Unexpected complication of diaphragmatic hernia: Compression of the heart by liver

A 51-year-old female patient was admitted to our hospital with complaints of shortness of breath and chest pain since 3 months. Her history revealed dual mesh repair for a large diaphragmatic hernia defect because of the compression of the right heart chambers by liver hernia 11 years ago and hypertension. Physical examination revealed elevated jugular venous pressure, hepatomegaly, and mild lower-extremity edema. Electrocardiography revealed sinus rhythm with negative T waves in DIII and aVF derivations. Chest X-ray revealed an elevated right-sided hemidiaphragm (Fig. 1). Two-dimensional transthoracic echocardiography demonstrated hepatic compression of the right atrium and right ventricle (Fig. 2a and 2b, Video 1). Doppler flow pattern across the tricuspid valve gradient (maximum gradient: 34 mm Hg; mean gradient: 16 mm Hg) was also noted (Fig. 2c). Left ventricular ejection fraction was 60%. Chest computed tomography identified the mass as a large transdiaphragmatic herniation of the left liver lobe protruding through a defect and hepatic compression of the right atrium and right ventricle (Fig. 2d-2f). As a definitive treatment, we recommended dual mesh repair for the diaphragmatic hernia defect, but the patient refused to get operated