Haemodynamic effects of acute intravenous landiolol in Takotsubo cardiomyopathy with dynamic left ventricular outflow tract obstruction

Takotsubo cardiomyopathy (TCM) leads to serious left ventricular outflow tract (LVOT) obstruction with cardiogenic shock in 6%-20% of cases. The onset of LVOT obstruction, coupled with mitral regurgitation resulting from systolic anterior motion of mitral valve leaflets, can lead to haemodynamic instability in addition to severely impaired systolic function. We describe three patients who experienced chest discomfort following emotional stress. These patients displayed pronounced abnormalities on ECGs, insignificant obstructive coronary disease and haemodynamic instability due to LVOT obstruction. The infusion of landiolol, a short-acting beta blocker, was effective in releasing the gradient. Dynamic outflow obstruction is the major predictor of haemodynamic collapse. We suggested that an early identification of this complication in hypotensive patients with suspected TCM could be of utmost importance to optimise the therapeutic approach in the acute setting.

Pretreatment with Betablockers, a Potential Predictor of Adverse Cardiovascular Events in Takotsubo Syndrome

Introduction: Treatment with betablockers is controversial in Takotsubo syndrome (TTS); however, many physicians intuitively initiate or continue betablocker therapy in these patients. The effect of preadmission betablocker use on adverse cardiovascular events has not been studied in the literature. Methods: To investigate this issue, we evaluated clinical complications, defined by the endpoint of occurrence of hemodynamically relevant arrythmia, cardiac decompensation, and all-cause adverse cardiac events, during hospitalization, in 56 patients hospitalized for TTS between April 2017 and July 2021. We compared the risk of adverse cardiovascular events between patients with preadmission betablocker therapy and those without preadmission betablocker therapy. Pretreatment betablocker therapy was defined as daily betablocker intake for more than a week including day of admission. Results: TTS patients taking preadmission betablockers had a significantly increased risk of all-cause complications relative to patients without betablockers in preadmission medication ((52.0% vs. 19.4%, p = 0.010; OR 4.5 (95% Cl 1.38–14.80)). Furthermore, TTS patients already taking betablockers on admission showed a statistically significant increased risk of cardiac decompensation when compared to patients without pretreatment with betablockers (p = 0.013). There were no significant differences in patient characteristics in patients who were taking beta blockers as an adjunct therapy prior to admission for TTS relative to those who were not. There is however an increase in comorbidities, hypertension, and atrial fibrillation, in past medical history in patients taking a preadmission betablocker. The difference is related to therapeutic applications for beta blockers and was not significant based on endpoints of our study. Conclusions: Preadmission betablocker treatment was associated with a 4.5 times higher risk of adverse cardiac events. This increased risk of all-cause complications and of cardiac decompensation within the acute phase of TTS is presumably due to the negative inotropic effects of betablockers and upregulation of β-adrenergic receptors in patients with chronic betablocker therapy.

Case report: A patient with transient sigmoid septum in takotsubo syndrome with left ventricular outflow tract obstruction

Left ventricular outflow tract obstruction is now recognized as a common complication of takotsubo syndrome, resulting in more serious acute and long-term outcomes. We describe a case of takotsubo syndrome where a transient sigmoid septum produced left ventricular outflow obstruction and explore the mechanisms leading to this occurring. This phenomenon has not been previously described. <Learning objective: Left ventricular outflow tract (LVOT) obstruction is a complication of takotsubo syndrome. A sigmoid septum is a risk factor for LVOT obstruction occurring. This case highlights that a sigmoid septum can be transient and may be secondary to surge in catecholamines and inflammatory markers.>.

Pathophysiology of Takotsubo Syndrome - a joint scientific statement from the Heart Failure Association Takotsubo Syndrome Study Group and Myocardial Function Working Group of the European Society of Cardiology - Part 1: Overview and the central role for catecholamines and sympathetic nervous system

This is the first part of a scientific statement from the Heart Failure Association of the European Society of Cardiology focused upon the pathophysiology of Takotsubo syndrome and is complimentary to the previous HFA Position Statement on Takotsubo syndrome which focused upon clinical management. In part 1 we provide an overview of the pathophysiology of Takotsubo syndrome and fundamental questions to consider. We then review and discuss the central role of catecholamines and the sympathetic nervous system in the pathophysiology, and the direct effects of high surges in catecholamines upon myocardial biology including β-adrenergic receptor signaling, G protein coupled receptor kinases, cardiomyocyte calcium physiology, myofilament physiology, cardiomyocyte gene expression, myocardial electrophysiology and arrhythmogenicity, myocardial inflammation, metabolism and energetics. The integrated effects upon ventricular haemodynamics are discussed and integrated into the pathophysiological model. This article is protected by copyright. All rights reserved.

