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“Epsilon waves” in peripheral and precordial leads in arrhythmogenic rightventricular cardiomyopathy with severe right ventricular involvement
Francesco Rotondi MD, FANMCO, FESC, Giuseppe Amoroso MD,Fiore Manganelli MD, FANMCO, FESC
PII: S0022-0736(14)00489-0DOI: doi: 10.1016/j.jelectrocard.2014.12.002Reference: YJELC 51971
To appear in: Journal of Electrocardiology
Please cite this article as: Rotondi Francesco, Amoroso Giuseppe, Manganelli Fiore,“Epsilon waves” in peripheral and precordial leads in arrhythmogenic right ventricularcardiomyopathy with severe right ventricular involvement, Journal of Electrocardiology(2014), doi: 10.1016/j.jelectrocard.2014.12.002
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“Epsilon waves” in peripheral and precordial leads in arrhythmogenic right ventricular
cardiomyopathy with severe right ventricular involvement
Francesco Rotondi MD FANMCO FESC*, Giuseppe Amoroso MD, and Fiore Manganelli MD
FANMCO FESC
Department of Cardiology and Cardiovascular Surgery, ‘San Giuseppe Moscati’ Hospital, Avellino,
Italy
* Corresponding author. Tel: +390825203239; fax: +390825203239, Email:
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A 43-year-old woman with a medical history of severe arrhythmogenic right ventricular
cardiomyopathy (ARVC), registered on the heart transplant waiting list, was admitted to our
hospital with symptoms of congestive heart failure.
Standard 12-lead electrocardiogram (S-ECG) revealed sinus rhythm with heart rate of 40 bpm, PR
= 200 ms, right frontal axis deviation, incomplete right bundle branch block, QTc interval
prolongation (QT interval 0.600 msec; QTc interval 0.49 msec), T-waves inversion in V1–V6 and
in I, II and aVF and small “epsilon waves” (EW) in the right precordial leads (Fig 1). However,
EW were clearly visible also in the peripheral leads, by quadrupling the sensitivity of the record
(40 mm/mV) (Fig. 2).
EW are low-amplitude waves localised between the end of the QRS complex and the beginning of
the ST segment. EW are caused by postexcitation of the right ventricular myocardium and are
considered a major diagnostic criteria for ARVC according to the Task Force (1) .
The reported ECG prevalence of EW in ARVC ranges from 4% to 29%. They are usually seen
only in leads V1 through V3 (2). In our view, it is possible that detection of EW also in the limb
leads, with a S-ECG, could be related to a severe and extensive involvement of the right ventricle
(Fig.3).
Our report suggest that the detection rate of EW in other leads beyond “classical leads” V1-V3
may be improved simply by increasing the sensitivity of S-ECG. This easy technical solution can
be performed even if EW are not in leads V1-V3 and can facilitate the diagnosis in daily practice.
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References
[1] F. I. Marcus, W.J. McKenna, D. Sherrill et al. Diagnosis of arrhythmogenic right ventricular
cardiomyopathy/dysplasia: proposed modification of the Task Force Criteria.
Circulation. 2010; 121: 1533-1541
[2] F. I. Marcus, W. Zareba. The electrocardiogram in right ventricular cardiomyopathy/dysplasia:
how can the electrocardiogram assist in understanding the pathologic and functional changes of the
heart in this disease? J Electrocardiol 2009; 42:136.e1–136e5
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Fig. 1
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Fig. 2
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Fig. 3
