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Comparative Study
. 2025 Nov;36(11):2818-2826.
doi: 10.1111/jce.70035. Epub 2025 Aug 7.

Intermittent Ventricular Pre-Excitation: Clinical Features and Electrophysiological Properties

Antonio Gianluca Robles  1   2 , Zefferino Palamà  2   3 , Francesco Santoro  4 , Martin Rauber  5 , Bor Antolič  5 , Domenico Gianfrancesco  1 , Francesco Bartolomucci  1 , Pierluigi Pellegrino  4 , Simona Alfieri  4 , Alessio Borelli  2   6 , Antonio Scarà  2   6 , Gabriele De Masi De Luca  2 , Ermenegildo de Ruvo  7 , Leonardo Calò  7 , Matevž Jan  8 , Andrej Pernat  5 , Silvio Romano  2 , Luigi Sciarra  2   6
Affiliations
Comparative Study

Intermittent Ventricular Pre-Excitation: Clinical Features and Electrophysiological Properties

Antonio Gianluca Robles et al. J Cardiovasc Electrophysiol. 2025 Nov.

Abstract

Background: Intermittent ventricular pre-excitation has long been considered a low-risk marker for sudden death. Accessory pathways (APs) with high-risk intermittent antegrade conductive properties may exist, but this still represents a gray area in current guidelines. We evaluated differences in risk characteristics between symptomatic and asymptomatic patients with intermittent pre-excitation (IPX) and those with persistent pre-excitation (PPX) in a multicenter international registry.

Methods: 392 consecutive patients [IPX: 79 (20.15%); PPX: 313 (79.85%)] underwent electrophysiological (EP) study. Data on arrhythmia inducibility (AVRT/AF), AP antegrade conduction properties (ERP/SPERRI), site, and number were collected.

Results: No significant differences were found in demographic characteristics and EP features between PPX and IPX patients, including antegrade conductive properties, prevalence of multiple APs, and AP locations, except for AVRT inducibility which was more frequent in IPX group. Similarly, no differences were detected between symptomatic and asymptomatic IPX patients.

Conclusions: Except for AVRT inducibility, our study shows no significant differences in demographic and other electrophysiological features between PPX and IPX patients. Likewise, no differences in demographic and EP features were detected between symptomatic and asymptomatic IPX patients. Therefore, intermittent pre-excitation is an unreliable noninvasive marker of arrhythmic risk and it warrants an invasive risk assessment via EP study.

Keywords: Wolff–Parkinson–White syndrome; electrophysiological study; intermittent ventricular pre‐excitation; risk stratification; sudden cardiac death.

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Figure 1
Figure 1
A case of intermittent pre‐excitation in baseline at the beginning of an EP study. All the QRS complexes are narrow, but the 3°, 4° and the 11°, 12°, are wide and show an initial δ wave. δ wave is positive in V1, negative in D3‐aVF, and positive in D1‐aVL thus suggesting a left‐sided postero‐septal AP (confirmed by 3D‐mapping). The majority of beats abruptly show normal PQ, no δ wave and narrow QRS with normal morphology (physiological septal activation testified by the small q wave in V5–V6). This is a teaching case of intermittent pre‐excitation because of the abrupt disappearance of δ wave is not related to heart rate variation (the heart rate is fixed at 78 bpm as confirmed by mesaurement of P‐P cycle lenght) or isoproterenol infusion.
Figure 2
Figure 2
Study design synopsis.
Figure 3
Figure 3
APs site distribution. R, right‐sided; L, left‐sided; AS, antero‐septal; MS, Mid‐septal; RPS, right postero‐septal; LPS, Left postero‐septal; CS, coronary sinus; T, tricuspid valve; Mitral valve. Notably, septal AP include AS, MS, RPS, proximal CS and LPS.
Figure 4
Figure 4
Box plot: intergroup comparison (PPX vs. IPX) of AP antegrade conductive properties (shortest ERP/SPERRI).
Figure 5
Figure 5
Box plot: intragroup comparison (symptomatic IPX vs. asymptomatic IPX) of AP antegrade conductive properties (shortest ERP/SPERRI).
See this image and copyright information in PMC

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