Risk factors for Takotsubo syndrome following cardiac surgery: A case-control study

OBJECTIVE

Takotsubo syndrome following cardiac surgery is a rare occurrence. However, early diagnosis is essential to prevent treatment which could increase the left ventricular outflow tract pressure gradient in patients with Takotsubo syndrome, and lead to cardiogenic shock. Therefore, our study aimed to identify the incidence of Takotsubo syndrome after cardiopulmonary bypass and the associated risk factors and prognosis.

METHODS

We retrospectively studied 5773 patients who underwent cardiopulmonary bypass between February 2007 and July 2017. Among these, Takotsubo syndrome was diagnosed in 52 (0.9%). To evaluate the risk factors for Takotsubo syndrome, 104 of the remaining 5721 patient were randomly selected as the control group (1:2 ratio). Univariate and multivariate logistic regression analyses were used for risk factor analysis.

RESULTS

Majority of patients (69.2%) in the Takotsubo syndrome group underwent mitral valve surgery, compared with 32.7% in the control group. The following risk factors of Takotsubo syndrome were identified: atrio-ventricular valve surgery (odds ratio (OR) 10.5; 95% confidence interval (CI), 2.6-42.5; p = 0.001); and the immediate postoperative use of epinephrine (OR, 3.3; 95% CI, 1.0-10.7; p = 0.05) and dobutamine (OR, 4.8; 95% CI, 1.72-13.3; p = 0.003). Hypertension was a significant protective factor against Takotsubo syndrome following cardiac surgery (OR, 0.22; 95% CI, 0.06-0.73; p = 0.01).

CONCLUSION

Takotsubo syndrome following cardiac surgery is rare. Immediate postoperative use of epinephrine and doputamine, as well as atrio-ventricular valve surgery were factors associated with the development of Takotsubo syndrome.

Systemic inflammation in patients with Takotsubo syndrome: a review of mechanistic and clinical implications

Over recent decades, systemic inflammation  as  quantified  with  inflammation  markers  or  indices has been extensively  investigated  in the setting of  various  cardiovascular  conditions  including heart failure (HF),  acute coronary syndromes (ACS). In contrast, systemic inflammation  in patients with  takotsubo syndrome (TTS) has been an underrated  phenomenon in clinical practice. On the other hand, experimental and clinical data  have been  rapidly  accumulating  in the recent years  regarding   pathogenetic, prognostic as well as therapeutic implications of  systemic inflammation in TTS.  Accordingly, the present article  aims to provide a general perspective  on mechanistic and  clinical aspects of  systemic  inflammation in the setting of  TTS.

Concurring hypertrophic cardiomyopathy and takotsubo cardiomyopathy: Assessment and management

The prevalence of takotsubo cardiomyopathy (TCM) has been on the rise, but co-occurrence with hypertrophic cardiomyopathy (HOCM) remains rare. Although presenting patient demographics were similar to those in TCM, the potential for hemodynamic compromise was significantly compounded by the presence of underlying HOCM. Management was similar to standalone TCM, although use of inotropic agents and mechanical support appears to be more prevalent. Despite the increased potential for complications and the paucity of data regarding management, outcomes appear to be mostly favorable in both the hospitalization period and at follow-up. Interestingly, despite a new diagnosis of HOCM in about half the cases described, which signifies no significant left ventricular outflow tract (LVOT) gradient prior to TCM, half of those patients had a persistently elevated LVOT gradient after resolution of TCM. This poses a question of whether or not TCM can predispose to LVOT obstruction in HOCM patients even after its resolution.

