Resolution of Roemheld Syndrome After Hiatal Hernia Repair and LINX Placement: Case Review

Abstract

Roemheld syndrome, also known as gastrocardiac syndrome, was first studied as a relationship between gastrointestinal and cardiovascular symptoms through the vagus nerve. Several hypotheses have attempted to explain the pathophysiology of Roemheld syndrome, but the underlying process remains unclear. We present a clinically diagnosed case of Roemheld syndrome in a patient with a hiatal hernia whose gastrointestinal and cardiac symptoms were successfully treated with robotic assisted hernia repair, esophagogastroduodenoscopy (EGD), and LINX magnetic sphincter augmentation. Our case is a 60-year-old male with a history of esophageal stricture and hiatal hernia who presented with complaints of gastroesophageal reflux disease (GERD) and related arrhythmias for five years. The patient did not have a history of cardiovascular disease other than hypertension. The cause of the hypertension was assumed to be primary, as workup for possible pheochromocytoma was negative. Cardiac work-up revealed arrhythmias that were characterized as supraventricular tachycardia with intermittent pre-ventricular contractions (PVC); however, testing was unable to determine a cause for the arrhythmias. High-resolution manometry showed low pressure in the lower esophageal sphincter with normal esophageal motility. Further evaluation included a 96-hour Bravo test and DeMeester score of 31 was recorded, confirming mild GERD; however, EGD was unremarkable. Surgeons elected to perform a robotic assisted hiatal hernia repair, EGD, and magnetic sphincter augmentation. Four months following surgery, the patient denied symptoms of GERD or episodes of palpitation and subsequently weaned off proton pump inhibitors with continual lack of symptoms. GERD is a common complaint among the primary care setting; however, ventricular dysrhythmias among this population and a clinical diagnosis of Roemheld syndrome is unique. One hypothesis may be that protrusion of the stomach into the chest cavity may exacerbate current reflux, and the anatomical relationship between a herniated fundus and anterior vagal nerve may cause direct physical stimulation that is a more potent risk factor for the development of arrythmias. However, Roemheld Syndrome is a unique diagnosis, and the pathophysiology is still yet to be understood.