Risultati per: Sindromi coronariche acute

Circulation, Volume 146, Issue Suppl_1, Page A13493-A13493, November 8, 2022. Background:Microalbuminuria is associated with adverse outcome in acute coronary syndrome (ACS) patients.Methods:To evaluate the very long-term association between microalbuminuria during ACS and the overall mortality and causes of death, we prospectively studied 579 ACS patients admitted to three Italian hospitals. The baseline albumin-to-creatinine ratio (ACR) was measured on days 1, 3, and 7 in 24-h urine samples. Patients were followed for 22 years or until death.Results:Virtually all patients completed the follow-up, representing 6756 person-years. During follow-up, 449(78%) had died: 41% due to non-sudden cardiac death (non-SCD), 19% sudden cardiac death (SCD), 40% due to non-cardiac (non-CD) death. The unadjusted Cox regression analysis showed that ACR is a significant predictor of all-cause mortality (HR:1.26; 95%CI 1.22-1.31; p˂0.0001) and the 3 causes of death (HR:1.40; 95%CI 1.32-1.48; p˂0.0001), (HR:1.22; 95%CI 1.12-1.32; p˂0.0001) and (HR:1.16; 95%CI 1.09-1.23; p˂0.0001) for non-SCD, SCD and non-CD respectively. Yet the fully adjusted model showed that ACR is a significant independent predictor of all-cause mortality (HR:1.12; 95%CI 1.08-1.16; p˂0.0001) and only non-SCD (HR:1.21; 95%CI 1.14-1.29; p˂0.0001).A positive interaction between ACR and history of AMI (HR:1.15; 95%CI 1.03-1.29; p=0.01), and the presence of heart failure during admission (HR:1.11; 95%CI 1.01-1.24; p=0.04), and a negative interaction with LVEF (HR:0.89; 95%CI 0.80-0.99; p=0.03) for all-cause death was also observed at the multivariable level.Conclusion:This prospective study shows that baseline ACR during ACS seems to be a strong independent predictor of the very long-term mortality risk, chiefly associated with non-sudden cardiac death. A positive independent interaction with indicators of heart failure has been also observed.Figure 1:Relative hazard estimates for all-cause and cause-specific mortality 22 years after ACS according to baseline ACR.

Circulation, Volume 146, Issue Suppl_1, Page A15880-A15880, November 8, 2022. Acute pulmonary embolism classically presents with dyspnea, tachypnea, and hypoxia, but self-recognition of symptoms and clinical findings is often challenging. This is particularly true in elder patients or those with cognitive impairments. Digital health technologies offer opportunities to remotely detect pre-symptomatic illness. We present a prodrome of an acute pulmonary embolism as it emerges in the home during continuous respiratory monitoring using a non-contact adherence-independent home bed sensor. The patient is an 85-year-old woman who is morbidly obese, has limited mobility, and multiple comorbidities including a recent diagnosis of atrial fibrillation for which she was prescribed anticoagulation but has not yet initiated. As part of an observational study, nocturnal respiratory rates (NRR) were longitudinally monitored in her home bed using a non-contact, adherence-independent bed sensor. Eight days prior to admission, increasing NRR prompted a patient call to family who noted no acute symptomatic changes. During the call it was discovered she had not been started on apixaban. On subsequent days, persistently elevated NRR prompted a second phone call 4 days prior to admission (PTA), where again no acute symptoms were noted. Anticoagulation still had not been started at that time. NRR worsened further on days following the second call prompting a home visit by an RN who found the patient dyspneic, tachypneic in the high 20s, and hypoxic with oxygen saturations in the 80s, prompting a transfer to the emergency department for further evaluation. She was eventually diagnosed with an acute pulmonary embolism. After a week-long hospitalization, the patient was discharged on adequate anticoagulation therapy.This case suggests that adherence-independent home bed monitoring of nocturnal respiratory rate may enable early detection of chronic volume overload and acute pulmonary embolism, potentially facilitating early intervention.

