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Background  Takotsubo syndrome is a stress-induced disease that makes up 23% of acute coronary syndrome cases. However, its onset mechanism remains unclear. Although females are overwhelmingly affected, males end up having more cardiac complications.    Case presentation  We examined the differences in stress responses in the myocardium between sexes in patients with takotsubo syndrome. We biopsied samples from an over 70-year-old Japanese male and an over 80-year-old Japanese female. Tissues from the left ventricle apex in the acute phase and the apical ballooning-type were examined using histopathology and deoxyribonucleic acid (DNA) microarray analysis. Our data showed that left ventricular ejection fractions were 38% and 56%, and peak creatinine kinase concentrations during hospitalization were 629U/L and 361U/L, for the male and female patient, respectively. The pulmonary capillary wedge pressure was 26mmHg and 11mmHg for the male and female patient, respectively. Negative T did not return to normal in the male subject after 6months. Histopathology results indicated that contraction band necrosis and lymphocyte infiltration were more common in the male subject.    Conclusions  We noticed that possible differences may exist between male and female patients using pathological examination and some DNA analyses. In particular, it may help treat acute severity in males. We will elucidate the mechanism of takotsubo syndrome development by increasing the number of samples to support the reliability of the data in the future.    Supplementary Information  The online version contains supplementary material available at 10.1186/s13256-021-02856-9.

Examination of gender differences in patients with takotsubo syndrome according to left ventricular biopsy: two case reports