Acute Left Heart Failure in Twin Pregnancies: Clinical Characteristics and Outcomes-A 10‑Year Retrospective Analysis of 24 Cases.

This retrospective study evaluated the clinical characteristics, management, and maternal-neonatal outcomes of 24 twin pregnancies complicated by acute left heart failure (ALHF) delivered at Peking University Third Hospital from January 2015 to December 2025. Patients were stratified by timing of onset (antenatal vs. postnatal). The mean maternal age was 33.8 years, and 70.8% had preeclampsia. ALHF occurred antenatally in 9 cases (37.5%) and postnatally in 15 cases (62.5%). Dyspnea was the most common initial symptom (79.2%). The mean left ventricular end‑diastolic diameter was 50.6 ± 3.7 mm, and the median NT‑proBNP level was 1406.0 pg/ml (IQR: 1146.5-2053.5 pg/ml). All patients received multidisciplinary care and diuretics, with 37.5% requiring intensive care. Full cardiac recovery by 6 weeks postpartum was achieved in 87.5% of patients. The preterm birth rate was 87.5%, and the perinatal mortality rate was 10.4%. Compared with the postnatal‑onset group, the antenatal‑onset group had significantly higher NT‑proBNP levels at disease onset or diagnosis (2388.5 vs. 1257.0 pg/ml, p = 0.018), longer hospital stay (11 vs. 8 days, p = 0.019), earlier gestational age at delivery (30 vs. 36 weeks, p = 0.002), and higher rates of neonatal intensive care unit admission (92.3% vs. 40.0%, p = 0.01) and perinatal mortality (27.8% vs. 0, p = 0.016). In conclusion, ALHF in twin pregnancies predominantly occurs postnatally and is frequently associated with preeclampsia; maternal outcomes are favorable with multidisciplinary care, whereas neonatal outcomes were poorer in the antenatal-onset group, likely reflecting medically indicated early preterm delivery in the setting of maternal decompensation.