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BACKGROUND It is unknown if the severity of left ventricular dysfunction in patients with transient left ventricular ballooning syndrome (TLVBS) adversely affects clinical outcome. Furthermore, it remains unclear if the patterns of ventricular involvement are distinct patterns or if they represent varying stages of ventricular involvement. METHODS AND RESULTS All patients with TLVBS who presented to our hospital from August 1998 to August 2012 were prospectively identified and entered into a clinical database. Available ventriculograms were reviewed, the ejection fraction (EF) calculated and a new severity score of left ventricular (LV) involvement was developed to determine the degree of LV dysfunction. The incidence of in-hospital mortality, cardiogenic shock and major cardiac events (heart failure/pulmonary oedema or major cardiac arrhythmia) was recorded. In total, 145 TLVBS episodes were identified in 139 patients. Age at presentation was 67 ± 12 years and 89% (n = 123) of patients were female. Patients who developed cardiogenic shock or other acute cardiac events had a worse LVEF compared to those who did not (P < 0.01 and P = 0.05, respectively). In-hospital mortality was not related to worse EF (P = 0.58). In-hospital and 1-year mortality rates were 6.9% and 12.6%, respectively. Median time from symptom onset to clinical diagnosis was similar between the apical ballooning (n = 104; 12 [3-30] hours) and the mid-ventricular ballooning group (n = 25; 11 [4-35] hours, P = 0.97). CONCLUSIONS In TLVBS patients the severity of LV dysfunction determines the incidence of cardiogenic shock and early cardiac events. Apical and mid-ventricular forms of TLVBS appear to be distinct patterns.