Asymptomatic Diaphragmatic Dome Hernia in an Elderly Adult: Case Report and Review on Conservative Management

Asymptomatic Diaphragmatic Dome Hernia in an Elderly Adult: Case Report and Review on Conservative Management | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Asymptomatic Diaphragmatic Dome Hernia in an Elderly Adult: Case Report and Review on Conservative Management Daudet Balonga Basakuwao, Augustin Kibonge Mukakala, Christian Bisimwa Wabene, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6559280/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 27 Nov, 2025 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted 20 You are reading this latest preprint version Abstract Background : Diaphragmatic dome hernia (DDH) is a rare condition in adults, often congenital or traumatic, involving a diaphragmatic defect allowing abdominal contents to herniate into the thorax. Late asymptomatic presentation is uncommon and diagnostically challenging. Case Presentation : A 73-year-old man with a productive cough was incidentally diagnosed with a large asymptomatic diaphragmatic hernia. Chest X-ray and thoraco-abdominal CT showed left intrathoracic colon causing left lung collapse and rightward mediastinal shift. Conservative management with clinical follow-up was chosen due to the patient’s age and stability, with no symptoms at six months. Conclusions : Asymptomatic adult DDH is rare and relies on imaging for diagnosis. Conservative management with vigilant monitoring is viable for stable patients with high surgical risks, requiring individualized risk assessment. Diaphragmatic hernia Asymptomatic Conservative management Imaging Adult Figures Figure 1 Figure 2 Background Diaphragmatic dome hernia (DDH) in adults is a rare and potentially severe condition of congenital or traumatic origin. It results from a defect in the diaphragmatic muscle, allowing abdominal contents to protrude into the thoracic cavity, which may impair lung expansion [ 1 , 2 ]. Congenital DDH is characterized by the partial or complete absence of a diaphragmatic dome, leading to abnormal organ displacement into the thorax during critical stages of fetal lung development [ 3 ]. This condition is often associated with significant morbidity and mortality due to pulmonary hypoplasia, pulmonary hypertension, and heart failure [ 4 – 6 ]. The incidence of diaphragmatic hernia is approximately 1 in 3,500 live births, with a slight male predominance [ 4 , 7 – 9 ]. ]. Antenatal diagnosis is primarily achieved through routine fetal ultrasonography, but in neonates and adults with delayed presentation, additional radiological examinations are often required to confirm the diagnosis [ 4 , 7 , 9 – 11 ]. DDH may occur in isolation or in association with other malformations, such as pulmonary hypoplasia, pulmonary arterial hypertension, patent ductus arteriosus, pulmonary sequestration, septal defects, intestinal malrotation, Meckel’s diverticulum, or Down syndrome [ 4 , 7 , 12 – 16 ]. This case report aims to highlight, in light of the literature, the asymptomatic presentation of certain DDH cases, which can complicate clinical diagnosis. It also seeks to open a discussion on the indications for surgical intervention in such cases. Case presentation A 73-year-old man presented to our hospital with a three-week history of productive cough and rhinorrhea. He was previously diagnosed with a flu-like illness at a peripheral health center. A chest X-ray revealed intrathoracic abdominal contents, prompting referral to our department for further management. The patient reported a productive cough and rhinorrhea but denied significant respiratory symptoms, vomiting, heartburn, or bowel dysfunction. His medical history included an exploratory laparotomy for typhoid intestinal perforation 11 years prior, complicated by a surgical site infection that was successfully treated. On physical examination, the patient was in stable condition with a symmetrical thorax and eupneic, with a respiratory rate of 18 breaths per minute. Vocal fremitus was more pronounced on the right than the left. Chest percussion revealed tympanism on the left side, with markedly reduced air entry and audible bowel sounds in the left thorax. Heart sounds were audible but displaced to the right. Abdominal examination showed a midline laparotomy scar. Chest X-ray demonstrated a discontinuity of the left diaphragmatic dome, significant bowel presence in the left thoracic cavity, severe left lung collapse, and rightward mediastinal shift (Fig. 1 ). A thoraco-abdominal CT scan confirmed pulmonary fibrosis in the ventral segment of the left upper lobe, passive left lung collapse next to a large