Higher right precordial leads and Fontaine leads: the better detection of QRS fragmentation and epsilon wave in arrhythmogenic right ventricular dysplasia-cardiomyopathy

Abstract

Epsilon waves (EW) in right precordial leads are reliable diagnostic electrocardiographic criteria of arrhythmogenic right ventricular dysplasia-cardiomyopathy (ARVD/C). The definition of EW remains difficult because within the QRS complex are inscribed notches or deflections called fragmentation of the QRS complex (f-QRS). The f-QRS at the beginning, on the top, and at the end of QRS complex (termed “pre-, top-, and postsilons”) was proposed as typical extended definition of EW. We described a 59-year-old female with ARVD with severe left ventricular involvement, ejection fraction — 23%. The standard 12-lead ECG showed QRS fragmentation in 7 leads. It can be a marker of ARVD with severe left ventricular disease. EW may be enhanced visually to 50–75% by following placing: the left arm should be placed on the xyphoid process and the right arm lead on the manubrium sternum, with the left leg in the location of V4 or V5 this is called the Fontaine bipolar precordial lead (F-ECG). Detection of right precordial f-QRS can be improved using higher right precordial leads (similar as in Brugada syndrome). The case we described reminds that EW could be enhancing by F-ECG leads and f-QRS by using higher right precodial leads