Electroanatomic correlates of depolarization abnormalities in arrhythmogenic right ventricular dysplasia/cardiomyopathy

Tanyanan Tanawuttiwat, Anneline S.J.M. Te Riele, Binu Philips, Cynthia A. James, Brittney Murray, Crystal Tichnell, Abhishek C. Sawant, Hugh Calkins, Harikrishna Tandri

Research output: Contribution to journalArticlepeer-review

21 Scopus citations


EAM Correlates of Depolarization in ARVD Background Epsilon waves and other depolarization abnormalities in the right precordial leads are thought to represent delayed activation of the right ventricular outflow tract in arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C). However, no study has directly correlated cardiac electrical activation with the surface ECG findings in ARVD/C. Methods and Results Thirty ARVD/C patients (mean age 32.7 ± 11.2 years, 16 men) underwent endocardial and epicardial electroanatomical activation mapping in sinus rhythm. Twelve-lead ECGs were classified into 5 patterns: (1) normal QRS (11 patients); (2) terminal activation delay (TAD) (3 patients); (3) incomplete right bundle branch block (IRBBB) (5 patients); (4) epsilon wave (5 patients); (5) complete right bundle branch block (CRBBB) (6 patients). Timing of local ventricular activation and extent of scar was then correlated with surface QRS. Earliest endocardial and epicardial RV activation occurred on the mid anteroseptal wall in all patients despite the CRBBB pattern on ECG. Total RV activation times increased from normal QRS to prolonged TAD, IRBBB, epsilon wave, and CRBBB, respectively (103.9 ± 5.6, 116.3 ± 6.5, 117.8 ± 2.7, 146.4 ± 16.3, and 154.3 ± 6.3, respectively, P < 0.05). The total epicardial scar area (cm2) was similar among the different ECG patterns. Median endocardial scar burden was significantly higher in patients with epsilon waves even compared with patients with CRBBB (34.3 vs. 11.3 cm2, P < 0.01). Timing of epsilon wave corresponded to activation of the subtricuspid region in all patients. Conclusion We found that epsilon waves are often associated with severe conduction delay and extensive endocardial scarring in addition to epicardial disease. The timing of epsilon waves on surface ECG correlated with electrical activation of the sub-tricuspid region.

Original languageEnglish (US)
Pages (from-to)443-452
Number of pages10
JournalJournal of cardiovascular electrophysiology
Issue number4
StatePublished - Apr 1 2016


  • arrhythmogenic right ventricular
  • catheter ablation
  • dysplasia/cardiomyopathy
  • epicardial mapping
  • epsilon wave
  • right bundle branch block

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)


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