Furthermore, cases of TTC with involvement of the RV distal portion and sparing of the base have been reported.5,6 Transient RV dysfunction as assessed by conventional echocardiography was reported by Elesber et al7 in eight of 25 patients (27%) with TTC. This was associated with lower LVEF, more in-hospital complications, and longer hospital stay. In another recent retrospective study RV involvement detected by MRI was present in nine of 34 (26%) patients with TTC.8 Our report describes a case of TTC characterized by biventricular ballooning, pulmonary hypertension, and hemodynamic instability associated with prolonged hospitalization. In the case of high clinical suspicion of TTC, a comprehensive TTE examination should be performed not only to evaluate LV function but also to unmask possible RV involvement. Although ECG assessment of RV is generally based on visual assessment, additional tools, such as VVI, may provide quantitative parameters reflecting regional right heart anatomy and function.9 For example, a myocardial contraction pattern characterized by delayed peak systolic strain of RV apex was previously described in chronic pulmonary hypertension.10 In this case, the elevated systolic pulmonary pressure seems to be related to increased LV filling pressure (as indicate by mitral E/E′ ratio) that in turn determines postcapillary pulmonary hypertension. Furthermore, VVI and strain analysis demonstrate a different pattern showing paradoxical peak systolic strain of RV distal segments. Such a peculiar pattern is related to the apical dyskinesis (ballooning) typically described in TTC. In conclusion, RV involvement should be evaluated in the acute phase of TTC. VVI and strain analysis could be useful in depicting a regional myocardial contraction pattern due to RV apical ballooning. Moreover, RV dysfunction along with pulmonary hypertension could identify a subgroup of patients with TTC at higher risk and might have a significant impact on management and outcome.