Unusual finding in patient with severe acute cardiogenic pulmonary edema

Introduction: Diaphragmatic hernia represent the protrusion of abdominal viscera in the pleural space through a diaphragmatic defect. It can be congenital or acquired. In adults, it is usually caused by a traumatic factor, although cases of congenital hernia diagnosed in adulthood have been reported. Patients may be asymp-tomatic for a long time but in some cases the condition can cause circulatory, cardiac and respiratory distress. Methods: We present the case of a patient with severe acute pulmonary edema and a giant diaphragm hernia newlly diagnosed.

Results: A 52-year-old smoker, hypertensive patient, presents for dyspnea with orthopnea and atrial fibrilla-tion with a170/min. In the last year he presented 3 epi-sodes of dyspnea and palpitations with spontaneous remission and without compliance to the recommen-ded treatment. The chest radiography shows the left hemidiafragm ascended, with the cardio-mediastinal complex displaced to the right of the median line and the suspicion of diaphragmatic hernia was made. The clinical examination revealed breath sounds absent in the left lung field, with the exception of the apex and pulmonary rales crackles at the level of the right chest. Transthoracic echocardiography was made from totally atypical windows: the cholecystic point for the paras-ternal and right axillary on the medial-clavicular line for the apical window; ECG without signs of dextro-cardia. Ecocardiography shows FEVS 40% with global hypokinesia without significant valvulopathy. CT of the thorax has detected left diaphragmatic relaxation with the ascending splenic flexure of the colon in the chest, which causes the heart and mediastinum to move to the right. Evolution was slowly favorable, initially with severe dyspnea and difficult heart rate control, sub-sequent with cardiac and respiratory compensation under maximal treatement. The patient was transferred to the surgery clinic after 48 hours for evaluation and intervention in the multidisciplinary team.

Conclusions: Diaphragmatic hernia is a condition that can remain asymptomatic for a long time but in some cases can lead to pulmonary edema and heart failure through compression phenomena. It requires a high degree of suspicion and targeted investigations that will lead to an early diagnosis and appropriate therapeutic strategy. Surgery should not be delayed, because severe, life-threatening complications may occur. The particularity of this case is the severity of pul-monary edema in patient without severe cardiac patho-logy, the determinant substrate being newly diagnosed: a giant diaphragmatic hernia which completely occu-pied the left chest. A challenge in this case was also the difficulty of conducting the echocardiographic exami-nation with atypical windows.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)