A Differential Diagnosis for Left Atrial Mass on Transthoracic Echocardiography: Hiatus Hernia
An 81-year-old female with a background of stable ischaemic heart disease and hypertension was referred to the cardiology department complaining of dyspnoea on exertion over a period of 12 months. This was more appreciable on inclines. She did not suffer from chest pain, orthopnoea, ankle swelling or syncope. She denied fever, weight loss, change in appetite, dyspepsia or gastrointestinal bleeding. Her medication list included aspirin, a statin, a proton-pump inhibitor and an angiotensin receptor blocker. There was no significant family history and she was a non-smoker.\nPhysical examination was normal; in particular there were no finger clubbing, no cardiac murmurs on auscultation and no signs of fluid retention such as elevated jugular venous pressure and peripheral oedema. Resting electrocardiography demonstrated normal sinus rhythm. Her haemoglobin, leukocyte count, renal and liver function blood tests were all normal. B-type natriuretic peptide was within normal limits.\nGiven her past medical history of cardiovascular disease, she was referred for echocardiography to assess for structural or functional cardiac disease possibly contributing to her unexplained dyspnoea. Transthoracic echocardiography using standard views was performed. Alarmingly, the study demonstrated a large echolucent mass with the appearance of a left atrial space-occupying lesion (fig. ). Left ventricular size and contractile function were preserved and there was no significant valvular disease. Right ventricular size and function were normal and there was no pericardial effusion.\nTo further delineate the intra-cardiac mass, the patient underwent cardiac magnetic resonance imaging (MRI). The study revealed no intra-cardiac masses, with normal heart structure and function. It demonstrated a large hiatus hernia containing food and compressing and distorting the posterior wall of the left atrium (fig. ).\nThe patient has been referred on for surgical correction of her hiatus hernia.