Update of takotsubo syndrome in the era of COVID-19

Takotsubo cardiomyopathy or takotsubo syndrome (TTS) has become a well-known disease not only in Japan but also in the rest of the world. Early reports suggested that TTS is a self-limiting disease with better prognosis than acute coronary syndrome. However, recent data showed that TTS is not a benign disease as compared with acute coronary syndrome. In addition to the apical ballooning, several other types of wall motion abnormalities have been classified as variants of TTS. In particular, right ventricular involvement, or biventricular TTS, is not uncommon and is associated with poor in-hospital as well as long-term outcomes. With respect to the pathophysiology, modulation (desensitization) of the beta-adrenergic receptor is suspected as a possible mechanism for transiently depressed myocardial contraction. Although specific treatments to improve prognosis of TTS are still uncertain, observational data suggest favorable impact of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Finally, in the era of COVID-19, we should pay attention to a variety of cardiovascular conditions related to COVID-19. TTS is one of these conditions that can be triggered by both emotional and physical impact of the COVID-19 pandemic.

Rationale for using the velocity-time integral and the minute distance for assessing the stroke volume and cardiac output in point-of-care settings

Background

Stroke volume (SV) and cardiac output (CO) are basic hemodynamic parameters which aid in targeting organ perfusion and oxygen delivery in critically ill patients with hemodynamic instability. While there are several methods for obtaining this data, the use of transthoracic echocardiography (TTE) is gaining acceptance among intensivists and emergency physicians. With TTE, there are several points that practitioners should consider to make estimations of the SV/CO as simplest as possible and avoid confounders.

Main body

With TTE, the SV is usually obtained as the product of the left ventricular outflow tract (LVOT) cross-sectional area (CSA) by the LVOT velocity–time integral (LVOT VTI); the CO results as the product of the SV and the heart rate (HR). However, there are important drawbacks, especially when obtaining the LVOT CSA and thus the impaction in the calculated SV and CO. Given that the LVOT CSA is constant, any change in the SV and CO is highly dependent on variations in the LVOT VTI; the HR contributes to CO as well. Therefore, the LVOT VTI aids in monitoring the SV without the need to calculate the LVOT CSA; the minute distance (i.e., SV × HR) aids in monitoring the CO. This approach is useful for ongoing assessment of the CO status and the patient’s response to interventions, such as fluid challenges or inotropic stimulation. When the LVOT VTI is not accurate or cannot be obtained, the mitral valve or right ventricular outflow tract VTI can also be used in the same fashion as LVOT VTI. Besides its pivotal role in hemodynamic monitoring, the LVOT VTI has been shown to predict outcomes in selected populations, such as in patients with acute decompensated HF and pulmonary embolism, where a low LVOT VTI is associated with a worse prognosis.

Conclusion

The VTI and minute distance are simple, feasible and reproducible measurements to serially track the SV and CO and thus their high value in the hemodynamic monitoring of critically ill patients in point-of-care settings. In addition, the LVOT VTI is able to predict outcomes in selected populations.

Intraventricular thrombus and severe mitral regurgitation in the acute phase of takotsubo cardiomyopathy: two case reports

Background

Takotsubo cardiomyopathy is characterized by chest symptoms, electrocardiographic changes, and new regional wall motion abnormality in the apical segment of the left ventricle in the absence of obstructive coronary artery disease. Particularly, apical ballooning is broadly recognized as the classic form of takotsubo cardiomyopathy. Although the prognosis of most patients with takotsubo cardiomyopathy is generally favorable, complications associated with the morphological features of transient apical ballooning are not uncommon.

Case presentation

We describe two cases of transient complications in postmenopausal patients with takotsubo cardiomyopathy. Intraventricular thrombus was observed in Asian patient 1, and severe mitral regurgitation was observed in Asian patient 2. These complications were confirmed by transthoracic echocardiography immediately after typical takotsubo cardiomyopathy with apical ballooning was diagnosed. Anticoagulant therapy with heparin and warfarin was continued for 1 week in patient 1. After the therapy, complete resolution of the apical thrombus and recovery of systolic function of the left ventricle was observed by follow-up transthoracic echocardiography. In patient 2, transthoracic echocardiography indicated significant mitral regurgitation, which was caused by left ventricular tethering of the anterior mitral leaflet rather than left ventricular outflow tract obstruction or systolic anterior motion. Because the hemodynamic stability in patient 2 had been preserved, she was managed with conservative treatment. After approximately 1 month, follow-up transthoracic echocardiography revealed that mitral regurgitation had almost disappeared with complete resolution of left ventricular wall motion abnormalities.

