{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,12]],"date-time":"2026-09-12T10:16:25Z","timestamp":1789208185401,"version":"build-2803163510"},"reference-count":49,"publisher":"MDPI AG","issue":"15","license":[{"start":{"date-parts":[[2021,7,22]],"date-time":"2021-07-22T00:00:00Z","timestamp":1626912000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Takotsubo syndrome (TTS) is characterized by acute, generally transient left ventricular (LV) dysfunction. Although TTS has been long regarded as a benign condition, recent evidence showed that rate of acute complications and in-hospital mortality is comparable to that of patients with acute coronary syndrome. In particular, the prevalence of cardiogenic shock ranges between 6% and 20%. In this setting, detection of mechanisms leading to cardiogenic shock can be challenging. Besides a severely impaired systolic function, onset of LV outflow tract obstruction (LVOTO) together with mitral regurgitation related to systolic anterior motion of mitral valve leaflets can lead to hemodynamic instability. Early identification of LVOTO with echocardiography is crucial and has important implications on selection of the appropriate therapy. Application of short-acting b1-selective betablockers and prudent administration of fluids might help to resolve LVOTO. Conversely, inotrope agents may increase basal hypercontractility and worsen the intraventricular pressure gradient. To date, outcomes and management of patients with TTS complicated by LVOTO as yet has not been comprehensively investigated.<\/jats:p>","DOI":"10.3390\/jcm10153235","type":"journal-article","created":{"date-parts":[[2021,7,22]],"date-time":"2021-07-22T22:35:31Z","timestamp":1626993331000},"page":"3235","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":44,"title":["Dynamic Left Intraventricular Obstruction Phenotype in Takotsubo Syndrome"],"prefix":"10.3390","volume":"10","author":[{"given":"Davide","family":"Di Vece","sequence":"first","affiliation":[{"name":"University Heart Center, Department of Cardiology, University Hospital Zurich, 8091 Zurich, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Angelo","family":"Silverio","sequence":"additional","affiliation":[{"name":"Department of Medicine and Surgery, University Hospital of Salerno, 84131 Salerno, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michele","family":"Bellino","sequence":"additional","affiliation":[{"name":"Department of Medicine and Surgery, University Hospital of Salerno, 84131 Salerno, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gennaro","family":"Galasso","sequence":"additional","affiliation":[{"name":"Department of Medicine and Surgery, University Hospital of Salerno, 84131 Salerno, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carmine","family":"Vecchione","sequence":"additional","affiliation":[{"name":"Department of Medicine and Surgery, University Hospital of Salerno, 84131 Salerno, Italy"},{"name":"Vascular Pathophysiology Unit, IRCCS Neuromed, Via Atinense, 18, 86077 Pozzilli, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giovanni","family":"La Canna","sequence":"additional","affiliation":[{"name":"IRCCS Humanitas Clinical and Research Center, Applied Diagnostic Echocardiography Unit, 20089 Rozzano, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rodolfo","family":"Citro","sequence":"additional","affiliation":[{"name":"Department of Medicine and Surgery, University Hospital of Salerno, 84131 Salerno, Italy"},{"name":"Cardio-Thoracic-Vascular Department, University Hospital \u201cSan Giovanni di Dio e Ruggi d\u2019Aragona\u201d, 84131 Salerno, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2021,7,22]]},"reference":[{"key":"ref_1","unstructured":"Kodama, K., Haze, K., and Hori, M. (1990). Tako-tsubo-like left ventricular dysfunction due to multivessel coronary spasm. Clinical Aspect of Myocardial Injury: From Ischemia to Heart Failure, Kagakuhyoronsha Publishing Co.. (In Japanese)."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"929","DOI":"10.1056\/NEJMoa1406761","article-title":"Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy","volume":"373","author":"Templin","year":"2015","journal-title":"N. Engl. J. Med."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"333","DOI":"10.1016\/j.jacc.2009.08.057","article-title":"Natural history and expansive clinical profile of stress (tako-tsubo) cardiomyopathy","volume":"55","author":"Sharkey","year":"2010","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1253\/circj.68.77","article-title":"Time course of electrocardiographic changes in patients with tako-tsubo syndrome: Comparison with acute myocardial infarction with minimal enzymatic release","volume":"68","author":"Kurisu","year":"2004","journal-title":"Circ. J."