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Endgames Case Review

A man with a murmur and missing heart

BMJ 2015; 351 doi: (Published 04 December 2015) Cite this as: BMJ 2015;351:h5386
  1. Mithun Chakravorty, core medical trainee1,
  2. Abdallah Al-Mohammad, consultant cardiologist1,
  3. Peter Brown, consultant radiologist2,
  4. Amit Allahabadia, consultant endocrinologist3,
  5. Ever Grech, consultant cardiologist3
  1. 1Northern General Hospital, Sheffield S5 7AU, UK
  2. 2Department of Radiology, Northern General Hospital
  3. 3Sheffield Teaching Hospitals NHS Trust, Sheffield
  1. Correspondence to: M Chakravorty mithun.chakravorty{at}

An 81 year old man presented with increased lethargy over several months and progressive dyspnoea on exertion. He had no orthopnoea, paroxysmal nocturnal dyspnoea, chest pain, palpitations, or syncope. He had hypertension and glaucoma and was a non-smoker. His regular drugs were aspirin, simvastatin, candesartan, omeprazole, and latanoprost eye drops.

Clinical examination showed a grade 3/6 ejection systolic murmur heard throughout the precordium, including the aortic region, radiating to the carotids. His pulse was regular, of normal character and good volume. He had no evidence of congestive cardiac failure and the rest of the physical examination was unremarkable.

Routine blood tests showed abnormal thyroid function and low serum testosterone. He was referred to endocrinology and transthoracic echocardiography was performed. The parasternal views were poor but indicated moderate to severe aortic stenosis. He had mild left ventricular hypertrophy but good biventricular systolic function, biatrial dilatation, and mild diastolic dysfunction. Electrocardiography showed sinus rhythm with no abnormalities.

Transoesophageal echocardiography was performed to assess the severity of aortic stenosis but the heart could not be seen at all. Computed tomography of the thorax (fig 1) was performed to investigate the reason for this.


  • 1. What is the pathological finding in the computed tomogram?

  • 2. What further investigation would help assess the severity of the cardiac condition?

  • 3. What are the treatment options for the cardiac condition?


1. What is the pathological finding in the computed tomogram?

Short answer

Large hiatus hernia.


The diagnosis of a large hiatus hernia was suspected at the time of transoesophageal echocardiography so computed tomography of the thorax was preferred to chest radiography. Computed tomography enabled the size and extent of the hernia to be determined and clearly demonstrated the gastric air between the oesophagus and the heart (fig 2). Chest radiography would have enabled diagnosis of the hernia but would not have provided the extra details provided …

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