Compression of the right ventricle by the liver through a diaphragmatic hernia after right gastroepiploic artery coronary bypass grafting

Received 6 May 2013; accepted for publication 26 June 2013. A 62-year-old women was admitted with atypical chest pain and class III NYHA dyspnoea. There was a previous history of CABG in 2000 – after anterior STEMI infarction – with LIMA and RIMA grafts, respectively, on the LAD and circumflex arteries and a right gastroepiploic artery (GEA) graft on the RPD artery. Transthoracic echocardiography showed a large 5 × 4 cm mass compressing the right ventricle and the atrio-ventricular junction (figure 1). The Doppler flow pattern across the tricuspid valve was normal during inspiration and expiration. We also note the absence of respiratory variation of the Doppler mitral inflow pattern. Contrast-enhanced MDCT (multidetector computer tomography) identified the mass as a large transdiaphragmatic herniation of the left liver lobe protruding through a 5-cm defect. The GEA graft was clearly permeable but appears raised by the hernia. The right atrioventricular compression was evident (figures 2 and 3). Abdominal MRI, performed to investigate a simultaneous pancreatic serous cystadenoma, also perfectly illustrated the hernia (figure 4). The need for surgical repair was driven by the degree of clinical symptoms, the large width of the hernia defect and the compression of the right ventricle. Compression of the right ventricle by the liver through a diaphragmatic hernia after right gastroepiploic artery coronary bypass grafting