• Images in cardiology

A 26 year old woman with episodes of syncope was referred to our university hospital for further evaluation. Her elder sister died suddenly at the age of 18. Chest radiographs showed cardiac enlargement with a cardiothoracic ratio of 52%. The ECG showed a sinus rhythm at a rate of 62, QRS prolongation, and inverted T waves. There were prominent upright deflections after the QRS complex in leads V1–3 (arrows). These waves are called epsilon waves. Echocardiography revealed severe dilatation of the right ventricle and reduction of the right ventricular wall motion. Left bundle branch block type ventricular tachycardia was documented. Endomyocardial biopsy sample from the right ventricle showed fibro-fatty degeneration, and a diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC) was made.

Epsilon waves are one of the major diagnostic criteria of ARVC. Epsilon waves can be recorded using 12 lead electrocardiography during sinus rhythm, and are useful for establishing a diagnosis of ARVC.