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Looking beyond the heart: a unique case of gastric band slippage mimicking acute coronary syndrome
Session:
MELHORES CASOS CLÍNICOS
Speaker:
Inês Gomes Campos
Congress:
CPC 2025
Topic:
A. Basics
Theme:
02. Clinical Skills
Subtheme:
---
Session Type:
Sessão de Casos Clínicos
FP Number:
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Authors:
Inês Gomes Campos; Rafaela G. Lopes; Inês Oliveira; Joel Monteiro; Aurora Andrade
Abstract
<p style="text-align:justify"><span style="font-size:medium"><span style="font-family:"Times New Roman",serif"><span style="color:#000000"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">Case report: A 52-year-old woman with an history of gastric band surgery in 2006, was admitted in the emergency department due to epigastric pain after a meal, associated with nausea, with 45-minute duration. In the previous week, she was evaluated for the same symptoms. Previous exertional angina was denied. On physical examination, blood pressure was 106/72mmHg, heart rate 106bpm, with no murmurs or signs of congestion, and no signs of peripheral malperfusion. Electrocardiogram (ECG) showed sinus rhythm with ST segment elevation in aVR and ST segment depression in the inferior, lateral and inferolateral leads. Seriated high-sensitivity troponin measurements were negative. Transthoracic echocardiography revealed a large mass with gaseous and liquid content, compressing the left atrium; preserved biventricular systolic function and no regional wall motion abnormalities. To better characterize the mass, a thoraco-abdominal computerized tomography (CT) was requested, revealing significant dilation of the esophagus, fundus and proximal gastric body, with hydro-air level. Angio-CT showed discrete coronary artery calcification.</span></span></span></span></span></p> <p style="text-align:justify">The presentation with epigastric pain and ST segment changes in ECG made it mandatory to rapidly exclude ACS. However, echocardiography along with other imaging modalities played an important role in establishing the differential diagnosis. In addition, negative seriated troponin and low probability of coronary artery atherosclerosis in angio-CT made an ACS improbable, and no cardiologic intervention was performed. Therefore, in a multidisciplinary team, the epigastric pain and ST segment changes were interpreted as a probable consequence of esophageal and gastric dilation compressing the left atrium and the coronary arteries. Three hours later, the patient was asymptomatic with no ST-T changes in the ECG. </p> <p style="text-align:justify"><span style="font-size:medium"><span style="font-family:"Times New Roman",serif"><span style="color:#000000"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">A few weeks later, the patient was successfully submitted to surgical reintervention, with extraction of the gastric band. </span></span></span></span></span></p> <p style="text-align:justify"><span style="font-size:medium"><span style="font-family:"Times New Roman",serif"><span style="color:#000000"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">At an 8-month follow-up, the patient reported a significant symptomatic relief with no recurrence of epigastric pain. ECG showed sinus rhythm with no significant ST-T changes. Myocardial perfusion imaging excluded regional motion wall abnormalities and ischemic changes.</span></span></span></span></span></p> <p style="text-align:justify"><span style="font-size:medium"><span style="font-family:"Times New Roman",serif"><span style="color:#000000"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">Discussion: </span></span></span></span></span><span style="font-size:medium"><span style="font-family:"Times New Roman",serif"><span style="color:#000000"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:black">This case report is of significant importance as it serves to alert clinicians to uncommon etiologies of cardiac symptoms. The occurrence of intermittent inferolateral ischemia resulting from extrinsic cardiac compression by a megaesophagus, secondary to gastric band slippage, represents an exceedingly rare phenomenon, only seldom reported in the literature. This report underscores the critical value of point-of-care echocardiography in the assessment of patients with ACS, and emphasizes the need for a low threshold for multimodal imaging techniques to elucidate atypical clinical presentations.</span></span></span></span></span></span></p>
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