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The authors presented a case of congestive heart failure in a patient with end-stage renal disease on hemodialysis. The patient has low blood pressure and fluid overload making removal of the fluid by hemodialysis challenging task. The authors put a theory forward for discrepancies in the pressure between the two sides of the heart and propose a surgical procedure “septetomy of the inter-atrial septum” that might resolve the issue of hypotension on dialysis patients with fluid overload.