A 75-year-old woman with a history of Type 2 diabetes, hypertension, cerebrovascular accident, hiatal hernia, and recently diagnosed peritoneal mesothelioma with ascites was referred to our department for transthoracic echocardiography under suspicion of cardiac tamponade. During the preceding few weeks, the patient experienced shortness of breath and abdominal distension. Physical examination revealed a critically ill patient with features of shock including tachypnoea, tachycardia (117 b.p.m.), low blood pressure (90/65 mmHg), and cold extremities. Heart sounds were normal. The electrocardiogram showed a sinus tachycardia of 110/min with low voltages, without signs of electrical alternans. Transthoracic echocardiography demonstrated almost complete compression of the left atrium by a large and dense extracardiac mass (white arrow, Figure 1 and Video 1) leading to significant inflow obstruction over the mitral valve with ∼33% drop in mitral E-wave velocity on inspiration. Computed tomography revealed a large hiatal hernia with herniation of the stomach (blue arrow) and peritoneal sac filled with ascites (yellow arrow), resulting in compression of the left atrium (black arrow) and basal left ventricle causing inflow obstruction and compression atelectasis (Figure 2). After discussing the poor prognosis with the patient and her relatives, palliative care was implemented including drainage of her ascites.
Figure 1.
Transthoracic echocardiogram (parasternal long axis view) showing almost complete compression of the left atrium by a dense extracardiac mass (white arrow).
Figure 2.
Computed tomography showing a hiatal hernia with herniation of the stomach (blue arrow) and peritoneal sac filled with ascites (yellow arrow) compressing the left atrium (black arrow) and basal left ventricle.
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Conflict of interest: none declared.