SAGES 2026 Annual Meeting Emerging Technology Session

Resolution of Treatment-Resistant Atrial Fibrillation After Paraesophageal Hernia Repair

Atrial fibrillation (AF) and other atrial tachyarrhythmias affect over 0.5% of the entire world’s population (Lippi, 2020).
There is correlation between gastroesophageal reflux disease. (GERD) and AF (Roman, 2012).
PPI use can decrease the frequency of arrhythmias (Mohamed, 2020; Weigl, 2003).
Hiatal hernia have been reported in association with multiple variations of cardiac arrhythmia (Kraweic 2021).
79-year-old female with a two-year history of paroxysmal atrial fibrillation (PAF) complicated by atrial thrombus refractory to maximal medical management and longstanding GERD.

Not willing to undergo ablative therapy unless necessary.
ICD in place, on Eliquis.
Elected to undergo workup for GERD and was found to have a large PEH on esophagram and CT (Figure 1).
Underwent robotic-assisted laparoscopic paraesophageal hernia repair with Collis gastroplasty and Nissen fundoplication.
Uneventful hospital stay of two days and was discharged home tolerating a full liquid diet.
Repeat esophagram was performed as a part of routine outpatient follow-up noting no evidence of recurrent hernia with normal esophageal passage of contrast into the intra-abdominal stomach (Figure 2).
Interrogation of ICD over next 12 months noted sinus rhythm with only one non-sustained episode of AF. Advanced ablative therapies were no longer indicated

Two mechanisms of hiatal hernia precipitating tachyarrhythmia have been proposed:

Mechanical compression on the left atrium or irritation of the lower esophagus affecting vagal tone (Mo hamad 2020).
Cytokine release from the adjacent esophagus or stomach altering electrical conduction of the heart (Mohamed, 2020; Armaganijan, 2012).

In a 2013 retrospective study, 7.1% of patients with PEH were found to also have AF, and the prevalence of predisposing conditions was less frequent in patients with both PEH and AF.
In this case, AF persisted despite goal-directed treatment and was only cured following surgical repair of hiatal hernia.

Further research is necessary to delineate the exact mechanism of atrial arrhythmia development in patients with GERD.
Investigation of reversible gastroenterological factors perpetuating PAF in patients who are considering electrophysiological intervention may be warranted.
Additional investigation exploring the co-occurrence of PEH and PAF may provide us with information regarding the etiology of AF, especially in previously healthy patients without a known provoking factor.

RESOLUTION OF TREATMENT RESISTANT ATRIAL FIBRILLATION AFTER PARAESOPHAGEAL HERNIA REPAIR