 While the finding of regional wall motion abnormalities on a TTE would be highly suggestive of an ischemic etiology for chest discomfort, the finding of normal systolic thickening would be reassuring. Our echocardiographic examination revealed normal left ventricular wall motion and thickness, making ischemic chest pain unlikely.

The echocardiogram instead revealed an echogenic mass posterior to the left atrium. TTE can be used to determine the size, anatomic location, and heterogeneity of the lesion. Understanding these features of the mass may help the clinician to distinguish among tumor, cyst, thrombus, aneurysm, or hiatal hernia. By contrast, transesophageal echocardiography may be problematic in this setting because the mass is often positioned either between the esophageal probe and the heart, obscuring visualization of the cardiac silhouette by air in the hiatal hernia, or retroesophageal as in this patient, introducing the possibility that transesophageal echocardiography may require significant probe manipulation to visualize the mass.

Mass location and vascularity were assessed with several maneuvers. The mass was determined to be extracardiac in nature after IV contrast completely opacified the left atrium.2 In the apical, 4-chamber view with anterior angulation, or the apical 5-chamber view, respiratory fluctuation of the mass with a stationary aortic valve also suggested an extracardiac mass (Video 2, see Supplemental Digital Content 2,; see Appendix for video legend).3 Assessment of vascularity with color Doppler was supplemented by an evaluation of delayed IV contrast. The absence of delayed enhancement of the mass after IV contrast suggested that the mass was not highly vascular.

There are limitations to TTE in the perioperative setting. Whereas our patient tolerated lateral decubitus positioning, TTE image acquisition may be hindered in postoperative patients who must remain supine. When evaluating for ischemia, TTE is somewhat limited in the absence of previous studies for comparison. Hiatal hernia diagnosis is unreliable with TTE because the hiatal hernia may be too distant in the far field to be adequately visualized. Note that for patients deemed unable to tolerate swallowing, agitated normal saline (10 mL) could have been injected via orogastric tubing to observe microbubbles within the mass.2,4

In our patient, the diagnosis of a hiatal hernia was ultimately confirmed by a computed tomographic scan (Fig. 3), but the TTE was key to understanding this patient's postoperative chest pain. Acute ischemia was excluded by examining regional myocardial wall motion function. Subsequently, a mass posterior to the left atrium was evaluated with color Doppler and perflutren contrast injection, which isolated the mass as extracardiac and avascular. Finally, carbonated beverage ingestion followed by computed tomographic scan confirmed a hiatal hernia as the cause of the patient's postoperative chest pain. Looking toward the future, a basic understanding of TTE should be considered as an additional diagnostic aid for anesthesiologists in the perioperative setting.

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Name: Jeffrey S. Berger, MD, MBA.

Contribution: This author helped write the manuscript.

Attestation: Jeffrey S. Berger approved the final manuscript.

Name: Michael Goldstein, MD.

Contribution: This author helped conduct the study, analyze the data, and write the manuscript.

Attestation: Michael Goldstein approved the final manuscript.

Name: Paul Dangerfield, MD.

Contribution: This author helped conduct the study.

Attestation: Paul Dangerfield approved the final manuscript.

Name: Jonathan Perry, MD.

Contribution: This author helped conduct the study and write the manuscript.

Attestation: Jonathan Perry approved the final manuscript.

Name: Kendra N. Boyd, MD.

Contribution: This author helped conduct the study and write the manuscript.

Attestation: Kendra N. Boyd approved the final manuscript.

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The authors acknowledge the efforts of Rachel Berger, MD, in editing the manuscript. Additionally, Nikodimos Fikru assisted with annotation of video clips.

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Video 1. Transthoracic, parasternal, long-axis view with color flow Doppler fails to show vascular flow within the hiatal hernia (HH). LA = left atrium; LV = left ventricle.

Video 2. Transthoracic, apical, 4-chamber view with anterior angulation before and after IV contrast demonstrating lack of left atrium (LA) filling defect. LV = left ventricle; RA = right atrium; RV = right ventricle; AV = aortic valve; HH = hiatal hernia.

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1. Cheitlin MD, Armstrong WF, Aurigemma GP, Beller GA, Bierman FZ, Davis JL, Douglas PS, Faxon DP, Gillam LD, Kimball TR, Kussmaul WG, Pearlman AS, Philbrick JT, Rakowski H, Thys DM, Antman EM, Smith SC, Alpert JS, Gregoratos G, Anderson JL, Hiratzka LF, Hunt SA, Fuster V, Jacobs AK, Gibbons RJ, Russel RO. ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography). J Am Soc Echocardiogr 2003; 16: 1091–110
2. Smelley M, Lang RM. Large mass impinging on the left atrium: diagnostic value of a new cocktail. J Am Soc Echocardiogr 2007; 20: 414.e5–7
3. D'Cruz IA, Hancock HL. Echocardiographic characteristics of diaphragmatic hiatus hernia. Am J Cardiol 1995; 75: 308
4. Frans EE, Nanda NC, Patel V, Vengala S, Mehmood F, Fonbah WS, Bodiwala K. Transesophageal two-dimensional echocardiographic identification of hiatal hernia. Echocardiography 2005; 22: 533–5
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Clinician's Key Teaching Points By Martin M. Stechert M.D., Kent H. Rehfeldt M.D., and Martin J. London M.D.
  • A hiatal hernia is a prolapse of a portion of the stomach through the esophageal hiatus. Its incidence increases with age and is associated with obesity and gastroesophageal reflux disease. Although the most common clinical symptom is heartburn, it is known for its potential to cause atypical chest pain and is thus included in the differential diagnosis of an acute coronary syndrome.
  • Using standard transthoracic echocardiogram (TTE) imaging planes such as the parasternal long- and short-axis views together with apical 4-chamber and 2-chamber views, the finding of normal global ventricular function, together with a lack of regional wall motion abnormalities, will generally help the clinician exclude myocardial ischemia as a cause of acute chest pain. Although diagnosis of hiatal hernia is usually made by either upper endoscopy or contrast radiography, it may occasionally also be recognized during echocardiographic examinations.
  • In this case, although TTE was helpful in excluding myocardial ischemia as a cause of this patient's chest pain, it did reveal a mass posterior to the left atrium suspicious for hiatal hernia. The lack of contrast enhancement after IV perflutren (a lipid microsphere preparation used as an echo contrast agent) administration indicated that the mass was not in immediate communication with the heart or great vessels. The subsequent appearance of microbubbles within the mass after ingestion of a carbonated beverage confirmed the diagnosis of hiatal hernia.
  • Patients who complain of chest pain in the perioperative period require prompt evaluation. Based on the nature of the symptoms and the patient's history, TTE may be considered in those patients in whom initial studies such as electrocardiogram are nondiagnostic or confounded by paced rhythms or bundle branch blocks. Hiatal hernia should be considered in the differential diagnosis and may be recognized on TTE imaging.

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© 2011 International Anesthesia Research Society