Percutaneous Balloon Mitral Valvotomy in Twin Pregnancy: Procedural Challenges and Tailored Technical Strategies.

Twin pregnancy imposes a hemodynamic burden in patients with severe mitral stenosis, increasing maternal and fetal risk. Percutaneous balloon mitral valvotomy (PBMV) is an established intervention for symptomatic severe mitral stenosis during pregnancy; however, experience in twin gestation remains limited. We report 3 cases of severe rheumatic mitral stenosis with twin pregnancy managed with PBMV at a tertiary care center. The first case, previously reported, involved a 33-year-old woman with an in vitro fertilization-conceived twin pregnancy who underwent PBMV at 27 weeks of gestation. The second and third cases involved 24- and 26-year-old primigravidae presenting at 26 and 22 weeks, respectively. Each case presented distinct procedural challenges requiring tailored transseptal and balloon-delivery strategies. All procedures were successfully completed with favorable maternal and fetal outcomes. This series highlights the importance of procedural adaptability, radiation minimization, and multidisciplinary decision-making in PBMV during twin pregnancy. The psychosocial burden on patients and operators also warrants consideration.