Circulation, Volume 146, Issue Suppl_1, Page A9448-A9448, November 8, 2022. Introduction:Statins have protective effects against ischemic injury, and pre-stroke statin use augments cerebral blood flow, reduces infarct size, and improves neurological function in mice.Hypothesis:Pre-stroke statin is associated with mild neurological symptoms at the onset of acute ischemic stroke (AIS).Methods:We retrospectively included patients with AIS admitted to our institution within 24 hours of onset between April 2011 and March 2019. We collected data on age, sex, pre-stroke use of stains, antiplatelets, anticoagulants, antihypertensive drugs, and diabetes drugs, the National Institutes of Health Stroke Scale (NIHSS) score, serum levels of albumin, glucose, glycated hemoglobin, lipids, and c-reactive protein, and stroke subtypes at admission. In addition, we defined mild neurological symptoms (mNS) as the NIHSS score of three or less. We compared variables between patients with and without pre-stroke statins and identified variables with significant differences between them. We conducted a logistic regression analysis using variables for pre-stroke statin use except for the NIHSS score, mNS, lipids, or stroke subtypes, calculated propensity scores for a pre-stroke statin and implemented a one-to-one propensity score matching (PSM). We evaluated differences between matched pairs and whether pre-stroke statin was significant for mNS at admission. We used the McNemar test to evaluate symmetry on a binary matched pairs contingency table of mNS.Results:Two thousand six hundred fifteen patients met our inclusion criteria during the study period. In 594 patients (22.7%) with pre-stroke statins and 2021 patients without them, 308 (51.9%) and 895 (44.3%) patients presented mNS (p=0.0012). After one-to-one PSM, 555 patients underwent pre-stroke statin treatment, and 555 patients did not undergo it. There were no differences in variables between matched pairs except for the NIHSS score, mNS, or cholesterol levels; 286 patients with pre-stroke stains and 252 patients without them presented mNS at admission (p=0.0411), and the binary matched pairs contingency table of mNS was not symmetrical (p=0.0385).Conclusions:Pre-stroke statin use is associated with mNS at the onset of AIS.

Circulation, Volume 146, Issue Suppl_1, Page A12647-A12647, November 8, 2022. Introduction:Acute corticosteroid therapy has been used in the prophylaxis against atrial fibrillation following cardiac surgery or acute myocardial infarction (AMI). Glucocorticoid (GR) and mineralocorticoid (MR) receptors are highly expressed in cardiac tissue. While MR activation during AMI was linked to Na+/H+exchanger (NHE1) activation-mediated increase in infarct size and contractile dysfunction, lesser is known about GR effects. The aim of this work is to seek the functional effects of an acute dose of a low potency corticosteroid (hydrocortisone, HC) in a rat model of AMI.Methods:AMI was promoted in isolated hearts from Wistar rats by 40min of regional ischemia followed by 60min reperfusion (ischemic control “I”, n=4). 10nM HC (HC10, n=3) or HC10 plus the GR inhibitor Mifepristone (M, 10uM, n=5) was added to the perfusate during the first 10min of reperfusion. In isolated papillary muscles from non-infarcted hearts NHE1 activity was measure by analyzing the pH recovery from an acute transient acidosis (TA) in control conditions, and in the presence of HC 1nM (HC1) or HC10. Protein phosphorylation and expression were determined by western blot. Data are expressed as mean±S.E.M.Results:HC treatment reduced infarct size (% of risk area: 38±3 I; 9±3 HC10, p

Circulation, Volume 146, Issue Suppl_1, Page A9391-A9391, November 8, 2022. Acute myocardial infarction (AMI) is related to rupture of atheroma plaques containing pro-inflammatory cytokines, oxidized low-density lipoprotein (oxLDL) and MMP9, a microenvironment compatible with the presence of a pathogenic microbial community. Recently, infectious extracellular vesicles (iEVs) were discovered to be released in co-infections. Previously, we found iEVs positive for archaea DNA andMycoplasma pneumoniae(Mp) antigens in vulnerable plaques. Now, looking for serum particles biomarkers to differentiate atherosclerotic clinical outcomes we studied 168 patients (pts) from groups: Atherosclerotic (ATR), AMI, AMI with major severity (sAMI) and healthy (CTL)Methods:We quantified and characterized serum iEVs (0.79-1.34μm) through their content using theFlow Cytometrytechnique and for cytokines using CBA kit, for exosomes (

