Cardiac catheterization and hemodynamic study is the gold standard for the diagnosis of pericardial constriction. Careful interpretation of the hemodynamic data is essential to differentiate it from other diseases with restrictive physiology. In this hemodynamic review we shall briefly discuss the physiologic basis of various hemodynamic changes seen in a patient with constrictive pericarditis.

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A 42-year-old woman presented herself to the emergency services in cardiogenic shock. She had a history of progressively worsening breathlessness for the past year; however, no medical evaluation had been performed earlier. At presentation, her pulse rate was 110 beats per minute, regular, and low volume, and her blood pressure was 90/70 mm Hg. On auscultation, third heart sound was present, but no murmurs were heard. Soon after presentation, she had an asystolic cardiac arrest. However, she was resuscitated successfully and mechanically ventilated, and she required inotropic support with dopamine and noradrenaline for maintaining blood pressure.Her ECG showed normal sinus rhythm and nonspecific ST-T changes, and chest radiograph showed cardiomegaly with features of pulmonary venous hypertension (Figure 1). Her echocardiogram showed severe left-ventricular systolic dysfunction with a left-ventricular ejection fraction of 20% ( Figure 2). Her routine blood biochemistry, including liver and renal function tests, was within normal limits, except for mild anemia with hemoglobin of 9.5 g/dl. A diagnosis of dilated cardiomyopathy with cardiogenic shock was made, and the patient was treated accordingly. Subsequently, she was weaned off the ventilator, but she continued to require inotropic support.She remained markedly symptomatic with fatigue and complained of blackouts on getting up. There was a postural drop of 25 mm Hg in systolic blood pressure on sitting up. Furthermore, it was noticed that her heart rates did not go beyond 110 beats per minute, despite being on high doses of inotropes and remaining hypotensive. On close scrutiny, patchy pigmentation of face was noticed along with loss of axillary and pubic hair.Further inquiry into her past history revealed that she had nearly bled to death in her last pregnancy 14 years ago. Since then, she had no menstruation and lactation. In light of this, she was investigated for endocrine disorder and was found to be having panhypopituitarism (Table)-thus a case of Sheehan syndrome. The diagnosis remarkably changed her management because along with cardiogenic shock, she also had additional hypoadrenal shock. She was started on glucocorticoids, thyroxine, and fludrocortisone, and within 2 days she was weaned off inotropes. Her blood pressure by guest on

Left ventricular outflow tract obstruction (LVOTO) has been reported with bio-prosthetic and mechanical mitral valves (MV), though it is more common with the former. The obstruction can be dynamic or fixed. We hereby report a case of fixed LVOTO following bio-prosthetic MV replacement (MVR).

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