diaphragmatic hernia containing the left colon, which was also compressing the stomach within the hernial sac (Fig. 2 ). No other associated malformations were identified. Given the patient’s age and the asymptomatic nature of the diaphragmatic hernia, a conservative approach was proposed. The patient and his family agreed to a clinical follow-up plan with monthly medical evaluations. At follow-up visits one-and-a-half then six months later, the patient remained stable, with resolution of his initial symptoms. Discussion and Conclusions Diaphragmatic hernia is a rare and potentially severe condition of congenital or traumatic origin, resulting from a diaphragmatic defect that allows abdominal contents to protrude into the thoracic cavity. This condition, whether due to congenital embryopathy or mechanical compression of the cardiopulmonary system, is associated with pulmonary hypoplasia, reduced pulmonary vasculature, pulmonary arterial hypertension (PAH), and, in severe cases, heart failure. These anatomical and functional abnormalities contribute to the wide variability in clinical presentation at birth [ 17 , 18 ]. The diagnosis of DDH in adulthood is exceedingly rare in clinical practice and the literature, with most reported cases linked to trauma. In the present case, a 73-year-old man with no trauma history was diagnosed with DDH, highlighting its rarity, as late-presenting DDH accounts for 5–45% of cases [ 10 , 19 ]. The pathophysiology of delayed DDH presentation remains poorly understood. Obstruction of the diaphragmatic defect by abdominal organs, such as the liver or spleen, may delay symptom onset. Symptoms may manifest during events that increase intra-abdominal pressure, such as coughing, physical exertion, vomiting, or trauma [ 19 , 20 ]. In DDH, clinical latency can be prolonged, with symptoms often absent until the hernia is revealed, as observed in this patient. No pathognomonic clinical presentation exists, and severe complications like strangulation, volvulus, or sudden death, though rare, have been reported. The number and volume of herniated organs vary and may include the spleen, colon, liver, stomach, kidney, or pancreatic tail, with the colon and stomach most commonly involved [ 18 , 21 , 22 ]. In this case, a large left colon herniation into the left thoracic cavity caused left lung collapse and fibrosis in the ventral segment of the left upper lobe. In congenital diaphragmatic hernia (CDH), typically diagnosed prenatally or in newborns, respiratory symptoms predominate due to pulmonary hypoplasia or lung compression. Common manifestations include dyspnea, wheezing, recurrent respiratory infections, and cough [ 4 , 23 – 25 ]. This case raises questions about the nature of the DDH: Was it a congenital hernia that remained asymptomatic until adulthood, or was it acquired? Could it be related to the patient’s laparotomy 11 years prior for typhoid intestinal perforation? If congenital, the hernia might have been identified intraoperatively during the prior surgery, as the abdominal cavity is thoroughly explored. Conversely, an acquired hernia due to an intraoperative diaphragmatic injury would likely have caused symptoms earlier. The absence of trauma history further complicates the etiopathogenesis, prompting discussion on the clinical manifestations, etiology, and prognosis of atraumatic DDH in adults. In older children, symptoms are often abdominal, including nausea, vomiting, and pain, with complications like gastric volvulus or splenic torsion occasionally revealing the condition[ 21 , 26 – 31 ]. In both neonatal and delayed-presenting cases, left posterolateral (Bochdalek) hernias are most common, consistent with embryological patterns and clinical data [ 22 , 26 , 32 – 34 ]. Diagnosis relies heavily on radiological imaging. A coronal chest X-ray is often the initial modality, but findings such as pneumonia, pneumothorax, pleural effusion, or diaphragmatic masses may obscure or mimic the condition, posing diagnostic challenges [ 18 , 35 – 38 ]. In this case, a thoraco-abdominal X-ray revealed a left intrathoracic colon compressing the ipsilateral lung and causing rightward mediastinal shift (Fig. 1 ). A thoraco-abdominal CT scan confirmed pulmonary fibrosis in the ventral segment of the left upper lobe, passive left lung collapse, and a large diaphragmatic hernia containing the left colon, which compressed the stomach (Fig. 2 ). Contrast-enhanced thoracic CT or MRI can further aid in confirming the diagnosis. Treatment of diaphragmatic hernia typically involves surgical repair of the defect after reducing herniated organs, using open or laparoscopic approaches[ 39 – 41 ]. However, in this case, given