Circulation, Volume 146, Issue Suppl_1, Page A11590-A11590, November 8, 2022. Introduction:Safety net community hospitals (SNCH) care for patients with disproportionately high prevalence of adverse social and behavioral determinants of health (SBDH). We evaluated the impact of adverse SBDH on in-hospital mortality and 30-days readmission after a first atherosclerotic cardiovascular disease (ASCVD) event at a large urban SNCH.Methods:We performed a retrospective review of patients presenting with an ASCVD event (coronary heart disease, cerebrovascular disease, or peripheral artery disease) between 2015 and 2019. Adverse SBDH was defined as history of homelessness, mental illness, incarceration, or substance use disorder. We used logistic regression analysis to evaluate independent predictors of in-hospital mortality and 30-day readmission following ASCVD event.Results:A cohort of 1974 patients was identified, mean age 63.8 years with standard deviation (SD) of 14.5, patients with adverse SBDH were 8 years younger than those without any adverse SBDH (58.5 years,SD:12 vs. 66 years,SD:14.8; p

Circulation, Volume 146, Issue Suppl_1, Page A11659-A11659, November 8, 2022. Introduction:The prevalence of cardiovascular disease (CVD) has increased in patients with cancer, contributing significantly to mortality among cancer survivors. Cardiotoxicity of anti-cancer drugs may play a role in the development of CVD among cancer survivors, including incidence of acute myocardial infarction (AMI). We analyzed AMI rates in patients with non-small cell lung cancer (NSCLC) treated with one of four cancer regimens.Methods:We used national data from the Veterans Affairs (VA) Corporate Data Warehouse and VA Cancer Registry. We identified 9,619 veterans diagnosed with NSCLC during 2015-2019 who initiated one of four oncological therapies: chemotherapy, immune checkpoint inhibitors (ICI) with chemotherapy, ICI monotherapy, or tyrosine kinase inhibitors monotherapy (TKI). Patients were categorized according to the first therapy received. We identified subsequent hospitalizations for AMI within two years of initiating the oncological treatment. We estimated AMI rates per 100 patient-years and risk adjusted relative hazard ratio (HR) of AMI by treatment type using Cox Regression Model to adjust for age, AMI history, comorbidities, malignancy stage, and histology.Results:Among 9,618 veterans identified, 5,510 (57.3%) initiated treatment with chemotherapy, 2,820 (29.3%) ICI with chemotherapy, 829 (8.6%) with ICI monotherapy, and 459 (4.8%) with TKI. Over a follow-up period of 2 years, 158 (1.6%) patients experienced an AMI and 5,917 (61.5%) died. The incidence of AMI per 100 patient-years (95% CI) was as follows; chemotherapy 0.86 (0.70-1.06), ICI with chemotherapy 0.77 (0.58-1.03), ICI monotherapy 0.91 (0.52-1.60), and TKI 0.43 (0.16-1.15). When compared to chemotherapy alone, adjusted HR (95% CI) for ICI with chemotherapy, ICI monotherapy, and TKI were 1.09 (0.91-1.31), 1.02 (0.75-1.38), and 1.50 (0.94-2.37), respectively. When compared to TKI or ICI with chemotherapy, the ICI monotherapy cohort did not have a statistically significant adjusted HR for AMI risk.Conclusion:Among Veterans with NSCLC, the incidence of AMI was low and there was no difference in risk between the initial oncological regimens. The high competing risk of mortality in our cohort may also have contributed to the lack of between-group differences.

Circulation, Volume 146, Issue Suppl_1, Page A14546-A14546, November 8, 2022. Introduction:Management of acute type A aortic dissection complicated by brain malperfusion remains controversial. We previously reported an excellent recovery of consciousness for patients with coma if aortic repair performed within 5 hours from onset of symptoms. This study evaluates neurological outcomes after 19 years with this approach.Methods:Between 8/03 and 12/21, aortic repair was performed in 400 patients with acute type A aortic dissection, including 59 (12.7%) presented with brain malperfusion on arrival. Brain malperfusion was defined as distributed consciousness or paralysis in patients with dissection in carotid artery on hospital arrival. Forty patients (67.8 %) were repaired within 5 hours from onset of symptoms (immediate repair) while 19 (32.2 %) were repaired after 5 hours (later repair). We compared the immediate repair group with the later repair group. The mean age of the patients was 70.0±11.7 and 70.0±9.0 years, respectively, and prevalence of shock, cardiac tamponade, EuroSCORE were not significantly different between two groups. Preoperative coma (GCS

