New Onset of Left Ventricular Dysfunction Associated with Selenium, Zinc and Copper Deficiency Presenting Late after Gastric Bypass Surgery: Case Report and Review of the Literature

The increasing rate of obesity and heart disease remain a global epidemic. Since 1980, the obesity rate has more than doubled to 1.4 billion adults worldwide and is related to 23% of all cases of ischemic heart disease [1]. Strategies to reduce body mass index (BMI) include diet, exercise, supplements and bariatric surgery. With proven benefit for sustained weight loss and improved cardiovascular parameters including lipids, glucose levels and blood pressure, gastric bypass surgery has increased in popularity [2-4]. The gold standard Roux-en-Y gastric bypass, indicated in patients who are morbidly obese (BMI >40 kg/m2) or in those with a BMI >35 kg/m2 with other significant comorbidities, can lead to both restrictive and malabsorptive effects. Though the effect of caloric restriction is thought to be the primary reason for weight loss, bypassing segments of bowel results in nutritional malabsorption and subsequent dyshomeostasis in minerals and micronutrients. The malabsorption following Roux-en-Y bypass is primarily due to the bypass of the duodenum, which could result in a lack of cation absorption. Of these, selenium, copper and zinc are integral for cellular function and the activity of endogenous antioxidant defenses, and reduction in their levels have been linked to dilated cardiomyopathy [5-8]. Witte et al. demonstrated a reduction in left ventricular (LV) volume and improvement in LV ejection fraction (LVEF) in heart failure patients supplemented with high dose minerals and vitamins [9]. In addition, small studies suggest a link between Vitamin B1 (thiamine) deficiency (TD), reversible heart failure, and wet Beri-beri [10-13]. Animal models demonstrated that TD leads to cardiac hypertrophy and depressed cardiac function and arrhythmias even in the absence of Beri-beri [14-16]. Thus we present a case of a young female with the acute onset of hypoglycemia ten years post gastric bypass surgery associated with severe malnutrition and significant micronutrient deficiencies in selenium, copper, zinc and B1 and subsequent development of systolic heart failure. Although other mechanisms leading to cardiomyopathy cannot be excluded, we propose that the chronic deficiency in micronutrients in conjunction with exacerbating factors associated with acute hypoglycemia/dumping syndrome may have played an important role in the development of cardiomyopathy that subsequently resolved after aggressive micronutrient supplementation.