the patient’s age, asymptomatic presentation, and absence of complications, a conservative approach with monthly clinical follow-up was chosen. After four visits, the patient remained asymptomatic. The necessity of surgical intervention for asymptomatic, atraumatic diaphragmatic hernias in adults remains controversial. Studies support non-surgical management in stable, asymptomatic patients, particularly those with high surgical risks. For example, Takahashi et al. (2016) successfully monitored two asymptomatic cases (a stable iatrogenic diaphragmatic hernia and a Bochdalek hernia) without surgery [ 42 ], while Elfiky et al. (2019) and Gunia et al. (2022) deferred surgery in high-risk patients with minimal symptoms, prioritizing comorbidities and stability [ 43 , 44 ]. However, Antony et al. (2021) reported a fatal case due to undetected progression, highlighting potential risks [ 45 ]. A wait-and-see approach with vigilant clinical and imaging follow-up is viable for asymptomatic hernias but requires individualized risk assessment to balance surgical risks against potential complications. In conclusion, adult DDH in an atraumatic context is rare, often clinically latent, and diagnosed via radiological imaging, including chest X-ray, abdominal ultrasound, thoraco-abdominal CT, or MRI. The decision to pursue surgical intervention for asymptomatic cases remains debated. Evidence supports conservative management in stable, asymptomatic adults, particularly with high surgical risks, but rigorous monitoring is essential to detect complications. This nuanced approach aligns with personalized medicine, balancing immediate intervention against expectant management based on individual risk profiles. Abbreviations CT Computed Tomography DDH Diaphragmatic Dome Hernia MRI Magnetic Resonance Imaging PAH Pulmonary Arterial Hypertension Declarations Ethics approval and consent to participate Not applicable Consent for publication  Written informed consent was obtained from the patient for the publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.. Availability of data and materials  All the data and materials supporting our findings are included within the article. Competing interests  The authors declare no competing interests. Funding  Not applicable Authors' contributions  Conceptualization and Manuscript Drafting : D.B.B., A.K.M., and C.B.W. Patient Management and Follow-Up : D.B.B. and A.K.M. CT Scan Image Analysis : R.K.N., M.M.K., and J.K.K. Figure Preparation : C.B.W. Manuscript Revision : C.B.W., A.A.A., and A.R.A. All authors read and approved the final manuscript. 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Cite Share Download PDF Status: Published Journal Publication published 27 Nov, 2025 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted Editorial decision: Revision requested 14 Sep, 2025 Reviewers agreed at journal 12 Jul, 2025 Reviews received at journal 11 Jul, 2025 Reviewers agreed at journal 11 Jul, 2025 Reviews received at journal 11 Jul, 2025 Reviews received at journal 11 Jul, 2025 Reviewers agreed at journal 11 Jul, 2025 Reviewers agreed at journal 10 Jul, 2025 Reviews received at journal 09 Jul, 2025 Reviewers agreed at journal 09 Jul, 2025 Reviews received at journal 09 Jul, 2025 Reviewers agreed at journal 09 Jul, 2025 Reviews received at journal 09 Jul, 2025 Reviewers agreed at journal 09 Jul, 2025 Reviewers agreed at journal 09 Jul, 2025 Reviewers agreed at journal 09 Jul, 2025 Reviewers invited by journal 09 Jul, 2025 Editor assigned by journal 02 May, 2025 Submission checks completed at journal 02 May, 2025 First submitted to journal 29 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6559280","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":483273389,"identity":"06e02eb1-0e5f-4b36-9dbd-b87389f46209","order_by":0,"name":"Daudet Balonga Basakuwao","email":"","orcid":"","institution":"Department of Surgery, Cardiothoracic Surgery Sub-Unit, University Clinics of Lubumbashi, Faculty of Medicine, University of 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16:11:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2694525,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6559280/v1/e3b628b7-1a25-4ea4-b26e-e972cf8bff45.