Circulation, Volume 146, Issue Suppl_1, Page A11491-A11491, November 8, 2022. Introduction:Post-acute sequelae of SARS-CoV-2 cardiovascular syndrome (PASC-CVS) is a heterogeneous disorder of post-COVID syndrome that involves a wide range of cardiovascular symptoms including palpitations, chest pain, dyspnea and dizziness. The clinical time-course of PASC-CVS is not well characterized. We sought to understand predictors of time to symptom improvement for patients with PASC-CVS.Methods:Patients with PASC-CVS undergoing evaluation in a dedicated post-COVID cardiology clinic were recruited after informed consent. Information was obtained from chart review and included demographics, comorbidities, symptoms, time of infection to time of presentation to the clinic and time to improvement in symptoms. A multivariate linear regression model was used to determine predictors of time to improvement.Results:A total of 144 consecutive patients were included that had complete records available for review. Average age was 46 years, 74% were female and 94% were Caucasian. Comorbities included obesity (49%), mental health disorder (25%), hypertension (24%), hyperlipidemia (24%), pulmonary disease (18%), type II diabetes (9%), atrial arrhythmia (5%) and coronary artery disease (3%). Time from infection to presentation (p

Circulation, Volume 146, Issue Suppl_1, Page A15100-A15100, November 8, 2022. Introduction:Obstructive sleep apnea (OSA) is a common and underestimated chronic condition recognized as a risk factor for cardiovascular diseases. OSA and acute coronary syndrome (ACS) have been reported in several cases. This study aims to assess the prevalence of the OSA among patients with ACS.Hypothesis:We hypothesize that there is a correlation between OSA and ACS.Methods:This study is a cross-sectional, descriptive study that included 110 patients with ACS at the Cairo University Hospitals in Egypt between December 2018 and July 2019. We included patients diagnosed with ACS over the age of 40. We excluded patients who had disturbed consciousness levels, were intubated/mechanically ventilated, were on psychiatric medications, or used drugs. Furthermore, we excluded individuals with CKD or liver disease. We collected patients’ demographic characteristics, and chronic medical conditions, and performed a sleep assessment. Every patient had a detailed workup for ACS. We assessed OSA based on the STOP-BANG score. The significance of baseline and clinical characteristics, laboratory and imaging findings, and the severity of ACS and its outcome were studied.Results:The mean age of the patients was 58.2±9.6. The majority of patients were male (74.5%). 70.9% of the patients had metabolic syndrome. The mean body mass index was 28.6±4.8; the majority of patients presented with STEMI (60.9%), while only 26.4% and 12.7% presented with NSTEMI and unstable angina respectively. The prevalence of OSA among ACS patients was 63.6%, and of them, 55.7% presented with STEMI, while only 32.9% and 11.4% presented with NSTEMI and unstable angina respectively. Also, the study revealed a statistically significant relationship between OSA and NSTEMI patients (OR: 2.77 [95% CI 1.02-7.55], p=0.041), while there was no statistically significant relationship between OSA and unstable angina patients (OR: 0.73 [95% CI 0.2-2.3], p=0.579) and between OSA and STEMI patients (OR: 0.54 [95% CI 0.2-1.2], p=0.14).Conclusion:To the best of our knowledge, this is the first study to study the prevalence of OSA in ACS patients in the region of Africa. The study indicated a high prevalence of OSA among ACS patients, with a more significant correlation between OSA and NSTEMI patients.

Circulation, Volume 146, Issue Suppl_1, Page A13444-A13444, November 8, 2022. Introduction:Mechanical circulatory support (MCS) is known to potentiate hemolytic anemia. Nevertheless, patients are also at an increased risk of spontaneous bleeding due to anticoagulation or post-procedural complication. We present two cases of acute anemia due to spontaneous retroperitoneal bleeding following insertion of the Impella assist device.Case Presentation:Two male patients aged 65 and 74 presented with cardiogenic shock secondary to ischemic cardiomyopathy with a low ejection fraction of 10% and 15%). Both patients initially had an intra-aortic balloon pump (IABP) inserted. Because of progressively deteriorating hemodynamics, IABP was switched to the Impella 5.5 device through the axillary artery. Following insertion of the Impella, they developed anemia requiring multiple blood transfusions. Despite repositioning of Impella, hemoglobin continued to drop prompting further workup. CT abdomen/pelvis revealed left retroperitoneal hematoma. CT angiogram showed active bleeding from the left L3 lumbar artery in one patient and multiple foci of active arterial extravasation in the other patient. Coil embolization was performed, achieving hemostasis and stabilization of hemoglobin levels in both patients.Discussion:Hemolytic anemia associated with the use of the Impella that improves with repositioning or device removal is well known and documented. However, patients with MCS are also at increased risk of spontaneous bleeding due to procedural injury and the use of anticoagulation. We report 2 cases with retroperitoneal bleeding from the lumbar artery diagnosed a few days after the placement of Impella. The occurrence of retroperitoneal hemorrhage was possibly spontaneous due to anticoagulation along with Impella-induced hemolysis resulting in acute anemia. Neither patient had any vascular access through the left groin making post-procedural complications less likely. The concealed nature and non-specific symptoms of retroperitoneal bleed can lead to a delay in diagnosis. Early identification and control of bleeding can prevent fatal outcomes.Conclusion:Our cases highlight the importance of clinicians having a broad differential and low threshold to investigate other causes of anemia in patients with MCS.

