epsilon waves

Reproducible low-amplitude signals seen after the end of the QRS and before onset of the T wave, usually seen in the right precordial leads (V1-V3) and potentially extending to left precordial or inferior leads on a standard 12-lead ECG.

Epsilon waves are small positive 'blips' or deflections seen at the end of the QRS complex, typically caused by postexcitation of RV myocytes
Epsilon waves are the most characteristic finding in arrhythmogenic right ventricular dysplasia (ARVC/ARVD) where fibrofatty infiltration of the RV delays conduction
- - Associated with RV wall motion abnormalities
  - Also described in patients with posterior and RV MI, and infiltrative diseases
Uncommon finding (not sensitive) with great specificity for ARVC/D
Used to be considered a wave exclusively of leads V1-V3, but newer studies suggest they may also extend inferiorly and laterally
Epsilon waves are a sign of structural disease in the RV outflow tract area, and are associated with episodes of ventricular tachycardia

References:

Li GL, Saguner AM, Fontaine GH, Frank R. Epsilon waves: Milestones in the discovery and progress. Ann Noninvasive Electrocardiol. 2018;23(6):1-10. PMID: 29978588
Hauer RNW, Cox MGPJ, Groeneweg JA. Impact of new electrocardiographic criteria in arrhythmogenic cardiomyopathy. Front Physiol. 2012;3 SEP:1-7. PMID: 23015790
Protonotarios A, Anastasakis A, Tsatsopoulou A, et al. Clinical significance of epsilon waves in arrhythmogenic cardiomyopathy. J Cardiovasc Electrophysiol. 2015;26(11):1204-1210. PMID: 26183028
Orgeron GM, Crosson JE. Arrhythmogenic right ventricular dysplasia/cardiomyopathy. Cardiol Young. 2017;27(S1):S57-S61. PMID: 28084951
Sattar Y, Abdullah HM, Samani E, et al. Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia: An Updated Review of Diagnosis and Management. Cureus. 2019;11(8). PMID: 31616612

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