Giant epsilon waves in 12 leads in a patient with severe arrhythmogenic cardiomyopathy

The epsilon wave, which reflects a delayed conduction of the right ventricle and is chiefly found in the right-sided precordial leads, is a major criterion in the diagnosis of arrhythmogenic right ventricle dysplasia because of being considered highly specific. It is estimated to appear in 9–36% of the cases. We present a 65 years old woman who visited the Emergency Department with dyspnoea in the context of a congestive heart failure. During the admission in Cardiology, electrocardiogram, echocardiography, coronarography, cardiac magnetic resonance, and genetic testing were performed. As a result, the patient was diagnosed as having arrhythmogenic cardiomyopathy with biventricular involvement, due to meeting four major and one minor criteria. Genetic testing showed that she was a heterozygous Desmoglein-2 mutation carrier. The patient presented with a severe phenotype with dilatation and severe systolic dysfunction of both ventricles, with diffuse subepicardial biventricular late gadolinium enhancement and underwent implantable cardioverter defibrillator implantation for primary prevention. The standard 12-lead electrocardiogram showed sinus rhythm, left anterior fascicular block, narrow QRS, and inverted-flat T waves in precordial and inferior leads (Figure). We noted the presence of mega-epsilon waves in all 12 leads. This rare feature has been only mentioned once and may reflect an extensive and severe form of the disease. The full-length version of this report can be viewed at: http://www.escardio.org/Guidelines-&-Education/E-learning/Clinical-cases/Electrophysiology/EP-Case-Reports.