Conclusions

The presented cases indicated that important complications, such as intraventricular thrombus and severe mitral regurgitation, are associated with takotsubo cardiomyopathy in the acute phase. Because these complications are risk factors for developing a thromboembolic event or heart failure and/or pulmonary edema, timely and accurate identification of these complications is critical to achieving optimal clinical outcomes in patients with takotsubo cardiomyopathy.

A case of ultrashort-acting beta-blocker landiolol hydrochloride for takotsubo syndrome with left ventricular outflow tract obstruction

Takotsubo syndrome (TTS) has been known to have a favorable prognosis. Beta-blockers are reported to be effective for TTS patients with cardiogenic heart failure due to left ventricular outflow tract (LVOT) obstruction. However, there is no report on ultrashort-acting beta-blockers being used for treating TTS, and there are no clear guidelines for their dosages or applications. Herein, we describe a 72-year-old woman in whom landiolol hydrochloride was used in the acute phase of TTS with LVOT obstruction. In this case, the dose of landiolol hydrochloride was increased to 10 μg/kg/min, resulting in improvement of LVOT obstruction, which led to hemodynamic stabilization.

Misconceptions and Facts About Takotsubo Syndrome

Takotsubo syndrome, initially described in the 1990s by Sato, has been increasingly recognized around the world. Pathophysiology is directed towards central role of catecholamine surge , but other aspects like microvascular endothelial dysfunction and vasospasm have also been described. Dyspnea and chest pain are most common manifestations, but syncope can also be seen. Right ventricular involvement is not uncommon, and left ventricular outflow tract obstruction is a frequent complication. EKG can differentiate between Takotsubo syndrome and myocardial infarction, but coronary angiography should always be performed. Although treatment has been angiotensin converting enzyme inhibitors and betablockers, recent evidence from nonrandomized studies shows no benefit on betablockers regarding outcomes.

Dynamic left ventricular outflow tract obstruction complicated with takotsubo cardiomyopathy: The acute phase of takotsubo cardiomyopathy manifests latent left ventricular outflow tract obstruction

Dynamic left ventricular (LV) outflow tract (LVOT) obstruction is sometimes complicated with takotsubo cardiomyopathy (TC). The present case involves a 70-year-old woman with chest discomfort. Seven years earlier, transthoracic echocardiography revealed LVOT obstruction due to a sigmoid-shaped septum. She underwent urgent cardiac catheterization for suspected acute coronary syndrome. She was diagnosed as having TC with LVOT obstruction. After undergoing conservative treatment, her LV function normalized and the LVOT obstruction resolved. After the LV wall motion normalized, administering an intravenous infusion of dobutamine again provoked LVOT obstruction. In this situation, the presence of TC manifested latent LVOT obstruction. <Learning objective: Although dynamic left ventricular outflow tract (LVOT) obstruction is the important compication of takotsubo cardiomyopaty (TC), the mechanism of LVOT obstruction remains unclear. This case had latent LVOT obstruction due to sigmoid-shaped septum, and LVOT obstruction might be manifested in the acute phase of TC. This phenomenon has potential for mechanism of LVOT obstruction complicated with TC.>.

Left Ventricular Dysfunction in the Setting of Takotsubo Cardiomyopathy: A Review of Clinical Patterns and Practical Implications

Takotsubo cardiomyopathy (TTC) is primarily regarded as a form of acute and transient myocardial disease with a variety of characteristic wall-motion abnormalities. Importantly, a significant portion of TTC cases generally present with variable degrees of acute left ventricular (LV) dysfunction with or without clinical HF. On the other hand, LV dysfunction in the setting of TTC has been universally and exclusively considered as a synonym for systolic dysfunction, potentially overlooking other forms of myocardial pathologies, including transient diastolic dysfunction, in this setting. More interestingly, recent observations suggest that TTC, despite its macroscopic recovery, may not always manifest as a fully reversible phenomenon, suggesting persistence of microscopic changes at the cellular level to some degree. In clinical practice, these residual changes might largely account for the evolution of certain pathologies, including persistent diastolic dysfunction and subclinical LV dysfunction with variable symptomatology (particularly those arising during high levels of myocardial workload, including exercise, etc.) among TTC survivors. Within this context, the present review aims to highlight various clinical patterns and implications of LV dysfunction in the setting of TTC, and to provide basic information regarding morphological and mechanistic characteristics of wall-motion abnormalities in this setting.

