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Balloon mitral valvotomy is a common procedure done for rheumatic mitral stenosis. However, certain cases may pose challenges and rarely may be life-threatening. Here, three unusual cases of balloon mitral valvotomy are presented. Case 1 had procedural challenge in terms of Interatrial Septal (IAS) fibrotic thickening and calcification, posing difficulty in trans-septal puncture and crossing IAS with valvotomy balloon. Case 2 had bidirectional Ventricular Tachycardia (VT) with a single dose of intravenous digoxin, and stress cardiomyopathy. Case 3 had difficulty in negotiating valvotomy balloon towards apex and in the process, there was left ventricular free wall perforation.