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Asymptomatic Diaphragmatic Dome Hernia in an Elderly Adult: Case Report and Review on Conservative Management","fulltext":[{"header":"Background","content":"\u003cp\u003eDiaphragmatic dome hernia (DDH) in adults is a rare and potentially severe condition of congenital or traumatic origin. It results from a defect in the diaphragmatic muscle, allowing abdominal contents to protrude into the thoracic cavity, which may impair lung expansion [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Congenital DDH is characterized by the partial or complete absence of a diaphragmatic dome, leading to abnormal organ displacement into the thorax during critical stages of fetal lung development [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This condition is often associated with significant morbidity and mortality due to pulmonary hypoplasia, pulmonary hypertension, and heart failure [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe incidence of diaphragmatic hernia is approximately 1 in 3,500 live births, with a slight male predominance [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. ]. Antenatal diagnosis is primarily achieved through routine fetal ultrasonography, but in neonates and adults with delayed presentation, additional radiological examinations are often required to confirm the diagnosis [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. DDH may occur in isolation or in association with other malformations, such as pulmonary hypoplasia, pulmonary arterial hypertension, patent ductus arteriosus, pulmonary sequestration, septal defects, intestinal malrotation, Meckel\u0026rsquo;s diverticulum, or Down syndrome [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR13 CR14 CR15\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis case report aims to highlight, in light of the literature, the asymptomatic presentation of certain DDH cases, which can complicate clinical diagnosis. It also seeks to open a discussion on the indications for surgical intervention in such cases.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 73-year-old man presented to our hospital with a three-week history of productive cough and rhinorrhea. He was previously diagnosed with a flu-like illness at a peripheral health center. A chest X-ray revealed intrathoracic abdominal contents, prompting referral to our department for further management.\u003c/p\u003e\u003cp\u003eThe patient reported a productive cough and rhinorrhea but denied significant respiratory symptoms, vomiting, heartburn, or bowel dysfunction. His medical history included an exploratory laparotomy for typhoid intestinal perforation 11 years prior, complicated by a surgical site infection that was successfully treated.\u003c/p\u003e\u003cp\u003eOn physical examination, the patient was in stable condition with a symmetrical thorax and eupneic, with a respiratory rate of 18 breaths per minute. Vocal fremitus was more pronounced on the right than the left. Chest percussion revealed tympanism on the left side, with markedly reduced air entry and audible bowel sounds in the left thorax. Heart sounds were audible but displaced to the right. Abdominal examination showed a midline laparotomy scar.\u003c/p\u003e\u003cp\u003eChest X-ray demonstrated a discontinuity of the left diaphragmatic dome, significant bowel presence in the left thoracic cavity, severe left lung collapse, and rightward mediastinal shift (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eA thoraco-abdominal CT scan confirmed pulmonary fibrosis in the ventral segment of the left upper lobe, passive left lung collapse next to a large diaphragmatic hernia containing the left colon, which was also compressing the stomach within the hernial sac (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). No other associated malformations were identified.\u003c/p\u003e\u003cp\u003eGiven the patient’s age and the asymptomatic nature of the diaphragmatic hernia, a conservative approach was proposed. The patient and his family agreed to a clinical follow-up plan with monthly medical evaluations. At follow-up visits one-and-a-half then six months later, the patient remained stable, with resolution of his initial symptoms.\u003c/p\u003e"},{"header":"Discussion and Conclusions","content":"\u003cp\u003eDiaphragmatic hernia is a rare and potentially severe condition of congenital or traumatic origin, resulting from a diaphragmatic defect that allows abdominal contents to protrude into the thoracic cavity. This condition, whether due to congenital embryopathy or mechanical compression of the cardiopulmonary system, is associated with pulmonary hypoplasia, reduced pulmonary vasculature, pulmonary arterial hypertension (PAH), and, in severe cases, heart failure. These anatomical and functional abnormalities contribute to the wide variability in clinical presentation at birth [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe diagnosis of DDH in adulthood is exceedingly rare in clinical practice and the literature, with most reported cases linked to trauma. In the present case, a 73-year-old man with