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"408","DOI":"10.1016\/j.ahj.2007.11.008","article-title":"Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): A mimic of acute myocardial infarction","volume":"155","author":"Prasad","year":"2008","journal-title":"Am. Heart J."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"3255","DOI":"10.1093\/eurheartj\/ehaa210","article-title":"Coexistence and outcome of coronary artery disease in Takotsubo syndrome","volume":"41","author":"Napp","year":"2020","journal-title":"Eur. Heart J."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"199","DOI":"10.1007\/s12574-020-00480-y","article-title":"Multimodality imaging in takotsubo syndrome: A joint consensus document of the European Association of Cardiovascular Imaging (EACVI) and the Japanese Society of Echocardiography (JSE)","volume":"18","author":"Citro","year":"2020","journal-title":"J. Echocardiogr."},{"key":"ref_8","first-page":"277","article-title":"Clinical characteristics and cardiovascular magnetic resonance findings in stress (takotsubo) cardiomyopathy","volume":"306","author":"Eitel","year":"2011","journal-title":"JAMA"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"559","DOI":"10.1016\/j.hfc.2016.06.005","article-title":"Contemporary Imaging in Takotsubo Syndrome","volume":"12","author":"Citro","year":"2016","journal-title":"Heart Fail Clin."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"2032","DOI":"10.1093\/eurheartj\/ehy076","article-title":"International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology","volume":"39","author":"Ghadri","year":"2018","journal-title":"Eur. Heart J."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1002\/ejhf.424","article-title":"Current state of knowledge on Takotsubo syndrome: A Position Statement from the Taskforce on Takotsubo Syndrome of the Heart Failure Association of the European Society of Cardiology","volume":"18","author":"Lyon","year":"2016","journal-title":"Eur. J. Heart Fail"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"455","DOI":"10.1016\/j.ijcard.2016.06.039","article-title":"Clinical profile and in-hospital outcome of Caucasian patients with takotsubo syndrome and right ventricular involvement","volume":"219","author":"Citro","year":"2016","journal-title":"Int. J. Cardiol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"343","DOI":"10.1002\/ccd.23441","article-title":"Incidence and angiographic characteristics of patients with apical ballooning syndrome (takotsubo\/stress cardiomyopathy) in the HORIZONS-AMI trial: An analysis from a multicenter, international study of ST-elevation myocardial infarction","volume":"83","author":"Prasad","year":"2014","journal-title":"Catheter Cardiovasc. Interv."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"343","DOI":"10.1016\/j.amjcard.2004.04.030","article-title":"Clinical characteristics and thrombolysis in myocardial infarction frame counts in women with transient left ventricular apical ballooning syndrome","volume":"94","author":"Bybee","year":"2004","journal-title":"Am. J. Cardiol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"e4","DOI":"10.1016\/j.ijcard.2012.03.012","article-title":"Young girl with apical ballooning heart syndrome","volume":"161","author":"Berton","year":"2012","journal-title":"Int. J. Cardiol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"561","DOI":"10.1097\/PEC.0000000000000189","article-title":"A 6-year-old girl with undiagnosed hemophagocytic lymphohistiocytosis and takotsubo cardiomyopathy: A case report and review of the literature","volume":"30","author":"Otillio","year":"2014","journal-title":"Pediatr. Emerg. Care"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"539","DOI":"10.1056\/NEJMoa043046","article-title":"Neurohumoral features of myocardial stunning due to sudden emotional stress","volume":"352","author":"Wittstein","year":"2005","journal-title":"N. Engl. J. Med."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"2816","DOI":"10.1093\/eurheartj\/ehw057","article-title":"Is takotsubo syndrome a microvascular acute coronary syndrome? Towards of a new definition","volume":"37","author":"Luscher","year":"2016","journal-title":"Eur. Heart J."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"22","DOI":"10.1038\/ncpcardio1066","article-title":"Stress (Takotsubo) cardiomyopathy\u2014A novel pathophysiological hypothesis to explain catecholamine-induced acute myocardial stunning","volume":"5","author":"Lyon","year":"2008","journal-title":"Nat. Clin. Pract. Cardiovasc. Med."