New Information on Asymptomatic Pre-excitation

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Dear Sir,

I read with great interest the comprehensive review of Dr Brugada and Dr Keegan on asymptomatic pre-excitation, and the issues of risk stratification and need for catheter ablation.1 Perhaps the authors would like to comment on two additional studies that have just appeared, but contain vital information for the appropriate management of these patients. The first study emanates from a Danish registry of 310 individuals with pre-excitation (age range 8–85 years). A higher hazard of atrial fibrillation and heart failure, driven by a right anteroseptal accessory pathway, was detected in this population, and in patients >65 years of age there was also a statistically significant higher risk of death.2 In the second retrospective study in 912 young patients ≤21 years old with Wolff-Parkinson-White (WPW) syndrome, patients experienced rapidly conducted pre-excited AF (49 %), aborted sudden death (45 %) and sudden death (6 %). In those subjected to EPS risk stratification, 22 of 60 (37 %) did not have EPS-determined highrisk characteristics, and 15 of 60 (25 %) had neither concerning pathway characteristics nor inducible atrioventricular re-entrant tachycardia. Do the authors interpret these results as clearly suggesting a more substantial role of ablation for patients who present with an active, anterogradely conduction accessory pathway?


  1. Brugada J, Keegan, R. Asymptomatic ventricular pre-excitation: between sudden cardiac death and catheter ablation. Arrhythm Electrophysiol Rev 2018;7:32–8.
    Crossref | PubMed
  2. Skov MW, Rasmussen PV, Ghouse J, et al. Electrocardiographic preexcitation and risk of cardiovascular morbidity and mortality: results from the Copenhagen ECG study. Circ Arrhythm Electrophysiol 2017;10:pii,e004778.
    Crossref | PubMed
  3. Etheridge SP, Escudero CA, Blaufox AD, et al. Life-threatening event risk in children with Wolff–Parkinson–White syndrome. A multicenter international study. J Am Coll Cardiol 2018;4:433–44.