OBJECTIVES: A combination of surgical and medical approaches may address both the underlying pathophysiological processes and the most threatening symptoms in twin-twin transfusion syndrome (TTTS). CASE: A primigravida with monochorionic twin pregnancy was referred with signs of TTTS at 16 weeks. One twin was severely hydropic with normal amniotic fluid, the co-twin had anhydramnios. Laser treatment was performed. Nevertheless, signs of severe cardiac decompensation in the recipient remained unchanged. After treatment with digoxin restoration of congestive heart failure and a resolution of the hydrops were achieved. Activity and inter-twin contacts increased significantly. At 37 weeks 2 healthy boys were delivered. Postnatal computerangiography of the placenta revealed no arteriovenous anastomoses. CONCLUSIONS: This case suggests that a combined causal and symptomatic therapy in cases with cardiac decompensation of the recipient can be beneficial as demonstrated by echocardiography, venous Doppler and behavioral analysis. Computer angiography of the placenta may demonstrate the effect of laser treatment