no trauma history was diagnosed with DDH, highlighting its rarity, as late-presenting DDH accounts for 5–45% of cases [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe pathophysiology of delayed DDH presentation remains poorly understood. Obstruction of the diaphragmatic defect by abdominal organs, such as the liver or spleen, may delay symptom onset. Symptoms may manifest during events that increase intra-abdominal pressure, such as coughing, physical exertion, vomiting, or trauma [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn DDH, clinical latency can be prolonged, with symptoms often absent until the hernia is revealed, as observed in this patient. No pathognomonic clinical presentation exists, and severe complications like strangulation, volvulus, or sudden death, though rare, have been reported. The number and volume of herniated organs vary and may include the spleen, colon, liver, stomach, kidney, or pancreatic tail, with the colon and stomach most commonly involved [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In this case, a large left colon herniation into the left thoracic cavity caused left lung collapse and fibrosis in the ventral segment of the left upper lobe.\u003c/p\u003e\u003cp\u003eIn congenital diaphragmatic hernia (CDH), typically diagnosed prenatally or in newborns, respiratory symptoms predominate due to pulmonary hypoplasia or lung compression. Common manifestations include dyspnea, wheezing, recurrent respiratory infections, and cough [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e–\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis case raises questions about the nature of the DDH: \u003cem\u003eWas it a congenital hernia that remained asymptomatic until adulthood, or was it acquired?\u003c/em\u003e Could it be related to the patient’s laparotomy 11 years prior for typhoid intestinal perforation? If congenital, the hernia might have been identified intraoperatively during the prior surgery, as the abdominal cavity is thoroughly explored. Conversely, an acquired hernia due to an intraoperative diaphragmatic injury would likely have caused symptoms earlier. The absence of trauma history further complicates the etiopathogenesis, prompting discussion on the clinical manifestations, etiology, and prognosis of atraumatic DDH in adults.\u003c/p\u003e\u003cp\u003eIn older children, symptoms are often abdominal, including nausea, vomiting, and pain, with complications like gastric volvulus or splenic torsion occasionally revealing the condition[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan additionalcitationids=\"CR27 CR28 CR29 CR30\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e–\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. In both neonatal and delayed-presenting cases, left posterolateral (Bochdalek) hernias are most common, consistent with embryological patterns and clinical data [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e–\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDiagnosis relies heavily on radiological imaging. A coronal chest X-ray is often the initial modality, but findings such as pneumonia, pneumothorax, pleural effusion, or diaphragmatic masses may obscure or mimic the condition, posing diagnostic challenges [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan additionalcitationids=\"CR36 CR37\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e–\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this case, a thoraco-abdominal X-ray revealed a left intrathoracic colon compressing the ipsilateral lung and causing rightward mediastinal shift (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). A thoraco-abdominal CT scan confirmed pulmonary fibrosis in the ventral segment of the left upper lobe, passive left lung collapse, and a large diaphragmatic hernia containing the left colon, which compressed the stomach (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Contrast-enhanced thoracic CT or MRI can further aid in confirming the diagnosis.