Higher right precordial leads and Fontaine leads: the better detection of QRS fragmentation and epsilon wave in arrhythmogenic right ventricular dysplasia-cardiomyopathy

Epsilon waves (EW) in right precordial leads are reliable diagnostic electrocardiographic criteria of arrhythmogenic right ventricular dysplasia-cardiomyopathy (ARVD/C). The definition of EW remains difficult because within the QRS complex are inscribed notches or deflections called fragmentation of the QRS complex (f-QRS). The f-QRS at the beginning, on the top, and at the end of QRS complex (termed "pre-, top-, and postsilons") was proposed as typical extended definition of EW. We described a 59-year-old female with ARVD with severe left ventricular involvement, ejection fraction - 23%. The standard 12-lead ECG showed QRS fragmentation in 7 leads. It can be a marker of ARVD with severe left ventricular disease. EW may be enhanced visually to 50-75% by following placing: the left arm should be placed on the xyphoid process and the right arm lead on the manubrium sternum, with the left leg in the location of V 4 or V 5 this is called the Fontaine bipolar precordial lead (F-ECG). Detection of right precordial f-QRS can be improved using higher right precordial leads (similar as in Brugada syndrome). The case we described reminds that EW could be enhancing by F-ECG leads and f-QRS by using higher right precodial leads.