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1289","DOI":"10.1093\/eurheartj\/ehaa575","article-title":"2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation","volume":"42","author":"Collet","year":"2021","journal-title":"Eur. Heart J."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"413","DOI":"10.1161\/CIRCULATIONAHA.118.036164","article-title":"Outcomes Associated With Cardiogenic Shock in Takotsubo Syndrome","volume":"139","author":"Citro","year":"2019","journal-title":"Circulation"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"2047","DOI":"10.1093\/eurheartj\/ehy077","article-title":"International Expert Consensus Document on Takotsubo Syndrome (Part II): Diagnostic Workup, Outcome, and Management","volume":"39","author":"Ghadri","year":"2018","journal-title":"Eur. Heart J."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"119","DOI":"10.1016\/j.jcmg.2013.09.020","article-title":"Echocardiographic correlates of acute heart failure, cardiogenic shock, and in-hospital mortality in tako-tsubo cardiomyopathy","volume":"7","author":"Citro","year":"2014","journal-title":"JACC Cardiovasc Imaging"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"e50","DOI":"10.1016\/j.ijcard.2007.04.166","article-title":"Ventricular arrhythmias during Tako-tsubo syndrome","volume":"128","author":"Bonello","year":"2008","journal-title":"Int. J. Cardiol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"780","DOI":"10.1093\/europace\/euq435","article-title":"Arrhythmia occurrence with takotsubo cardiomyopathy: A literature review","volume":"13","author":"Syed","year":"2011","journal-title":"Europace"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"2142","DOI":"10.1093\/eurheartj\/ehz170","article-title":"Cardiac arrest in takotsubo syndrome: Results from the InterTAK Registry","volume":"40","author":"Gili","year":"2019","journal-title":"Eur. Heart J."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"279","DOI":"10.1161\/ATVBAHA.119.313491","article-title":"Intraventricular Thrombus Formation and Embolism in Takotsubo Syndrome: Insights From the International Takotsubo Registry","volume":"40","author":"Ding","year":"2020","journal-title":"Arterioscler Thromb Vasc Biol."},{"key":"ref_28","first-page":"2693062","article-title":"Ventricular Septal Defect from Takotsubo Syndrome","volume":"2016","author":"Lu","year":"2016","journal-title":"Case Rep. Cardiol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1027","DOI":"10.1093\/eurheartj\/ehs054","article-title":"Ventricular rupture in Takotsubo cardiomyopathy","volume":"33","author":"Jaguszewski","year":"2012","journal-title":"Eur. Heart J."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"2733","DOI":"10.1093\/eurheartj\/ehu284","article-title":"2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy: The Task Force for the Diagnosis and Management of Hypertrophic Cardiomyopathy of the European Society of Cardiology (ESC)","volume":"35","author":"Elliott","year":"2014","journal-title":"Eur. Heart J."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"86","DOI":"10.1016\/j.ijcard.2020.01.021","article-title":"Multidisciplinary evaluation and management of obstructive hypertrophic cardiomyopathy in 2020: Towards the HCM Heart Team","volume":"304","author":"Pelliccia","year":"2020","journal-title":"Int. J. Cardiol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"749","DOI":"10.1161\/CIRCRESAHA.117.311059","article-title":"Hypertrophic Cardiomyopathy: Genetics, Pathogenesis, Clinical Manifestations, Diagnosis, and Therapy","volume":"121","author":"Marian","year":"2017","journal-title":"Circ. Res."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1688","DOI":"10.1016\/j.amjcard.2020.03.004","article-title":"Phenotyping Left Ventricular Obstruction With Postprandial Re-Test Echocardiography in Hypertrophic Cardiomyopathy","volume":"125","author":"Scarfo","year":"2020","journal-title":"Am. J. Cardiol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"34","DOI":"10.1007\/s12574-017-0352-6","article-title":"Causes of an increased pressure gradient through the left ventricular outflow tract: A West Coast experience","volume":"16","author":"Kobayashi","year":"2018","journal-title":"J. Echocardiogr."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"543","DOI":"10.1016\/j.ahj.2008.05.002","article-title":"Prevalence and characteristics of left ventricular outflow tract obstruction in Tako-Tsubo syndrome","volume":"156","author":"Mansencal","year":"2008","journal-title":"Am. Heart J."