Takotsubo syndrome (TS) is a condition of transient cardiac dysfunction that develops in the setting of abrupt sympathetic stimulation. Although classically identified by ballooning of the apical segment, TS can also present in atypical forms with abnormalities of the basal, mid-ventricular, or other focal segments. In the perioperative setting, anaesthetic effects and physiologic perturbations from surgery can further confound the diagnosis. We present a narrative review of the most recent evidence for underlying pathophysiologic mechanisms of the variable ballooning patterns and highlight important anaesthetic considerations in the diagnosis and management of these patients.