Epsilon wave in ECG

The epsilon wave is a small positive deflection (‘blip’ or ‘wiggle’) buried in the end of the QRS complex.
Epsilon waves are caused by postexcitation of the myocytes in the right ventricle.
Epsilon waves are the most characteristic finding in arrhythmogenic right ventricular dysplasia (ARVD).
Here myocytes are replaced with fat, producing islands of viable myocytes in a sea of fat.
This causes a delay in excitation of some of the myocytes of the right ventricle and causes the little wiggles seen during the ST segment of the ECG.

1. MBBS, FCPS, MD, FACC, FESC, FRCP, FSCAI,
FCCP,FAPSC, FAPSIC, FAHA,FACP,FASE
Professor and Head of Cardiology
Colonel MalekMedical College , Manikganj.
[email protected]
Fundamentals of ECG

2. [email protected]
Epsilon Wave
Professor DrMdToufiqurRahman
Theepsilonwaveisasmall
positivedeflection(‘blip’or
‘wiggle’)buriedintheendofthe
QRScomplex.
Epsilonwavesarecausedby
postexcitationofthemyocytesin
therightventricle.
Fundamentals of ECG

3. [email protected]
Epsilon Wave
Professor DrMdToufiqurRahman
Epsilonwavesarethemostcharacteristic
findinginarrhythmogenicrightventricular
dysplasia(ARVD).
Heremyocytesarereplacedwithfat,producing
islandsofviablemyocytesinaseaoffat.
Thiscausesadelayinexcitationofsomeof
themyocytesoftherightventricleand
causesthelittlewigglesseenduringtheST
segmentoftheECG.
Fundamentals of ECG

4. [email protected]
Epsilon Wave
Professor DrMdToufiqurRahman
Epsilonwaveshavealsobeen
describedinpatientswith
posteriormyocardialinfarction;
rightventricularinfarction;
infiltrationdisease,and
sarcoidosis.
Fundamentals of ECG

5. [email protected]
Epsilon Wave
Professor DrMdToufiqurRahman
Epsilonwavesarebest
seenintheSTsegments
ofleadsV1andV2,and
mostcommonlyseenin
leadsV1throughV4.
Fundamentals of ECG

6. [email protected]
Epsilon Wave
Professor DrMdToufiqurRahman
Fundamentals of ECG

7. [email protected]
Epsilon Wave
Professor DrMdToufiqurRahman
Fundamentals of ECG

8. [email protected]
Epsilon Wave
Professor DrMdToufiqurRahman
Fundamentals of ECG

9. [email protected]
Epsilon Wave
Professor DrMdToufiqurRahman
History
The Epsilonwaves in
arrhythmogenicrightventricular
dysplasiawerefirstdefinedand
describedin1977byGuy
Fontaine(1936-2018).
Thewavesmaybeseenmorereadily
usingFontaineleads.
Fundamentals of ECG

10. [email protected]
Epsilon Wave
Professor DrMdToufiqurRahman
History
The term “epsilon” was nice, because it
occurs in the Greek alphabet after
delta; thus, delta represents the pre-
excitation and epsilon the post-excitation
phenomenon.
In addition, epsilon is also used in
mathematics to express a very small
phenomenon…
Fundamentals of ECG

11. [email protected]
Delta Wave & Epsilon Wave
Professor DrMdToufiqurRahman
Fundamentals of ECG

12. [email protected]
Epsilon Wave
Professor DrMdToufiqurRahman
History
Fontaine bipolar precordial leads(F-
ECG) can be used to increase the
sensitivity ofepsilon wavedetection.
Leads are placed as shown:
•Right Arm (RA) over the manubrium;
•Left Arm (LA) over the xiphoid process;and
•Left Leg (LL) in the standard V4 position
(5
th
ICS MCL).
Fundamentals of ECG

13. [email protected]
Epsilon Wave
Professor DrMdToufiqurRahman
Instead of regular leads I, II, and III there
are now threebipolarchest leads that are
termed FI, FII, and FIII which record the
potentials developed in the right ventricle,
from the infundibulum to the diaphragm.
The vertical bipolar lead FI, (similar to aVF)
magnifies the atrial potentials and can be
used to record epsilon waves
Fundamentals of ECG

14. [email protected]
Epsilon Wave
Professor DrMdToufiqurRahman
Fontaine bipolar precordial leads (F-ECG)
Fundamentals of ECG

15. [email protected]
Epsilon Wave
Professor DrMdToufiqurRahman
ArrhythmogenicRight Ventricular Dysplasia (ARVD)
The ECG changes inArrhythmogenicRight Ventricular
Dysplasiainclude:
Epsilon wave (most specific finding, seen in 30% of
patients)
T wave inversions in V1-3 (85% of patients)
Prolonged S-wave upstroke of 55ms in V1-3 (95%
of patients)
LocalisedQRS widening of 110ms in V1-3
Paroxysmal episodes of ventricular tachycardia
with a LBBB morphology
Fundamentals of ECG

16. [email protected]
Epsilon Wave
Professor DrMdToufiqurRahman
Epsilon wave should be
search for AV dissociation in
ventricular tachycardia; and
to study abnormal atrial
rhythms when the P waves are
too small on regular leads.
Fundamentals of ECG