Circulation, Volume 146, Issue Suppl_1, Page A11310-A11310, November 8, 2022. Introduction:The aim of this study was to evaluate malperfusion in patients presenting with acute type A dissection (ATAD) and correlate with mortality based on organ system involved.Methods:A registry of all patients who underwent ATAD repair at our tertiary referral center between 2002 and 2018 was retrospectively queried. Patients with type B aortic dissection and chronic type A aortic dissections (time from presentation > 14 days) were excluded. Malperfusion syndromes at presentation including central nervous system (brain and spinal cord), visceral renal, and lower extremity (LE) were documented. Preoperative and intraoperative variables were analyzed, and post-operative outcomes were correlated with the malperfused organ system.Results:From 2002 to 2018, 378 patients underwent ATAD repair at our tertiary referral center. The average age was 57 years, 68% were male, and 51% were white. Approximately 70% of the cohort were transferred from an outside hospital. A total of 124 patients (33%) presented with malperfusion of at least one organ: 16% (N=62) LE, 8% (N=31) brain, 8% (N=30) renal, 3% (N=11) with visceral malperfusion, and 2% (N=8) with spinal cord malperfusion. On multivariate analysis, 30-day mortality was significantly increased in patients presenting with visceral ischemia (OR=3.7, P=0.04). The average follow-up was 2.3 years. Kaplan Meier survival curves showed a significant decrease in long term survival in patients presenting with brain (P=0.01), visceral (P=0.002), and renal ischemia (P

Circulation, Volume 146, Issue Suppl_1, Page A15810-A15810, November 8, 2022. Establishment of mechanical thrombectomy as the standard of care provides a unique opportunity to refine stroke subtype mechanism by studying thrombus retrieved from stroke patients. Using traditional pathologic methods, researchers have described the form and structure of cerebral thrombi. These methods do not spatially resolve tissues and cell populations with functional segmentation. We applied next generation genomic tools to determine the spatially resolved transcriptome within cerebral thrombus.Methods:Cerebral thrombus was retrieved under sterile conditions. Tissue was formalin-fixed and paraffin embedded in standard fashion. Using the GeoMx Digital Spatial Profiling platform, morphology marker antibodies and WTA RNA probes coupled to photocleavable oligonucleotide tags were applied to the slide. After hybridization of the probes to tissue sections, 24 regions of interest (ROIs) were selected, and oligonucleotide tags were released from the discrete regions of the tissue via UV exposure. Released tags were quantitated using next generation sequencing and counts were mapped back to tissue location, yielding a spatially-resolved digital profile of analyte abundance.Results:Sequencing quality was inspected for sufficient saturation and data normalized to the third quartile to account for differences in cellularity. 18,676 genes were assayed across the 24 ROI. Of these, 4,590 genes were expressed in 10% of ROI and 1,127 genes were expressed in 50% of ROI.Conclusion:Significant transcriptional activity is seen within cerebral thrombus and preliminary analysis shows feasibility for a novel application of spatial transcriptomics. Further evaluation of expressed genes provides information about the microenvironment of thrombus origin and mechanistic insight to stroke subtype etiology.Figure.Number of genes detected across increasing % of ROIs.