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"De Backer, O., Debonnaire, P., Gevaert, S., Missault, L., Gheeraert, P., and Muyldermans, L. (2014). Prevalence, associated factors and management implications of left ventricular outflow tract obstruction in takotsubo cardiomyopathy: A two-year, two-center experience. BMC Cardiovasc Disord, 14.","DOI":"10.1186\/1471-2261-14-147"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"928","DOI":"10.1016\/j.jchf.2018.05.015","article-title":"Short- and Long-Term Prognostic Relevance of Cardiogenic Shock in Takotsubo Syndrome: Results From the RETAKO Registry","volume":"6","author":"Lobo","year":"2018","journal-title":"JACC Heart Fail"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"647","DOI":"10.1016\/j.jacc.2007.04.057","article-title":"Left ventricular apical ballooning syndrome as a novel cause of acute mitral regurgitation","volume":"50","author":"Parodi","year":"2007","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1344","DOI":"10.1016\/S0735-1097(00)00830-5","article-title":"Systolic anterior motion begins at low left ventricular outflow tract velocity in obstructive hypertrophic cardiomyopathy","volume":"36","author":"Sherrid","year":"2000","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1700","DOI":"10.1016\/j.amjcard.2020.02.013","article-title":"Distinctive Hypertrophic Cardiomyopathy Anatomy and Obstructive Physiology in Patients Admitted With Takotsubo Syndrome","volume":"125","author":"Sherrid","year":"2020","journal-title":"Am. J. Cardiol."},{"key":"ref_41","first-page":"723","article-title":"Hypotension due to dynamic left ventricular outflow tract obstruction after percutaneous coronary intervention","volume":"38","author":"Dahhan","year":"2011","journal-title":"Tex. Heart Inst. J."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"982","DOI":"10.1016\/j.jacc.2018.12.033","article-title":"Takotsubo Recurrence: Morphological Types and Triggers and Identification of Risk Factors","volume":"73","author":"Kato","year":"2019","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"161","DOI":"10.1111\/1755-5922.12182","article-title":"Hemodynamic Effects, Safety, and Feasibility of Intravenous Esmolol Infusion During Takotsubo Cardiomyopathy With Left Ventricular Outflow Tract Obstruction: Results From A Multicenter Registry","volume":"34","author":"Santoro","year":"2016","journal-title":"Cardiovasc Ther."},{"key":"ref_44","first-page":"1280","article-title":"The Role of Ultrarapid Acting Betablocker Esmolol and Landiolol in Critically Ill Patients","volume":"144","author":"Gassanov","year":"2019","journal-title":"Dtsch Med. Wochenschr"},{"key":"ref_45","first-page":"306","article-title":"Impella in Takotsubo syndrome complicated by left ventricular outflow tract obstruction and severe mitral regurgitation","volume":"7","author":"Attisano","year":"2020","journal-title":"ESC Heart Fail"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"889","DOI":"10.1016\/j.ijcard.2015.10.022","article-title":"Tako-tsubo cardiomyopathy may lead to permanent changes in left ventricular geometry: Potential implications in the setting of pre-existing myocardial disease?","volume":"202","author":"Yalta","year":"2016","journal-title":"Int. J. Cardiol."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"202","DOI":"10.1016\/j.ijcard.2016.03.152","article-title":"Dynamic left ventricular outflow tract obstruction in recovery process of stress cardiomyopathy","volume":"214","author":"Fu","year":"2016","journal-title":"Int. J. Cardiol."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"328","DOI":"10.1016\/j.ihj.2016.12.004","article-title":"Late-onset dynamic outflow tract gradient in the setting of tako-tsubo cardiomyopathy: An interesting phenomenon with potential implications?","volume":"69","author":"Yalta","year":"2017","journal-title":"Indian Heart J."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"745","DOI":"10.1016\/j.echo.2017.03.016","article-title":"Alterations in Cardiac Deformation, Timing of Contraction and Relaxation, and Early Myocardial Fibrosis Accompany the Apparent Recovery of Acute Stress-Induced (Takotsubo) Cardiomyopathy: An End to the Concept of Transience","volume":"30","author":"Schwarz","year":"2017","journal-title":"J. Am. Soc. Echocardiogr."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/10\/15\/3235\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T06:33:26Z","timestamp":1760164406000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/10\/15\/3235"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,7,22]]},"references-count":49,"journal-issue":{"issue":"15","published-online":{"date-parts":[[2021,8]]}},"alternative-id":["jcm10153235"],"URL":"https:\/\/doi.org\/10.3390\/jcm10153235","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,7,22]]}}}