The Use of Fontaine Leads in the Diagnosis of Arrhythmogenic Right Ventricular Dysplasia

Abstract

We report a case of a 68-year-old man admitted to the emergency department with syncope preceded by rapid palpitations. His admission ECG demonstrated a sustained ventricular tachycardia (VT) originating from the right ventricular outflow tract (RVOT). This report highlights the importance of distinguishing ventricular tachycardia caused by arrhythmogenic right ventricular dysplasia (ARVD) from the more benign idiopathic RVOT-VT. Furthermore, we demonstrate the utility of the Fontaine leads placement in increasing the sensitivity for uncovering epsilon waves, a highly specific electrocardiographic feature that increases diagnostic accuracy in patients with ARVD.

Clinical Significance of Epsilon Waves in Arrhythmogenic Cardiomyopathy

“…Although our study utilized the later definition, epsilon wave prevalence remained high, which may be attributed to increased representation of the JUP and DSC‐2 clinical disease profiles. In a few studies the use of increased sensitivity, double speed, and Fontaine leads enhanced the frequency of epsilon wave detection . However, in this study we used only standard 12‐lead ECG recordings, which is the everyday clinical practice.…”

“…In a few studies the use of increased sensitivity, double speed, and Fontaine leads enhanced the frequency of epsilon wave detection. [18][19][20] However, in this study we used only standard 12-lead ECG recordings, which is the everyday clinical practice.…”

Differential Diagnosis of rSr’ Pattern in Leads V1-V2. Comprehensive Review and Proposed Algorithm

“…However in ARVD there is no ST‐segment elevation, the T wave is negative in leads V 1 to V 3 and usually the r’ corresponds to an epsilon wave that is a little separated of the QRS. Fontaine leads may help in making epsilon waves more obvious . In hyperkalemia, the T wave is usually greater than 7 mm in leads V 2 ‐V 3 , something that is never observed in Type‐2 Brugada pattern.…”

“…It may emulate an atypical rSr´ pattern because the epsilon wave sometimes is confused with an r´ wave. However usually the epsilon wave is a little separated of the QRS complex; ( 6) Ebstein disease : May show a pattern of RBBB with R’ > r and often with very abnormal P wave.…”

“…However, in cases of ARVD T‐wave inversion in leads V 1 ‐V 3 is frequently seen and there is no ST‐segment elevation. In addition, low voltages and epsilon wave are quite frequent . In hyperkalemia, ST‐segment ascent can occur but always the T wave in leads V 2 ‐V 3 is very tall (>7 mm) what is not seen in Type‐2 Brugada pattern. If the base of the triangle is <4 mm, it is unlikely to correspond to a type‐2 Brugada pattern, there is no mismatch between leads V 1 /V 2 ‐V 5 /V 6 and the differential diagnosis include: (i) Incomplete RBBB (no ST‐segment ascent); (ii) Athletes (the ST‐segment ascent may exist but the Corrado index is <1; Fig.…”