Long-term consequences of disrupting adenosine signaling during embryonic development

There is growing evidence that disruption in the prenatal environment can have long-lasting effects on an individual's health in adulthood. Research on the fetal programming of adult diseases, including cardiovascular disease, focuses on epi-mutations, which alter the normal pattern of epigenetic factors such as DNA methylation, miRNA expression, or chromatin modification, rather than traditional genetic alteration. Thus, understanding how in utero chemical exposures alter epigenetics and lead to adult disease is of considerable public health concern. Few signaling molecules have the potential to influence the developing mammal as the nucleoside adenosine. Adenosine levels increase rapidly with tissue hypoxia and inflammation. Adenosine antagonists including the methlyxanthines caffeine and theophylline are widely consumed during pregnancy. The receptors that transduce adenosine action are the A1, A2a, A2b, and A3 adenosine receptors (ARs). We examined the long-term effects of in utero disruption of adenosine signaling on cardiac gene expression, morphology, and function in adult offspring. One substance that fetuses are frequently exposed to is caffeine, which is a non-selective adenosine receptor antagonist. Over the past several years, we examined the role of adenosine signaling during embryogenesis and cardiac development. We discovered that in utero alteration in adenosine action leads to adverse effects on embryonic and adult murine hearts. We find that cardiac A1ARs protect the embryo from in utero hypoxic stress, a condition that causes an increase in adenosine levels. After birth in mice, we observed that in utero caffeine exposure leads to abnormal cardiac function and morphology in adults, including an impaired response to β-adrenergic stimulation. Recently, we observed that in utero caffeine exposure induces transgenerational effects on cardiac morphology, function, and gene expression. Our findings indicate that the effects of altered adenosine signaling are dependent on signaling through the A1ARs and timing of disruption. In addition, the long-term effects of altered adenosine signaling appear to be mediated by alterations in DNA methylation, an epigenetic process critical for normal development.

Late-onset dynamic outflow tract gradient in the setting of tako-tsubo cardiomyopathy: An interesting phenomenon with potential implications?

In clinical practice, dynamic left ventricular outflow tract obstruction (LVOTO) in the setting of tako-tsubo cardiomyopathy (TTC) has been regarded as an early-onset complication typically emerging in accordance with wall motion abnormalities. However, dynamic LVOTO has, very rarely, been reported as a late-onset phenomenon in the setting of TTC as well (arising in the late stage or after recovery). Accordingly, the present paper aims to highlight clinical relevance and potential implications of late-onset LVOTO in the setting of TTC.

In Utero Caffeine Exposure Induces Transgenerational Effects on the Adult Heart

Each year millions of pregnant woman are exposed to caffeine, which acts to antagonize adenosine action. The long-term consequences of this exposure on the developing fetus are largely unknown, although in animal models we have found adverse effects on cardiac function. To assess if these effects are transmitted transgenerationally, we exposed pregnant mice to caffeine equivalent to 2–4 cups of coffee at two embryonic stages. Embryos (F1 generation) exposed to caffeine early from embryonic (E) day 6.5–9.5 developed a phenotype similar to dilated cardiomyopathy by 1 year of age. Embryos exposed to caffeine later (E10.5–13.5) were not affected. We next examined the F2 generation and F3 generation of mice exposed to caffeine from E10.5–13.5, as this coincides with germ cell development. These F2 generation adult mice developed a cardiac phenotype similar to hypertrophic cardiomyopathy. The F3 generation exhibited morphological changes in adult hearts, including increased mass. This report shows that in utero caffeine exposure has long-term effects into adulthood and that prenatal caffeine exposure can exert adverse transgenerational effects on adult cardiac function.

Echocardiography in shock management

Echocardiography is pivotal in the diagnosis and management of the shocked patient. Important characteristics in the setting of shock are that it is non-invasive and can be rapidly applied.

In the acute situation a basic study often yields immediate results allowing for the initiation of therapy, while a follow-up advanced study brings the advantage of further refining the diagnosis and providing an in-depth hemodynamic assessment. Competency in basic critical care echocardiography is now regarded as a mandatory part of critical care training with clear guidelines available. The majority of pathologies found in shocked patients are readily identified using basic level 2D and M-mode echocardiography. A more comprehensive diagnosis can be achieved with advanced levels of competency, for which practice guidelines are also now available. Hemodynamic evaluation and ongoing monitoring are possible with advanced levels of competency, which includes the use of colour Doppler, spectral Doppler, and tissue Doppler imaging and occasionally the use of more recent technological advances such as 3D or speckled tracking.