Circulation, Volume 146, Issue Suppl_1, Page A9407-A9407, November 8, 2022. Introduction:Acute myocarditis is extremely heterogenous in causal agents, clinical courses, and geographic regions. There is little long-term outcomes data for acute myocarditis prior to the COVID-19 pandemic.Hypothesis:The clinical profile of acute myocarditis would differ according to age at presentation.Methods:A retrospective nationwide cohort study was performed. All patients aged 20-79 who were hospitalized for acute myocarditis without underlying cardiac diseases from 2006 to 2018 in Korea. Complicated phenotype was defined as requiring hemodynamic or major organ support. Over 10 years, all-cause mortality and acute myocarditis-driven excess mortality were evaluated according to young-adult (20-39 years), mid-life (40-59 years), and older-adult (60-79 years) age groups.Results:Among 2988 patients (mean age 51.0 years), 362 (12.1%) were of complicated phenotype. All-cause death at 30 days occurred in 40 (4.7%), 52 (4.8%), and 105 (10.0%) patients in the young-adult, mid-life, and older adult groups, respectively (Figure A). Most short-term deaths occurred within 37 days of admission, primarily in the complicated phenotype. However, higher excess mortality compared to the age- and sex-matched general population remained over the 10-year follow-up even in younger patients with non-complicated phenotypes (Figure B).Conclusions:In patients with de novo acute hospitalized myocarditis, short-term mortality is high both in young and older adults, particularly those with advanced age, non-cardiac comorbidities, and severe clinical presentation. Furthermore, long-term excess mortality remains high over 10 years after index hospitalization. A cardiac monitoring strategy should be discussed for post-myocarditis patients against the long-term risk.

Circulation, Volume 146, Issue Suppl_1, Page A11674-A11674, November 8, 2022. Background:The acute cardiovascular effects of electronic nicotine delivery devices (ENDs) have not been well-characterized. We hypothesized differences in acute cardiovascular and autonomic function responses to use of ENDS by chronic ENDs users (“vapers”), use of combustible cigarettes by chronic “smokers,” and no product use among non-smoking/non-vaping controls.Methods:CLUES (HL1393301) was a cross-sectional study of 395 individuals: 164 exclusive vapers (exhaled carbon monoxide [CO] 5 ppm, positive urine NicCheck), and 114 non-vaping/non-smoking controls (CO 50 ms [PNN50]) before and 15’ after a product use challenge. Linear mixed models were created to predict outcome measures from group, time, and group*time with age, sex, and race as covariates, followed by group contrasts viapost-hoct-tests with Bonferroni-corrected p values.Results:Vapers were a mean (SD) 27.4 (10.6) years old (39% female, 86% white) and had vaped for 4.1 (2.7) years. Smokers were 42.8 (13.8) years old (44% female, 56% white) and had smoked for 23.0 (13.0) years. Controls were 30.8 (11.9) years old (50% female, 69% white). Model-adjusted mean (95% CIs) outcomes and p values for between group differences in challenge responses are in the Figure. Compared to controls, vapers had greater increases in systolic BP, diastolic BP, and HR (all p

Circulation, Volume 146, Issue Suppl_1, Page A12188-A12188, November 8, 2022. Background:For patients with functional mitral regurgitation (MR) who remain symptomatic despite GDMT, transcatheter mitral valve repair (TMVR) is emerging as a less-invasive alternatives and can improve symptoms and longevity. We describe a rare case of cardiogenic shock following TMVR.Case:63-year-old male with PMHx of CAD with prior CABG, severe MR with EF of 40% developed progressive dyspnea and evaluated for TMVR with a Mitraclip device. TEE pre-deployment confirmed moderate to severe MR (Figure 1). Right heart catheterization revealed preserved cardiac index.Intraoperative TEE after deployment showed improved MR. Post-procedure, he developed respiratory distress and progressive hypotension requiring vasopressors and inotropes. TTE showed mild MR with severely reduced biventricular function (EF 10%). Cardiac catheterization showed a severely reduced CO/CI 3.1/1.42. Mechanical circulatory support was initiated with Impella CP due to persistent cardiogenic shock. By POD 3, he was off all inotropes and MCS was discontinued. His EF recovered to 45% during a 3- month visit.Decision Making:Causes of cardiogenic shock post mitral valve procedure include cardiac tamponade, acute mitral stenosis, intrathoracic hemorrhage and afterload mismatch. Afterload mismatch is due to reduction in left ventricular stroke volume when preload is not compensated for an acute increase in afterload. It is a known complication after mitral valve surgery; however it is rarely seen post TMVR. This patient likely experienced afterload mismatch after his mitral clipping procedure as evidenced by the acute, transient decline in LVEF (55% to 10%).Conclusion:Afterload mismatch is a rare phenomenon that can cause cardiogenic shock post percutaneous mitral repair procedures. It must be rapidly addressed with inotropic and/or mechanical support to prevent permanent end organ dysfunction and circulatory collapse. Prompt treatment allows for excellent recovery.