\u003c/p\u003e\u003cp\u003eTreatment of diaphragmatic hernia typically involves surgical repair of the defect after reducing herniated organs, using open or laparoscopic approaches[\u003cspan additionalcitationids=\"CR40\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e–\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. However, in this case, given the patient’s age, asymptomatic presentation, and absence of complications, a conservative approach with monthly clinical follow-up was chosen. After four visits, the patient remained asymptomatic. The necessity of surgical intervention for asymptomatic, atraumatic diaphragmatic hernias in adults remains controversial. Studies support non-surgical management in stable, asymptomatic patients, particularly those with high surgical risks. For example, Takahashi et al. (2016) successfully monitored two asymptomatic cases (a stable iatrogenic diaphragmatic hernia and a Bochdalek hernia) without surgery [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], while Elfiky et al. (2019) and Gunia et al. (2022) deferred surgery in high-risk patients with minimal symptoms, prioritizing comorbidities and stability [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. However, Antony et al. (2021) reported a fatal case due to undetected progression, highlighting potential risks [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA wait-and-see approach with vigilant clinical and imaging follow-up is viable for asymptomatic hernias but requires individualized risk assessment to balance surgical risks against potential complications.\u003c/p\u003e\u003cp\u003eIn conclusion, adult DDH in an atraumatic context is rare, often clinically latent, and diagnosed via radiological imaging, including chest X-ray, abdominal ultrasound, thoraco-abdominal CT, or MRI. The decision to pursue surgical intervention for asymptomatic cases remains debated. Evidence supports conservative management in stable, asymptomatic adults, particularly with high surgical risks, but rigorous monitoring is essential to detect complications. This nuanced approach aligns with personalized medicine, balancing immediate intervention against expectant management based on individual risk profiles.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eComputed Tomography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDDH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDiaphragmatic Dome Hernia\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMagnetic Resonance Imaging\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePAH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePulmonary Arterial Hypertension\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Written informed consent was obtained from the patient for the publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal..\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the data and materials supporting our findings are included within the article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConceptualization and Manuscript Drafting\u003c/strong\u003e: D.B.B., A.K.M., and C.B.W.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Management and Follow-Up\u003c/strong\u003e: D.B.B. and A.K.M.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCT Scan Image Analysis\u003c/strong\u003e: R.K.N., M.M.K., and J.K.K.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure Preparation\u003c/strong\u003e: C.B.W.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eManuscript Revision\u003c/strong\u003e: C.B.W., A.A.A., and A.R.A.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLundgren J, Mousavie S, Negahi A, Varga G, Granehed H, Aky\u0026uuml;rek L, et al. A review on Traumatic diaphragmatic ruptur. Trauma Emerg Care. 2017;2(5):1\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDorgam Mau\u0026eacute;s CA, De Vasconcelos ELC, Da Silva Galv\u0026atilde;o R, Rios Rodriguez JE, Bastos Voronaya AL, De Castro GL. Diaphragmatic herniation after 3 years of penetrating trauma managed through laparotomy: A case report. Int J Surg Case Rep. 2021;79:58\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBenachi A, Saada J, Martinovic J, De Lagausie P, Storme L, Jani J. Hernie cong\u0026eacute;nitale du diaphragme: prise en charge ant\u0026eacute;natale. Rev Mal Respir. 2011;28:800\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChandrasekharan PK, Rawat M, Madappa R, Rothstein DH, Lakshminrusimha S. Congenital Diaphragmatic hernia \u0026ndash; a review. matern health neonatol perinatol. 2017;3:6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePaltaci. 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Birth Defects Res. 2024;116:e2301.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCannata G, Caporilli C, Grassi F, Perrone S, Esposito S. Management of Congenital Diaphragmatic Hernia (CDH): Role of Molecular Genetics. IJMS. 2021;22:6353.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChami Khazraji I, Charif Saibari R, Bennani S, Rami A, Ait Achour MA, Lafhal R, et al. Incidentally revealing of CHD in a 52 year-old man: Case report and literature review. Radiol Case Rep. 2024;19:4255\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOnifade A, Antoniou D, Robotin-Pal A, Paramalingam S. Laparoscopic repair of recurrent congenital diaphragmatic hernia: A case report. J Pediatr Surg Case Rep. 2023;97:102701.