The four core types of shock—cardiogenic, hypovolemic, obstructive, and vasoplegic—can readily be identified by echocardiography. Even within each of the main headings contained in the shock classification, a variety of pathologies may be the cause and echocardiography will differentiate which of these is responsible. Increasingly, as a result of more complex and elderly patients, the shock may be multifactorial, such as a combination of cardiogenic and septic shock or hypovolemia and ventricular outflow obstruction.

The diagnostic benefit of echocardiography in the shocked patient is obvious. The increasing prevalence of critical care physicians experienced in advanced techniques means echocardiography often supplants the need for more invasive hemodynamic assessment and monitoring in shock.

Takotsubo Syndrome: Insights from Japan

We report the history and new insights of takotsubo syndrome based on the achievements that Japanese researchers have contributed and summarize the evidence originally presented from Japan. Takotsubo syndrome is a newly described heart failure characterized by transient left ventricular dysfunction. We should be aware of this entity as a syndrome, not actual cardiomyopathy. Japanese researchers focus on the experimental approaches for clinical diagnosis and treatment of takotsubo syndrome. As representatives from a country originally naming this syndrome takotsubo, a global registry for takotsubo syndrome including Japan should be established.

Prevalence and Clinical Features of Focal Takotsubo Cardiomyopathy

BACKGROUND

Because it is difficult to distinguish between focal takotsubo cardiomyopathy and aborted myocardial infarction, there is little information about the prevalence and clinical features of focal takotsubo cardiomyopathy.

METHODS AND RESULTS

Our cardiac catheterization databases were queried to identify patients with focal takotsubo cardiomyopathy and other types of takotsubo cardiomyopathy. We defined focal takotsubo cardiomyopathy as hypo-, a- or dyskinesis in both anterolateral and septal segments without obstructive coronary artery disease explaining the wall motion abnormality. A total of 10 patients were diagnosed with focal takotsubo cardiomyopathy. The control group comprised patients with takotsubo cardiomyopathy with apical, mid-ventricular, or basal ballooning. Clinical features and in-hospital outcomes were compared between patients with focal takotsubo cardiomyopathy and those with other types of takotsubo cardiomyopathy. Among the 144 patients with takotsubo cardiomyopathy, the apical, mid-ventricular, basal, and focal types occurred in 85 (59.0%), 49 (34.0%), 0 (0%), and 10 patients (6.9%), respectively. The left ventricular ejection fraction was significantly higher in the focal group compared with the apical and mid-ventricular group (56±13 vs. 45±13 vs. 46±12%, P=0.03). In-hospital outcome was not significantly different among the 3 groups.

CONCLUSIONS

Focal takotsubo cardiomyopathy is not rare. Biplane left ventriculography is useful for its diagnosis. (Circ J 2016; 80: 1824-1829).

Echocardiographic assessment of takotsubo cardiomyopathy: beyond apical ballooning

It has been >25 years since the first report of the takotsubo cardiomyopathy (TC). Although left ventriculography was originally used to depict its typical and impressive wall motion abnormality mimicking "takotsubo", or octopus pot, echocardiography plays a pivotal role in detecting not only its left ventricular (LV) wall motion abnormality, apical ballooning, but also various other findings. First of all, apical ballooning is not an essential finding for TC anymore. Mid-ventricular LV asynergy with or without apical involvement is a basic pattern of the LV wall motion abnormality. Distribution and time course of the asynergy may be best detected by echocardiography and echo provides useful information to differentiate between TC and acute coronary syndrome or acute myocarditis. In addition to the wall motion assessment, echo detects complications of TC such as systolic anterior motion of the mitral leaflet with or without LV outflow obstruction, mitral regurgitation, LV thrombus, right ventricular (RV) involvement. In particular, RV involvement is not an uncommon finding and is associated with worse short-term as well as long-term prognosis. Finally, coronary flow measurements and speckle tracking by echo may offer additional and useful information about pathophysiology and prognosis of TC. In conclusion, echocardiography is a standard imaging modality for detecting various dynamic findings beyond apical ballooning in patients with TC.