International Journal of Human and Health Sciences Vol. 06 No. 01 January’22 136 Case report Point-of-Care Ultrasound (POCUS) and Epsilon wave Wong Choc Ky1, Mohd Hashairi Fauzi1,3, Andey Rahman1,3, Mohd Faiz Mohd Shukri1, Tuan Hairulnizam Tuan Kamauzaman1, Mohd Najib Abdul Ghani2 Abstract Arrhythmogenic right ventricular cardiomyopathy (ARVC) is often underdiagnosed in ruling out the cardiac cause for any syncope. It is an inherited cardiomyopathy characterized by fibro-fatty replacement of right ventricular myocardium. ARVC is the  second most common cause of sudden cardiac death (SCD) after hypertrophic obstructive cardiomyopathy (HOCM), causing up to 20% of SCD in younger patients (age <35 yo).  The prevalence is 1:5000 people overall. We described a case report of suspected ARVC and the role of bedside electrocardiography (ECG) and point-of-care ultrasound (POCUS) in Emergency Department. Keywords: ARVC, electrocardiography, POCUS, emergency department Correspondence to: Mohd Hashairi Fauzi, Department of Emergency Medicine, School of Medical Science, Universiti Sains Malaysia Health Campus, 16150 Kubang Kerian, Kelantan, Malaysia. E-mail: hashairi@usm.my 1. Department of Emergency Medicine, School of Medical Science, Universiti Sains Malaysia Health Campus, 16150 Kubang Kerian, Kelantan, Malaysia 2. Department of Emergency & Trauma, Hospital Raja Perempuan Zainab II,15586, Kota Bharu,  Kelantan, Malaysia 3. Department of Emergency, Hospital Universiti Sains Malaysia, Health Campus, 16150 Kubang Kerian, Kelantan, Malaysia International Journal of Human and Health Sciences Vol. 06 No. 01 January’22 Page : 136-139 DOI: http://dx.doi.org/10.31344/ijhhs.v6i1.389 Introduction Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a rare genetic disorder (autosomal dominant trait) which is characterised by progressive replacement of the RV myocardium by  fatty  and/or  fibrofatty  tissue.1 Subsequently, leads to poor contractility and right ventricle dilatation.2 This condition will predispose patient to developed fatal arrythmias such as ventricular tachycardia and risk of sudden cardiac death especially in young athletes.2,3 In hectic and busy Emergency department (ED), the diagnosis is quite challenging. However, in the presence of abnormal right ventricular features on point-of- care ultrasound (POCUS) aided with Epsilon wave on electrocardiogram (ECG) it will expedite early detection of possible ARVC and facilitate timely management this rare condition especially in resource-limited setting. Case Report A 17-year-old boy presented with syncope while riding a motorbike. Prior to this, he was well and had no preceded complaints. There was no loss of consciousness after the road traffic injury. On  further  questioning,  he  denied  any  significant  history of cardiac related death or sudden death in his family Primary and secondary survey revealed no life- threatening injuries. Cardiac monitor showed sinus arrhythmias with no evidence of ventricular arrythmias or ectopic features. CT Brain showed no evidence intracranial bleed or infarction. CK/CK-MB ratio was normal. Blood results showed normal blood glucose level (6 mmol/L) and normal renal/liver function test. Resting ECG showed Epsilon wave at V1, T wave inversion from V1-V3, prolonged S wave 137 International Journal of Human and Health Sciences Vol. 06 No. 01 January’22 upstroke (55ms), localised QRS widening (110ms) in V1-V3, RSR pattern at precordial leads. No other remarkable findings were detected on ECG.  (Figure 1 & 2) Focused cardiac ultrasound (FoCUS) showed right atrial and ventricular dilation as shown in Figure 3. Subsequently, patient was referred to cardio team and planned for Holter and MRI in CCU (coronary care unit). Throughout the stay he was stable and discharge after 3 days of admission with normal Holter and was planned for early outpatient MRI appointment. Unfortunately, he didn’t turn up for follow up. Figure 1: Epsilon wave at V1, T wave inversion from V1-V3, prolonged S wave upstroke (55ms), localised QRS widening (110ms) in V1-V3, RSR pattern at precordial leads. Figure 2: : ECG of Epsilon wave, a reproducible low amplitude signal between end of QRS complex to onset of T wave in right precordial leads particularly V1. International Journal of Human and Health Sciences Vol. 06 No. 01 January’22 138 Figure 3: Apical 4 Chamber view shows dilated RA/RV on Focused Cardiac Ultrasound (FoCUS). RV was bigger than LV and loss normal triangular shape. Discussion Diagnosing ARVC in ED is difficult and there is  no single diagnostic tool for ARVC. The diagnosis is a combination of clinical, electrocardiographic and radiological features, as defined by 2010 Task  Force Criteria.2,3 RV dilation based on ECHO, endomyocardial biopsy confirmation of fibro-fatty  changes of right myocardium, presence of Epsilon waves in V1-V3, T wave inversion in precordial leads, arrhythmias are all major criteria.2 In Emergency department (ED), ECG and ultrasound are two modalities that widely available, low cost and easy to use. Approximately 50-90% of ARVC patient will have ECG characteristics finding such as T-wave inversion in the anterior  precordial leads (V1 through V6), epsilon waves, or VT with a left bundle branch block pattern, although polymorphic and right bundle branch block patterns also have been reported.4,7 The epsilon wave is described as slurring tiny signals at the end of right precordial QRS complex ECG and was found 30% in ARVC patients.5 It represents delayed activation of right ventricular myofibres4. Although ECG has higher false positive results, the role of ECG screening as a tool to rule out cardiac syncope is worthwhile in all kinds of emergency setting. Over the years, point-of-care ultrasound (POCUS) has been extensively used by EM fraternity and become part of the mandatory training.8 It is useful as an extension of physical examination. POCUS could help the physician in detecting potential ARVC cases by looking at RA/RV dilatation and regional hypokinetic RV wall.3,4 Even though MRI still the goal standard in diagnosis ARVC6 previous studies have shown that POCUS is a one of the major tools for diagnosis of ARVC.3,9 However, POCUS especially cardiac ultrasound have some limitations such as patient habitus especially in obese patient that led to inadequate images. It also unable to localised regional abnormal findings on  RV wall in certain condition like minor ventricular bulge and focal aneurysms10. Despite limitations, we believed that abnormal RV on POCUS aided with Epsilon wave on ECG could help clinician in early detection of this rare condition especially in resource-limited setting whereby other advanced imaging techniques such as transoesophageal echo (TEE) and CT scan/ MRI are not available. Thus, urgent referral to appropriate team can be done in timely manner. 139 International Journal of Human and Health Sciences Vol. 06 No. 01 January’22 Conclusion All young and healthy adult patients present with syncope should consider ARVC in their differential  diagnoses. Usage of POCUS and ECG as bedside investigation could help in early identification and  fasten the management Source of fund (if any) : This case report did not receive any special funding Conflict of interest: The authors declared no conflict of interest.  Ethical clearance: No ethical approval needed for this case report Authors’ contribution: Conception: WCK, MHF, AR,MFMS; Collection and assembly of data: WCK,MHF,MNAG; Writing manuscript: WCK,MHF,MNAG; Editing and approval of final  draft: WCK,MHF,AR,MFMS,THTK,MNAG References 1. McNally E, MacLeod H, Dellefave-Castillo L. Arrhythmogenic Right Ventricular Cardiomyopathy. 2005 Apr 18 [Updated 2017 May 25]. In: Adam MP, Ardinger HH, Pagon RA, et al., editors. 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