1. Date of download: 6/2/2016 Copyright © The American College of Cardiology. All rights reserved. From: Left Atrial Compression and the Mechanism of Exercise Impairment in Patients With a Large Hiatal Hernia J Am Coll Cardiol. 2011;58(15):1624-1634. doi:10.1016/j.jacc.2011.07.013 Cardiac and Esophageal Anatomical Relationship The relevant infero-posterior cardiac structures (coronary sinus, left atrium [LA], and pulmonary veins) and their immediate relationship to the esophagus are demonstrated in the sagittal section (A). Compression by a large hiatal hernia is illustrated in B showing progressive involvement, in order, of the coronary sinus, LA, and inferior pulmonary veins with increasing size of the hernia. AO = aorta; BR = bronchus; LAA = left atrial appendage; LIPV = left inferior pulmonary vein; LSPV = left superior pulmonary vein. Figure Legend:

2. Date of download: 6/2/2016 Copyright © The American College of Cardiology. All rights reserved. From: Left Atrial Compression and the Mechanism of Exercise Impairment in Patients With a Large Hiatal Hernia J Am Coll Cardiol. 2011;58(15):1624-1634. doi:10.1016/j.jacc.2011.07.013 Cardiac CT and Doppler-Echocardiographic Findings Before and After HH Repair (A) Sagittal section summarizing the cardiac computed tomography (CT) abnormalities seen. Left atrial compression by a large hiatal hernia (HH) with flattening of the LA contour is demonstrated. Compression of the LIPV between the HH and a central bronchus, compression of the coronary sinus (CS), and sparing of the left superior pulmonary vein (LSPV) are also seen. (B) Post- operatively, there is resolution of cardiac compression with restoration of the size and contour of the LA. (C) Parasternal long-axis echocardiographic view demonstrating left atrial compression by a HH (*). Measurement of the left atrial diameter from the midpoints of anterior and posterior left atrial walls is shown. (D) Corresponding post-operative view showing resolution of left atrial compression with a significant increase in left atrial diameter. (E) Pre-operative apical 4-chamber view with left atrial compression by an HH (*) and increased atrial inflow velocity on color Doppler imaging. Peak systolic and diastolic pulse-Doppler velocities at the atrial inflow are shown (G). (F and H) Corresponding post-operative view showing a reduction in the atrial inflow velocity on color and pulse-Doppler imaging. Abbreviations as in Figure 1. Figure Legend:

3. Date of download: 6/2/2016 Copyright © The American College of Cardiology. All rights reserved. From: Left Atrial Compression and the Mechanism of Exercise Impairment in Patients With a Large Hiatal Hernia J Am Coll Cardiol. 2011;58(15):1624-1634. doi:10.1016/j.jacc.2011.07.013 Patient Evaluation Flowchart The final analysis was performed in the 30 patients who completed all pre-operative and post-operative investigations. CT = computed tomography; HH = hiatal hernia. Figure Legend:

4. Date of download: 6/2/2016 Copyright © The American College of Cardiology. All rights reserved. From: Left Atrial Compression and the Mechanism of Exercise Impairment in Patients With a Large Hiatal Hernia J Am Coll Cardiol. 2011;58(15):1624-1634. doi:10.1016/j.jacc.2011.07.013 Change in Functional Class and Exercise Capacity After HH Repair Change in New York Heart Association functional class (A) and mean exercise capacity (B) after hiatal hernia repair. Exercise capacity defined as metabolic equivalents (METS) achieved expressed as a percentage of age-predicted values. *p value for chi- square test for trend. Figure Legend:

5. Date of download: 6/2/2016 Copyright © The American College of Cardiology. All rights reserved. From: Left Atrial Compression and the Mechanism of Exercise Impairment in Patients With a Large Hiatal Hernia J Am Coll Cardiol. 2011;58(15):1624-1634. doi:10.1016/j.jacc.2011.07.013 Relationship Between Baseline Cardiac Compression and Change in Exercise Capacity After HH Repair Pre-operatively, qualitative assessment of left atrial (LA) compression on echocardiography and LA and right inferior pulmonary vein (IPV) compression on cardiac computed tomography (CT) predict a greater increase in exercise capacity after hiatal hernia (HH) repair. Change in exercise capacity is defined as post-operative exercise capacity minus pre-operative exercise capacity. *p value for linear trend. MET = metabolic equivalent. Figure Legend: