The document discusses epsilon waves, small positive deflections within the QRS complex of an ECG, primarily associated with arrhythmogenic right ventricular dysplasia (ARVD) and other cardiac conditions. These waves indicate postexcitation of right ventricular myocytes due to fat replacement, causing delays in excitation and are best observed in leads V1 to V4. Additionally, the text references the use of Fontaine bipolar precordial leads to enhance sensitivity in detecting these waves.

1. MBBS, FCPS, MD, FACC, FESC, FRCP, FSCAI,
FCCP,FAPSC, FAPSIC, FAHA,FACP,FASE
Professor and Head of Cardiology
Colonel Malek Medical College , Manikganj.
drtoufiq19711@yahoo.com
Fundamentals of ECG

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Epsilon Wave
Professor Dr Md Toufiqur Rahman
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.
Fundamentals of ECG

3. drtoufiq1971@gmail.com
Epsilon Wave
Professor Dr Md Toufiqur Rahman
 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.
Fundamentals of ECG

4. drtoufiq1971@gmail.com
Epsilon Wave
Professor Dr Md Toufiqur Rahman
Epsilon waves have also been
described in patients with
posterior myocardial infarction;
right ventricular infarction;
infiltration disease, and
sarcoidosis.
Fundamentals of ECG

5. drtoufiq1971@gmail.com
Epsilon Wave
Professor Dr Md Toufiqur Rahman
 Epsilon waves are best
seen in the ST segments
of leads V1 and V2, and
most commonly seen in
leads V1 through V4.
Fundamentals of ECG

6. drtoufiq1971@gmail.com
Epsilon Wave
Professor Dr Md Toufiqur Rahman
Fundamentals of ECG

7. drtoufiq1971@gmail.com
Epsilon Wave
Professor Dr Md Toufiqur Rahman
Fundamentals of ECG

8. drtoufiq1971@gmail.com
Epsilon Wave
Professor Dr Md Toufiqur Rahman
Fundamentals of ECG

9. drtoufiq1971@gmail.com
Epsilon Wave
Professor Dr Md Toufiqur Rahman
History
The Epsilon waves in
arrhythmogenic right ventricular
dysplasia were first defined and
described in 1977 by Guy
Fontaine (1936-2018).
The waves may be seen more readily
using Fontaine leads.
Fundamentals of ECG

10. drtoufiq1971@gmail.com
Epsilon Wave
Professor Dr Md Toufiqur Rahman
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

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Delta Wave & Epsilon Wave
Professor Dr Md Toufiqur Rahman
Fundamentals of ECG

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Epsilon Wave
Professor Dr Md Toufiqur Rahman
History
 Fontaine bipolar precordial leads (F-
ECG) can be used to increase the
sensitivity of epsilon wave detection.
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
(5th ICS MCL).
Fundamentals of ECG

13. drtoufiq1971@gmail.com
Epsilon Wave
Professor Dr Md Toufiqur Rahman
 Instead of regular leads I, II, and III there
are now three bipolar chest 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

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Epsilon Wave
Professor Dr Md Toufiqur Rahman
Fontaine bipolar precordial leads (F-ECG)
Fundamentals of ECG

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Epsilon Wave
Professor Dr Md Toufiqur Rahman
Arrhythmogenic Right Ventricular Dysplasia (ARVD)
The ECG changes in Arrhythmogenic Right Ventricular
Dysplasia include:
 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)
 Localised QRS widening of 110ms in V1-3
 Paroxysmal episodes of ventricular tachycardia
with a LBBB morphology
Fundamentals of ECG

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Epsilon Wave
Professor Dr Md Toufiqur Rahman
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