More Than A Heart and Lungs in The Chest, with Paul Thompson, MD

In his most recent column, Dr. Paul Thompson offers perspective on why he feels clinicians should consider performing a chest x-ray in patients with dyspnea or frequent palpitations, but no history of lung disease and a normal cardiac work-up.

Over the last 6 months, I have had two patients with more than a heart and lungs in their chest. The first was a retired teacher who developed dyspnea mowing his lawn. It sounded cardiac to me, but his echocardiogram and exercise stress test were normal. I ordered a chest x-ray because, years ago, I had a patient with similar symptoms who turned out to have a paralyzed right hemidiaphragm.

I was embarrassed by missing that prior patient and, consequently, very proud of myself when the present patient’s chest x-ray showed an elevated right hemidiaphragm. I shipped the patient off to a pulmonologist, who did a radiographic cine sniff test that showed normally moving hemidiaphragms bilaterally, but a very large hiatal hernia. The patient is scheduled for closed hiatal hernia repair because the pulmonologist is convinced that this is the cause of the patient’s dyspnea.

I also recently saw a distance runner with palpitations. He had had palpitations (and gastro-esophageal reflux) for several years but a recent prolonged episode of palpitations sent him to the emergency department (ED). I ordered an event monitor that showed that 10% of his beats were PVCs. His echocardiogram and left ventricular function were normal, but his chest x-ray from the ED showed a large hiatal hernia. Large hiatal hernias have been associated with ventricular ectopy, which was cured by hernia repair.1 We did not pursue hernia repair in this patient because his left ventricular ejection fraction was normal, and he and his wife declined because the patient had early dementia.

So, what’s the point? Consider doing a chest x-ray when patients have dyspnea or frequent palpitations, but no history of lung disease, and a normal cardiac workup. Sometimes there is more in the chest than just a heart and lungs, like a paralyzed hemidiaphragm or most of their stomach.

1. Gnanenthiran, SR et al.Posterior cardiac compression from a large hiatal hernia-A novel cause of ventricular tachycardia.HeartRhythm Case Rep. 2018 May 23;4(8):362-366.