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcGivern MR, Best KE, Rankin J, Wellesley D, Greenlees R, Addor M-C, et al. Epidemiology of congenital diaphragmatic hernia in Europe: a register-based study. 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Arch Pediatr. 2000;7(1):48\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBonnet JP, Louis D. Volvulus intrathoracique de la rate r\u0026eacute;v\u0026eacute;lateur d\u0026rsquo;une hernie diaphragmatique post\u0026eacute;rolat\u0026eacute;rale gauche. Archives de P\u0026eacute;diatrie. 1996;3:701\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSmith NP, Jesudason EC, Losty PD. Congenital diaphragmatic hernia. Paediatr Respir Rev. 2002;3:339\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbdelhalim M, Mohamed R, Khalid K, Souad D, Abderrahmane AM, Youssef B. La hernie diaphragmatique de Bochdalek \u0026eacute;trangl\u0026eacute;e: cause rare d\u0026rsquo;occlusion intestinale. Pan Afr Med J. 2012;11:48\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWilliams E, Greenough A. Respiratory Support of Infants With Congenital Diaphragmatic Hernia. Front Pediatr. 2021;9:808317.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHon KL, Fung RCM, Leung AKC. Delayed Presentation of Congenital Diaphragmatic Hernia with Acute Respiratory Distress: Challenges in Diagnosis and Management. Case Rep Pediatr. 2020;2020:1\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKuchnowska D, Luterek K, Węgrzyn P, Kosiński P. Review of the Evaluation of Pulmonary Hypoplasia as an Important Determinant of Clinical Outcomes in Infants with Congenital Diaphragmatic Hernia. Med Sci Monit. 2024;30:e943473.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAnekar AA, Nanjundachar S, Desai D, Lakhani J, Kabbur PM. Case Report: Late-Presenting Congenital Diaphragmatic Hernia With Tension Gastrothorax. Front Pediatr. 2021;9:618596.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eB\u0026eacute;tr\u0026eacute;mieux PDA, Chapuis M, Pladys P, Tr\u0026eacute;guier C, Fr\u0026eacute;mond B, Lefrancois C. Late Presenting Bochdalek Hernia Containing Colon: Misdiagnosis Risk. Eur J Pediatr Surg. 2008;5:113\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNagpal S, Magacha HM, Goenka P, Vedantam V. Acute Gastric Volvulus: A Rare Complication of Hiatal Hernia. Cureus. 2024;16(8):e66102.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZain M, Abada M, Abouheba M, Elrouby A, Ibrahim A. Acute intrathoracic gastric volvulus: A rare delayed presentation of congenital diaphragmatic hernia: A case report. Int J Surg Case Rep. 2020;70:123\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOueslati H, Jouini R. Perforated gastric volvulus in a child with undiagnosed congenital diaphragmatic hernia (case report). 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Population-based analysis of left‐ and right‐sided diaphragmatic hernias demonstrates different frequencies of selected additional anomalies. Am J Med Genet Pt A. 2007;143A:3127\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKelly AM, Frauenfelder T. Diseases of the Chest Wall, Pleura, and Diaphragm. In: Hodler J, Kubik-Huch RA, Von Schulthess GK, editors. Diseases of the Chest, Breast, Heart and Vessels 2019\u0026ndash;2022 [Internet]. Cham: Springer International Publishing; 2019 [cited 2025 Apr 18]. pp. 95\u0026ndash;106. 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Clin Radiol. 1993;47:104\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKumbhar S, Siddiqui S, Thakrar P. Avoiding misdiagnosis in postnatal presentation of congenital diaphragmatic hernia: A report of two cases and review of radiologic features. Radiol Case Rep. 2019;14:1288\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePandey D, Verma V, Kona L. Laparoscopic Repair of Congenital Diaphragmatic Hernia in Adults: A Tertiary Care Center Two-year Experience with Literature Review. World J Lap Surg. 2025;18(1):20\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchumacher L, Gilbert S. Congenital Diaphragmatic Hernia in the Adult. Torac Surg Clin. 2009;19:469\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eQuigley CP, Folaranmi SE. A Systematic Review Comparing the Surgical Outcomes of Open Versus Minimally Invasive Surgery for Congenital Diaphragmatic Hernia Repair. J Laparoendosc Adv Surg Tech. 2023;33:211\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTakahashi R, Akamoto S, Nagao M, Matsuura N, Fujiwara M, Okano K, et al. Follow-up of asymptomatic adult diaphragmatic hernia: should patients with this condition undergo immediate operation? A report of two cases. surg case rep. 2016;2:95.