Clinical Investigation
Left Atrial Pressure and Function Assessments
Feeding Induces Left Atrial Compression and Impedes Cardiac Filling in Patients With Large Hiatal Hernia

https://doi.org/10.1016/j.echo.2018.09.017Get rights and content

Highlights

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    People with large HH should be assessed post feeding to evaluate hemodynamic effects.

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    Feeding can produce marked LA compression in these patients.

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    LA inflow velocities, mitral inflow velocities and E/E′ increase in compensation.

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    Exaggerated HR and BP augmentation occur to increase CO, with modest SV increase.

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    These compensatory changes improve postoperatively after LA compression resolves.

Background

Patients with large hiatal hernias (HH) frequently experience postprandial dyspnea. The aim of this study was to evaluate whether feeding induced cardiac compression in these patients using echocardiography.

Methods

Transthoracic echocardiography was performed during fasting and 30 min after feeding (300 g rice pudding) in patients with HHs (n = 32; mean age, 72 ± 9 years). A subset of patients (n = 15; mean age, 76 ± 6 years) were evaluated postoperatively.

Results

Preoperatively, feeding decreased left atrial (LA) volumes (maximal 27.4 ± 11.3 vs 19.2 ± 9.7 mL/m2, P < .001; minimal 13.1 ± 7.0 vs 6.9 ± 5.1 mL/m2, P < .001), and increased LA inflow velocities (systolic wave 0.62 ± 0.14 vs 0.77 ± 0.17 m/sec, P < .01; diastolic wave 0.46 ± 0.13 vs 0.59 ± 0.13 m/sec, P < .01), mitral inflow velocities (E wave 0.79 ± 0.17 vs 0.94 ± 0.19 m/sec, P < .01; A wave 0.93 ± 0.20 vs 1.05 ± 0.22 m/sec, P < .01), and E/E′ ratio (12.1 ± 2.7 vs 13.7 ± 3.9, P < .01). Cardiac output (6.3 ± 1.6 vs 7.24 ± 2.0 L, P < .01) increased postprandially by marked heart rate augmentation (68.8 ± 7.0 vs 84.2 ± 8.4 beats/min, P < .01), with modest stroke volume increase (88.5 ± 16.7 vs 94.3 ± 19.5 mL, P = .03). After HH surgery, feeding did not change LA volumes (maximal 52.9 ± 13.6 vs 53.4 ± 12.5 mL, P = .89; minimal 28.6 ± 12.2 vs 27.4 ± 8.7 mL, P = .59) or E/E′ ratio (10.9 ± 2.1 vs 11.3 ± 2.3) and induced more modest alterations in LA inflow (systolic wave 0.58 ± 0.17 vs 0.68 ± 0.16 m/sec, P = .01; diastolic wave 0.41 ± 0.12 vs 0.47 ± 0.13 m/sec, P = .01) and mitral inflow (E wave 0.69 ± 0.15 vs 0.80 ± 0.13 m/sec, P < .01; A wave 0.92 ± 0.13 vs 1.01 ± 0.18 m/sec, P = .02). Postoperatively, feeding increased cardiac output by substantial stroke volume augmentation (81.9 ± 16.5 vs 90.8 ± 16.0 mL, P = .01), with only modest increase in heart rate (69.8 ± 9.1 vs 75.9 ± 10.5 beats/min, P < .01).

Conclusions

Feeding produces marked LA compression in patients with HHs, inducing compensatory exaggerated responses in cardiac inflow and hemodynamic status. These compensatory mechanisms improve postoperatively following resolution of LA compression, likely explaining the debility noted preoperatively.

Section snippets

Study Design

Between November 2015 and January 2017, consecutive patients who were undergoing surgical repair of large HHs were prospectively enrolled in an observational study. Patients were included if they met the following criteria: (1) age ≥ 18 years; (2) large HH identified on endoscopic, computed tomographic, or barium swallow evaluation, defined as a hernia consisting of >30% intrathoracic stomach; (3) medically suitable for laparoscopic hernia repair; and (4) able to provide informed consent.

Results

Thirty-three consecutive patients with large HHs who presented for cardiac assessment were recruited for this study. Of these, one patient was excluded because of a history of fundoplication. The cohort consisted of predominantly women (84%; mean age, 72.4 ± 9.2 years).

Baseline characteristics are summarized in Table 1. Exertional dyspnea was reported by the majority of patients (30 of 32 [93.8%]). Postprandial dyspnea and chest pain were frequent symptoms, reported in 37.5% and 43.8% of

Discussion

The effect of feeding on cardiac hemodynamic parameters as measured on echocardiography and its contribution to postprandial symptoms in patients with large HHs are unreported. We have demonstrated that in this subset of patients with HHs, even a small meal can exacerbate LA compression, blunt postprandial SV augmentation, and result in compensatory exaggerated responses in HR, LA inflow, and LV filling pressures. These hemodynamic changes suggest that patients with HHs have limited

Conclusion

In patients with large HHs, feeding exacerbates LA compression and is associated with marked alterations in LA inflow, E/E′ ratio, HR, and blood pressure. Surgical correction of the HH eliminates feeding-associated LA compression and reduces the effects on cardiac inflow and on hemodynamical parameters.

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