Pei Haifeng, Yu Qiujun, Su Xiaohua, Wang Zhen, Zhao Heng, Yang Dachun, Yang Yongjian, Li De
From the Departments of Cardiology (HP, XS, ZW, DY, YY, DL) and Ultrasonography (HZ), Chengdu Military General Hospital, Chengdu; Third Military Medical University, Chongqing (HP, YY), China; and Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (QY).
Medicine (Baltimore). 2016 Apr;95(16):e3442. doi: 10.1097/MD.0000000000003442.
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a crucial health problem. With sudden death often being the first presentation, early diagnosis for ARVC is essential. Up to date, electrocardiogram (ECG) is a widely used diagnostic method without invasive harms. To diagnose and treat ARVC as well as possible, we should clearly elucidate its pathophysiological alterations. A 66-year-old farmer presented to the Emergency Department with continuous palpitation, chest tightness, profuse sweating, and nausea with no obvious predisposing causes. An ECG indicated ventricular tachycardia (VT). The patient experienced a sudden drop in blood pressure and acute confusion. After an immediate electrical conversion, his consciousness was gradually restored, and symptoms relieved. The patient was then transferred to the Department of Cardiology to receive ECG, echocardiography, coronary angiogram, biochemical assays, endocardiac tracing, and radiofrequency ablation. In the end, he was diagnosed with ARVC, evidenced by bilateral ventricle dilation and epsilon waves in leads V1-V3. Appropriate therapies were provided for this patient including pharmacological intervention and radiofrequency ablation. Although the diagnosis of ARVC is not difficult, this patient's ECG manifested several interesting features and should be further investigated: T wave inversions were found extensively in the anterior and inferior leads, revealing the involvement of bilateral ventricles; VTs with different morphologies and cycle lengths were found, and some VTs manifested the feature of irregularly irregular rhythm, reminding us to carefully differentiate some special VTs from atrial fibrillation (AF); and epsilon waves gradually appeared in leads V1-V3 and avR since the onset of ARVC. Most importantly, the epsilon waves behind QRS complex appeared in both sinus rhythm and ventricular premature beats/VT originating from cardiac apex, whereas the epsilon waves prior to QRS complex occurred in VT originating from right ventricular outflow tract (RVOT). The features of T wave inversion and epsilon wave in ECGs and the appearance of VTs with different morphologies can reflect the progression of ARVC. The position relationship between epsilon wave and QRS complex in VT depends on ventricular activation sequence, that is, the localization of epsilon wave depends on where VT is originating from.
致心律失常性右室心肌病（ARVC）是一个重要的健康问题。由于猝死常为首发表现，ARVC的早期诊断至关重要。目前，心电图（ECG）是一种广泛应用的无侵入性危害的诊断方法。为了尽可能准确地诊断和治疗ARVC，我们应清楚地阐明其病理生理改变。一名66岁的农民因持续心悸、胸闷、大汗淋漓和恶心就诊于急诊科，无明显诱发因素。心电图显示室性心动过速（VT）。患者血压突然下降并出现急性意识模糊。立即进行电复律后，其意识逐渐恢复，症状缓解。随后患者被转至心内科接受心电图、超声心动图、冠状动脉造影、生化检测、心内膜标测及射频消融治疗。最终，他被诊断为ARVC，表现为双侧心室扩张及V1-V3导联出现epsilon波。为该患者提供了适当的治疗，包括药物干预和射频消融。虽然ARVC的诊断并不困难，但该患者的心电图表现出一些有趣的特征，值得进一步研究：前壁和下壁导联广泛出现T波倒置，提示双侧心室受累；发现了形态和周期长度不同的室性心动过速，部分室性心动过速表现为极不规则的节律，提醒我们要仔细鉴别某些特殊的室性心动过速与心房颤动（AF）；自ARVC发作以来，V1-V3导联及avR导联逐渐出现epsilon波。最重要的是，QRS波群之后的epsilon波出现在窦性心律以及起源于心尖的室性早搏/室性心动过速中，而QRS波群之前的epsilon波出现在起源于右心室流出道（RVOT）的室性心动过速中。心电图中T波倒置和epsilon波的特征以及不同形态室性心动过速的出现可反映ARVC的进展。室性心动过速中epsilon波与QRS波群的位置关系取决于心室激动顺序，即epsilon波的定位取决于室性心动过速的起源部位。
