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A 77-year-old man with a history of Coronary artery disease, COPD, and pulmonary fibrosis on 5 L of oxygen at home presented to the emergency department with dizziness.  Vital signs at presentation included temperature 37°C, pulse 160/min, blood pressure 86/60 mmHg, respiratory rate 24/min, oxygen saturation 96% on 5 L of oxygen. He had end-inspiratory crackles on lung auscultation.  His labs were unremarkable, but he had atrial fibrillation with a ventricular rate of 162 and non-specific T wave changes on EKG. Chest X-ray showed prominent interstitial markings representing fibrosis, and Chest CT revealed a large hiatal hernia with left pleural thickening and worsening emphysema. Transthoracic Echocardiogram (TTE) showed an Ejection fraction of 75%, extrinsic compression of the inferior, lateral, and inferolateral wall, and impaired relaxation. Other Echocardiographic findings were extrinsic compression of the left atrium, dilated right atrium, moderate tricuspid regurgitation, and estimated right ventricular systolic pressure of at least 96 mmHg (Figures 1a,b&amp;c).

Too close for comfort: A case of extrinsic compression of the left ventricle by a large hiatal hernia