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Iraqi Board Cardiology study materials
Iraqi Board Cardiology study resources

Iraqi Board Cardiology: Valvular heart disease

Iraqi Board Cardiology · Work through your exam, one topic at a time.

All guide sections

Valvular heart disease

Questions test severity thresholds, the timing of intervention and the distinction between primary and secondary valve disease. Numerical thresholds matter.

Aortic stenosis

  • Severe: peak velocity 4 m/s or more, mean gradient 40 mmHg or more, valve area 1.0 cm2 or less (0.6 cm2/m2 or less).
  • Symptoms (angina, syncope, dyspnoea) in severe AS are an indication for aortic valve replacement; asymptomatic severe AS is not automatically an indication.
  • Low-flow low-gradient AS with reduced EF requires dobutamine stress echocardiography or CT calcium scoring.
  • TAVR for high or prohibitive surgical risk and increasingly for intermediate risk; SAVR for younger low-risk patients.

Regurgitation and stenosis

  • Aortic regurgitation: wide pulse pressure, decrescendo diastolic murmur, Austin Flint murmur. Surgery for symptoms or ejection fraction 50% or less, or LV end-systolic diameter 50 mm or more.
  • Mitral stenosis: rheumatic, loud S1, opening snap, diastolic rumble. Percutaneous balloon valvotomy when morphology is suitable and there is no left atrial thrombus or moderate mitral regurgitation.
  • Mitral regurgitation: primary (leaflet or chordal) versus secondary (ventricular). Surgery for symptomatic severe primary MR, or EF 60% or less, or end-systolic diameter 40 mm or more. Secondary MR: optimise guideline therapy first, consider transcatheter edge-to-edge repair.

Endocarditis

  • Modified Duke criteria; three blood culture sets before antibiotics; TTE then TOE.
  • Prophylaxis only for prosthetic valves, prior endocarditis, unrepaired cyanotic congenital disease and repaired lesions with residual defects or prosthetic material.

Worked example

A 78-year-old with syncope, mean gradient 48 mmHg, valve area 0.7 cm2 and preserved EF has symptomatic severe AS and should be referred for valve replacement after heart team assessment.

Traps

  • Waiting for symptoms in severe AS, or operating on asymptomatic severe AS without other triggers.
  • Confusing primary and secondary MR when planning surgery.
  • Offering antibiotic prophylaxis for isolated bicuspid valve or mitral valve prolapse.