A Case of Improved Functional Mitral Regurgitation and Severe LV Dysfunction after the Closure of Hemodialysis Fistula

This is a case of 75-year-old woman with diabetes for 45 years complicated by nephropathy. She started peritoneal dialysis as the result of end-stage renal failure at age 73. At that time, she was found to have atrial septal defect (ASD) and underwent percutaneous ASD closure a year ago when she needed transition to hemodialysis. After starting hemodialysis, she gradually developed pulmonary congestion, severe mitral regurgitation (MR), and left ventricular (LV) dysfunction (LV ejection fraction = 21%) despite reducing the target dry weight. Given it became refractory, and she was a high-risk candidate for surgical treatment, optimal medical management had been tried with no success. While reviewing her history, it was thought that the fistula was aggravating her heart failure. Pulmonary artery catheterization predicted the improvement of hemodynamic with the test of closing her fistula. After the closure, her LV dysfunction and MR significantly improved. Currently patient has been doing well receiving hemodialysis through arterial puncture. For functional MR, surgery may be considered in patients with severe MR, LV ejection fraction <30%, who remain symptomatic despite optimal medical management and have low comorbidity, when revascularization is not indicated. This case illustrates the importance of assessing how fistula closure would alter patient's hemodynamic for high-risk patients. Our patient's MR and LV dysfunction were successfully treated with less invasive procedure.