The correct answer is: E. Arrhythmogenic right ventricular dysplasia

The ECG shows sinus bradycardia with rate of 55 beat per minute. The QRS axis is normal. The T-wave are inverted in V₁ – V₄ and are mildly asymmetric. The QRS duration was calculated at 80 milliseconds. The assessment of the QRS particularly in V₁ – V₃ shows a late S-wave upstroke with a duration 70 milliseconds (Figure 2, blue arrow). This is highly suspicious of arrhythmogenic right ventricular dysplasia (ARVD). The cardiac magnetic resonance imaging (MRI) showed severely dilated RV with RV dysplasia. Ablation was only partially successful. An ICD was implanted as well as sotalol therapy. The T-wave reflected RV enlargement and dysfunction with ARVD. ECG criteria of ARVD affect depolarization and repolarization of diseased RV outflow.

Figure 2

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Figure 2

Nasir et al. analyzed ECG in fifty patients with ARVD and concluded that:

• Epsilon wave was seen in 33%.
• QRS duration ≥110 milliseconds in V₁ – V₃ was noted in 64%.
• Right bundle-branch block (RBBB) was noted in 22%.
• Among patients without RBBB:
• T-wave inversions in V₁ – V₃ were reported in 85% of ARVD cardiomyopathy patients in the absence of RBBB
• Prolonged S-wave upstroke in V₁ – V₃ ≥55 milliseconds was the most noticed ECG parameters (95%) (Figure 2, blue arrow). It also correlated with disease severity and induction of VT on electrophysiological study.^1,2

References

1. Nasir K, Bomma C, Tandri H, et al. Electrocardiographic features of arrhythmogenic right ventricular dysplasia/cardiomyopathy according to disease severity: a need to broaden diagnostic criteria. Circulation 2004;110:1527-34.
2. Cox MGPJ, Nelen MR, Wilde AAM, et al. Activation delay and VT parameters in arrhythmogenic right ventricular dysplasia/cardiomyopathy: toward improvement of diagnostic ECG criteria. J Cardiovasc Electrophysiol 2008;19:775-81.