Asymptomatic ventricular pre-excitation: which path to take?

The management of asymptomatic patients with ventricular pre-excitation diagnosed occasionally is controversial. In fact, the lack of clinical arrhythmias does not necessarily define a benign condition: it could be possibly due to poor conduction over the accessory pathway or, conversely, to peculiar and individual conditions, which, even if the accessory pathway is capable of fast conduction, can prevent the onset of arrhythmias. These can occur unexpectedly during follow-up and may include malignant ventricular arrhythmias, although sudden death is very rare in this clinical scenario. An aggressive strategy aiming at extensive ablation in all cases with asymptomatic ventricular pre-excitation is not justified, as well as the "wait-and-see" approach. Clinically, it is important to accurately define the individual risk of any arrhythmia related to the accessory pathway, which may require treatment. For decades, the management of asymptomatic ventricular pre-excitation has been quite inhomogeneous among centers and in some cases it is still very different. Recently, a consensus document proposed the combined use of non-invasive and invasive diagnostic tools for accurate screening of these patients. If non-invasive methodologies are unable to demonstrate poor conduction over the accessory pathway, then an invasive approach is justified for arrhythmia risk definition and, if necessary, adequate therapy.