Mitral valve prolapse: the Merchant of Venice or the Tales of Hoffman?

0195-668X/02/010087+07 $35.00/0 especially its title. Whether MVP claimed the life of Shylock in the Merchant of Venice who claimed the heart of Portia’s lover or Antonia in the Tales of Hoffman who sang herself to death, there is no question that, though generally a benign condition, MVP may be a deadly disease at times. Up to 1989, 106 cases of sudden death have been reported as a complication of MVP. Whether increased plasma catecholamines related to stress (‘Dr Miracle sings: ‘Nineteen. Glorious springtime of life. And now, let me take your pulse . . . Sh! Quiet while I count . . . Her pulse — very uneven and fast (inegal et vif). A dangerous symptom! Now sing! Now sing!’. In Robert Lawrence’s analysis, ‘. . . the slimy Dr Miracle who . . . induces Antonia to sing herself to death while accompanying her on a macabre violin’ or present as an associated state of autonomic dysfunction/ imbalance may predispose subjects to ventricular ectopy or catastrophic tachyarrhythmias, or both, is not known, but has been suggested. Increased QT dispersion with or without QT prolongation in MVP has also been recently postulated as an arrhythmogenic mechanism and shown to be a marker for sudden cardiac death. MVP may either be primary or secondary. In coronary artery disease, MVP may be the result of papillary muscle dysfunction. On the other hand, MVP may induce coronary artery spasm. Then, MVP and coronary artery disease, both being common diseases, may coexist. MVP is not only the most frequently diagnosed valve disorder in the United States but also a universal disease, having been described in nearly every country in the world. The reported prevalence has varied from less than 1% to as high as 38%, depending on whether the diagnosis is based on clinical or echocardiographic examination (Table 1). When the diagnosis is based on echocardiographic examination, the view employed is also important, because the non-planar, hyperbolic–paraboloid or saddleshaped mitral anulus allows mitral leaflets that are on the left ventricular side of the mitral anulus in the long axis view to appear to ‘prolapse’ into the left atrium in the apical fourchamber view. As Stefanadis and Toutouzas concluded, ‘prudence in diagnosis, based on rigorous criteria and robust epidemiologic data, will define the true prevalence’ of this ubiquitous disorder. By knowing the true prevalence of MVP, one can then better assess the risks of the disease.