Epsilon Wave in Arrhythmogenic Cardiomyopathy

Revista de Medicina Clínica 2024;08(01):e22042408004 Epsilon Wave in Arrhythmogenic Cardiomyopathy Clinial Snapshot Luis López-Flores1, Rocío Cózar-León1,2 and Ernesto Díaz-Infante1 1Cardiac Electrophysiology Unit, Department of Cardiology, Virgen Macarena University Hospital, Seville, Spain 2Department of Medicine of the University of Seville, Seville Reception date of the manuscript: 07/Septiembre/2023 Acceptance date of the manuscript: 16/Abril/2024 Publication date: 22/Abril/2024 DOI: 10.5281/zenodo.14170391 Creative Commons: This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. Figure 1: 12-lead electrocardiogram. A. Epsilon wave. B. Ventricular extrasystoles. Contact data: Luis López-Flores, Av. Dr. Fedriani, 3, 41009 Seville, Spain., Phone number: (+34) 955 00 80 00, [email protected] 1 EPSILON WAVE IN ARRHYTHMOGENIC CARDIOMYOPATHY LÓPEZ-FLORES, L. et al. AA 54-year-old woman with hypertension presented to the emergency department after syncope occurred during prolonged standing. On arrival, heart rate and blood pressure were normal. Admission electrocardiogram (Figure 1, A) showed sinus rhythm at 55 bpm, PR 200 ms, a wide QRS complex with morphology of complete right bundle branch block (width 180 ms), with small electrical potentials immediately after the QRS in all leads, more variegated in right precordial leads – findings suggestive of epsilon wave-, and a negative T wave in all precordial leads. A subsequent electrocardiogram (Figure 1, B) also revealed ventricular extrasystoles of two morphologies, with criteria of epicardial origin, and in which the low amplitude component at the end of the QRS was also appreciated. Echocardiography showed severe biventricular systolic dysfunction and right ventricular (RV) apical akinesia. Cardiac magnetic resonance imaging confirmed the findings and further revealed areas of RV dyskinesia and late gadolinium enhancement at the subepicardial level of both ventricles. Coronary angiography showed no coronary lesions. With the diagnosis of arrhythmogenic cardiomyopathy, an implantable cardioverter defibrillator was implanted for primary prevention. Epsilon wave is a major criterion for the diagnosis of arrhythmogenic cardiomyopathy and reflects a delay in ventricular depolarization due to replacement of myocardial fibers by fibroadipose tissue.1The presence of epsilon waves beyond the right precordial leads is exceptional; however, in patients with left ventricular involvement, the epsilon wave may be recorded in the left and/or inferior leads,2as illustrated in this case. FUNDING paragraph The authors of this paper did not receive any funding from any public, commercial or non-profit agency or foundation. CONFLICT OF INTEREST paragraph The authors declare to respect the ethical principles of research and to be free of any conflict of interest. REFERENCES [1] Corrado D, Zorzi A, Cipriani A, Bauce B, Bariani R, Beffagna G, et al. Evolving diagnostic criteria for arrhythmogenic cardiomyopathy. J Am Heart Assoc. 2021;10(18):1–17. [2] Nunes De Alencar Neto J, Baranchuk A, Bayés-Genís A, Bayés De Luna A. Arrhythmogenic right ventricular dysplasia/cardiomyopathy: An electrocardiogram-based review. Europace. 2018;20(FI1):f3–12. 2