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eElfiky A, Daneshvar D, Krzyzak M, Mukherjee I. Adult Onset Morgagni Hernia: Medical vs. Surg Manage Cureus. 2019;11(5):e4626.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGunia D, Porter D, Alijani A, Patil P. A tale of two unconventional adult diaphragmatic hernias. annals. 2023;105:484\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAntony A, Suares S, Fernandes AV. Fatal adult-onset diaphragmatic hernia in the context of the COVID-19 pandemic. Autops Case Rep. 2022;12:e2021366.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Diaphragmatic hernia, Asymptomatic, Conservative management, Imaging, Adult","lastPublishedDoi":"10.21203/rs.3.rs-6559280/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6559280/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Diaphragmatic dome hernia (DDH) is a rare condition in adults, often congenital or traumatic, involving a diaphragmatic defect allowing abdominal contents to herniate into the thorax. Late asymptomatic presentation is uncommon and diagnostically challenging.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation\u003c/strong\u003e: A 73-year-old man with a productive cough was incidentally diagnosed with a large asymptomatic diaphragmatic hernia. Chest X-ray and thoraco-abdominal CT showed left intrathoracic colon causing left lung collapse and rightward mediastinal shift. Conservative management with clinical follow-up was chosen due to the patient’s age and stability, with no symptoms at six months.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Asymptomatic adult DDH is rare and relies on imaging for diagnosis. Conservative management with vigilant monitoring is viable for stable patients with high surgical risks, requiring individualized risk assessment.\u003c/p\u003e","manuscriptTitle":"Asymptomatic Diaphragmatic Dome Hernia in an Elderly Adult: Case Report and Review on Conservative Management","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-14 11:24:32","doi":"10.21203/rs.3.rs-6559280/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-14T14:43:01+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"328691358789333134065773246511022826729","date":"2025-07-12T05:58:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-11T19:56:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"207390102034282481366984268417339545569","date":"2025-07-11T17:41:46+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-11T13:32:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-11T09:16:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"323251459147363218127327467175709103325","date":"2025-07-11T09:08:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"27180030633719925734838139539507448991","date":"2025-07-10T05:03:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-09T23:38:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"99706547144492448686739951382581230540","date":"2025-07-09T21:56:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-09T20:16:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"7691243611028307218607441842855761002","date":"2025-07-09T19:16:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-09T10:28:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"7239815690904586098744167546837253280","date":"2025-07-09T09:15:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"285285964650130423665736079281167773047","date":"2025-07-09T09:11:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"105834629682239277721157049491810485250","date":"2025-07-09T09:09:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-09T09:04:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-03T03:20:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-03T03:20:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2025-04-29T20:01:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"57ea9330-6012-490e-8429-bc40fc5f1960","owner":[],"postedDate":"July 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T16:04:56+00:00","versionOfRecord":{"articleIdentity":"rs-6559280","link":"https://doi.org/10.1186/s13019-025-03745-8","journal":{"identity":"journal-of-cardiothoracic-surgery","isVorOnly":false,"title":"Journal of Cardiothoracic Surgery"},"publishedOn":"2025-11-27 15:58:33","publishedOnDateReadable":"November 27th, 2025"},"versionCreatedAt":"2025-07-14 11:24:32","video":"","vorDoi":"10.1186/s13019-025-03745-8","vorDoiUrl":"https://doi.org/10.1186/s13019-025-03745-8","workflowStages":[]},"version":"v1","identity":"rs-6559280","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6559280","identity":"rs-6559280","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}