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Iran Specialty Board - Cardiology study materials
Iran Specialty Board - Cardiology study resources

Iran Specialty Board - Cardiology: Valvular Heart Disease

Iran Specialty Board - Cardiology · Work through your exam, one topic at a time.

All guide sections

Valvular Heart Disease

The exam tests severity thresholds, the exact point at which symptoms or ventricular dimensions trigger surgery, and the choice between surgical and transcatheter approaches. Rheumatic mitral disease remains common in Iranian practice, so mitral stenosis items appear frequently.

Aortic stenosis

  • Severe: peak velocity 4 m/s or more, mean gradient 40 mmHg or more, valve area 1.0 cm2 or less (indexed 0.6 cm2/m2 or less).
  • Low-flow low-gradient with reduced ejection fraction: use low-dose dobutamine to assess contractile reserve; with preserved ejection fraction use CT calcium scoring.
  • Symptom onset is the trigger for intervention; asymptomatic severe disease is watched unless exercise testing is abnormal or LVEF falls.

Aortic regurgitation

  • Severe: vena contracta above 0.6 cm, holodiastolic flow reversal in the descending aorta, regurgitant volume 60 mL or more.
  • Surgery for symptoms, LVEF 50% or less, or LV end-systolic diameter above 50 mm.

Mitral disease

  • Primary severe MR: effective orifice area 0.4 cm2 or more, regurgitant volume 60 mL or more; operate for symptoms, LVEF 60% or less, or LV end-systolic diameter 40 mm or more.
  • Secondary MR: optimise heart failure therapy first; transcatheter edge-to-edge repair in selected patients.
  • Rheumatic mitral stenosis: valve area 1.5 cm2 or less defines severe disease; balloon valvuloplasty when morphology is favourable, there is no left atrial thrombus, and MR is moderate or less.

Prosthetic valves

  • Mechanical valves need lifelong warfarin: INR 2-3 aortic, 2.5-3.5 mitral.
  • Bioprostheses need aspirin; warfarin for 3-6 months in the mitral position.

Worked example

A 70-year-old with exertional syncope, mean aortic gradient 46 mmHg, valve area 0.8 cm2, and LVEF 55% has symptomatic severe AS and should be offered intervention, choosing TAVR or surgery by age, anatomy, and surgical risk.

Traps

  • Cardiac catheterisation gradients are unreliable in low-output states.
  • Vasodilators and aggressive diuresis can precipitate collapse in severe AS.
  • A gradient of 35 mmHg with a small area may still be severe low-flow disease.