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

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.