Prominent Epsilon Waves in a Patient With Cardiac Sarcoidosis

Figures

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  Figure 1. ECG Obtained at Presentation A 12-lead electrocardiogram (ECG) obtained at presentation shows ventricular tachycardia with a left bundle branch morphology at a rate of 188 beats/min. The axis in the frontal plane is directed inferiorly and to the right at approximately +120°.

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  Figure 2. ECG Obtained in Sinus Rhythm This 12-lead electrocardiogram (ECG) was obtained in sinus rhythm after termination of the ventricular tachycardia with intravenous amiodarone. Right atrial enlargement and low-voltage QRS complexes are observed in the frontal plane. Arrow indicates a prominent epsilon wave in V2 but can be observed following the QRS complex in all leads.

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  Figure 3. Core Biopsy From Axillary Lymph Node (A) Gram stain demonstrates noncaseating granulomas. (B) Grocott methenamine silver stain shows absence of fungal elements. (C) Ziehl-Neelsen stain was negative for acid fast bacilli.

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  Figure 4. Cardiac Magnetic Resonance Cardiac magnetic resonance imaging shows (A) 4-chamber spin echo with fat suppression and (B) short-axis spin echo with fat suppression. This study demonstrated decreased wall thickness in the left ventricular free wall and delayed gadolinium enhancement in the interventricular septum (arrow in A) and left ventricle free wall (arrow in B).

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  Figure 5. Voltage Map of Right Ventricle in Sinus Rhythm (A) Sequence of endocardial activation of the right ventricle obtained in sinus rhythm using a contact force mapping catheter and a nonfluoroscopic mapping system (Carto 3, Biosense Webster, Irvine, California). Late activation (white dotted arrow) occurs in the right ventricular free wall. At this site, late potentials occurring simultaneously with the epsilon wave were recorded (B). Bipolar mapping showed extensive areas with low voltage in the right free wall and right ventricular outflow tract (C). Bi = biventricular; CSD = coronary sinus distal; CSP = coronary sinus proximal; LAO = left anterolateral projection; LAT = lateral; RAA = right atrial appendage; RAO = right anterolateral projection.