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Biventricular Takotsubo Syndrome: Clinical Characteristics, Management Strategies, and Outcomes: a Systematic Review

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Abstract

Biventricular takotsubo syndrome (TTS) is an uncommon sudden transient cardiac failure involving both the right and left ventricles. It is more hemodynamically unstable than isolated left ventricular cardiomyopathy, requiring more invasive medical management with prolonged hospital stays. The scarce literature about this condition and an increasing number of cases highlights the importance of this review. We screened 17,254 studies in PubMed, Scopus, Embase, and Google Scholar databases with biventricular TTS keywords. After analyzing case reports and series written in English, we systematically included 60 case reports on biventricular TTS to outline the clinical characteristics, complications, management, and outcomes of biventricular TTS. In this study, patients with biventricular TTS had an average age of 62.8 years, with a majority being older women (> 60 years old). The USA accounted for 32.7% of cases, followed by Japan (14.6%). Common symptoms included shortness of breath (58.2%) and chest pain (32.7%). Hypertension (35.9%) was a common prevalent comorbidity. Echocardiography revealed a low ejection fraction in 18.9% of patients. Treatment modalities involved pressor therapy (50%), intra-arterial balloon pump (6.7%), and extracorporeal membrane oxygenation (4.2%). Triggers included recent bereavement (9.1%), emotional stress (7.3%), and COVID-19 infection (7.3%). Of all the reported complications, the most common were cardiogenic shock (11.7%), followed by AKI, cardiac arrest, multi-organ failure, and complete AV block. The mortality rate was 6.67% in patients with biventricular takotsubo syndrome. This study confirms that biventricular takotsubo syndrome (BiTTS) disproportionately affects older women and is strongly associated with severe clinical outcomes such as cardiogenic shock and mortality. These results underscore the need to prioritize developing evidence-based management strategies tailored to BiTTS to improve outcomes. Pressor therapy and mechanical assistance mitigate symptoms like shortness of breath and chest distress in biventricular TTS.

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Data availability

All data generated or analyzed during this study are included in this published article.

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Abbreviations

BiTTS:

Biventricular takotsubo syndrome

CS:

Cardiogenic shock

MCS:

Mechanical circulatory support

RV:

Right ventricle

LV:

Left ventricle

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Authors and Affiliations

  1. Department of Internal Medicine, University of Texas Rio Grande Valley, Weslaco, TX, 78596, USA

    Vamsikalyan Borra

  2. Department of Medicine, University of Massachusetts, Lowell, MA, USA

    Sai Priyanka Mellacheruvu

  3. Department of Medicine, SRM Medical College Hospital and Research Centre, Chennai, Tamil Nadu, India

    Arankesh Mahadevan

  4. Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI, USA

    Adil Sarvar Mohammed

  5. Department of Internal Medicine, MedStar Health, Baltimore, MD, USA

    Adhvithi Pingili

  6. Brigham and Women’s Hospital, Boston, MA, USA

    Shobana Krishnamurthy

  7. Department of Internal Medicine, Jacobi Medical Center/North Central Bronx, Albert Einstein College of Medicine, NYC Health & Hospitals, Bronx, NY, USA

    Vishal Reddy Bejugam

  8. Department of Hospital Medicine, Corewell Health Beaumont Royal Oak, Royal Oak, MI, USA

    Hafeezuddin Ahmed

  9. Department of Internal Medicine, Bassett Medical Center, Cooperstown, NY, USA

    Gayatri Bondi

  10. Department of Medicine, Sri Venkateshwara Medical College, Tirupati, Andhra Pradesh, India

    Nithya Borra

  11. Institute of Human Behaviour and Allied Sciences, Delhi, India

    Gurpreet Kaur

  12. Independent Outcomes Researcher, Atlanta, GA, USA

    Rupak Desai

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Contributions

RD: conceptualization, formal analysis, resources, data curation, writing—review and editing, project administration

VB: writing - original draft, writing - review and editing, visualization; project administration

PM: writing - original draft, writing - review and editing

AM: writing - original draft

ASM, AP: writing - original draft, and data curation

SK: writing - review and editing; and data curation

HA, GK, VRB: screening of studies and data extraction

NB, GB: tables, draft - editing and reviewing

Corresponding author

Correspondence to Vamsikalyan Borra.

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Since the data included in this review were de-identified and available in publicly accessible databases, the IRB review was not mandatory. This review was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

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Study Highlights

• Biventricular takotsubo syndrome is relatively less common than left ventricular takotsubo syndrome.

• The recurrence rate in Biventricular TTS patients was 11.7%, and all-cause mortality was 6.67%.

• The mean age of patients with biventricular TTS is 62.8 years, with female predominance (76.7%).

• RV involvement positively predicts shock and a composite score of mortality, cardiogenic shock, and acute heart failure.

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Borra, V., Mellacheruvu, S.P., Mahadevan, A. et al. Biventricular Takotsubo Syndrome: Clinical Characteristics, Management Strategies, and Outcomes: a Systematic Review. SN Compr. Clin. Med. 6, 2 (2024). https://doi.org/10.1007/s42399-023-01634-6

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