Guy Fontaine

Guy Hugues Fontaine (1936-2018) was a French cardiologist and electrophysiolgist.

Fontaine was a pioneer in modern electrophysiology and arrhythmia therapy. Worked to map the reentrant circuits in patients with ventricular tachycardia during surgery with the aim of interrupting the reentrant arrhythmia by ventriculotomy.

During this time described and defined arrhythmogenic right ventricular dysplasia; coin the term ‘epsilon wave‘ for the late QRS ‘wiggle’ seen in 30% of patients; and describe bipolar lead placements to best visualise the characteristic waves (Fontaine leads; F-ECG)

Biography

• Born on December 24, 1936 in Corbeil-Essonne, France
• Trained in electrical engineering and medicine
• 1966 – PhD on Contributions of Electrical Stimulation to the Human Heart
• Died on March 7, 2018 in Saint Mandé, France

Medical Eponyms

Arrhythmogenic right ventricular dysplasia and the epsilon wave

Fontaine coined the term arrhythmogenic right ventricular dysplasia (ARVD) as well as the epsilon wave – a small deflection (‘blip’ or ‘wiggle’) buried in the end of the QRS complex – the characteristic finding in ARVD.

The term “epsilon” was nice, because it occurs in the Greek alphabet after delta; thus, delta represents the pre-excitation and epsilon the post-excitation phenomenon. In addition, epsilon is also used in mathematics to express a very small phenomenon…

Fontaine 1997

Fontaine leads

Fontaine bipolar precordial leads (F-ECG) are used to increase the sensitivity of epsilon wave detection. Fontaine leads are placed as shown:

• Right Arm (RA) electrode on the manubrium;
• Left Arm (LA) electrode over the xiphoid process;
• Left Leg (LL) electrode in the standard V4 position (5^th ICS MCL).
• Creating F-ECG with F_I, F_II, F_III leads

Instead of regular leads I, II, and III there are now three bipolar chest leads that are termed F_I, F_II, and F_III which record the potentials developed in the right ventricle, from the infundibulum to the diaphragm.

The vertical bipolar lead FI, (similar to aVF) magnifies the atrial potentials and can be used to record epsilon waves; search for AV dissociation in ventricular tachycardia; and to study abnormal atrial rhythms when the P waves are too small on regular leads.

Instead of regular leads I, II, and III there are now three bipolar chest leads that are termed F_I, F_II, and F_III which record the potentials developed in the right ventricle, from the infundibulum to the diaphragm.

• Right Arm (RA) electrode on the manubrium;
• Left Arm (LA) electrode over the xiphoid process;
• Left Leg (LL) electrode in the standard V4 position (5^th ICS MCL).
• Creating F-ECG with F_I, F_II, F_III leads

Note: Increasing calibration from 10 to 20mm/mV; and paper speed from 25 to 50mm/second can further amplify the atrial activity.

[Epsilon] waves are better demonstrated by placement of a suction electrode connected to the right arm connection (negative) on the manubrium sternum and the left arm connection (positive) on the xyphoid. This produces a first (FI) bipolar chest lead. In addition, the placement of the foot lead (positive) in position V4 provides three bipolar chest leads (FI, FII, FIII) instead of regular leads (I, II, III). This arrangement is used to record more specifically the potentials developed by the delayed right ventricular fibers, covering the infundibulum, the apex, and the diaphragmatic aspect of the right ventricle.

Fontaine 1999

Major Publications

• Fontaine G, Grosgogeat Y, Welti J-J. The Essentials in Cardiac Pacing. 1978
• Fontaine G, Frank R, Guiraudon G, Pavie A, Tereau Y, Chomette G, Grosgogeat Y. Signification des troubles de conduction intraventriculaires observés dans la dysplasie ventriculaire droite arythmogène [Significance of intraventricular conduction disorders observed in arrhythmogenic right ventricular dysplasia]. Arch Mal Coeur Vaiss. 1984 Aug;77(8):872-9
• Fontaine G. Arrhythmogenic right ventricular dysplasia. Curr Opin Cardiol. 1995 Jan;10(1):16-20.
• Fontaine G, Fontaltaliran F. About the histology of arrhythmogenic right ventricular dysplasia. Circulation. 1997 Sep 16;96(6):2089-90.
• Fontaine G, Fontaliran F, Frank R. Arrhythmogenic right ventricular cardiomyopathies: clinical forms and main differential diagnoses. Circulation. 1998 Apr 28;97(16):1532-5
• Fontaine G, Fontaliran F, Hébert JL, Chemla D, Zenati O, Lecarpentier Y, Frank R. Arrhythmogenic right ventricular dysplasia. Annu Rev Med. 1999;50:17-35
• Fontaine GH. The multiple facets of right ventricular cardiomyopathies. Eur Heart J. 2011 May;32(9):1049-51
• Fontaine G, Chen HS. Arrhythmogenic right ventricular dysplasia back in force. Am J Cardiol. 2014 May 15;113(10):1735-9.

References

Biography

• Marcus FI. Guy Fontaine: a pioneer in electrophysiology. Clin Cardiol. 1998 Feb;21(2):145-6.
• Frank R. Guy Fontaine MD PhD HDR. European Heart Journal. 2018; 39(24): 2226–2227
• Li G. Guy Fontaine, a personal tribute. European Heart Journal. 2018; 39(24): 2228–2229
• Bibliography. Fontaine, Guy. WorldCat Identities

Eponymous terms

• Hurst JW. Naming of the waves in the ECG, with a brief account of their genesis. Circulation. 1998 Nov 3;98(18):1937-42.
• Berry D. Guy Fontaine and arrhythmogenic right ventricular dysplasia. Eur Heart J. 2011 May;32(9):1042-3
• Pérez-Riera AR, Barbosa-Barros R, Daminello-Raimundo R, de Abreu LC, García-Niebla J, de Deus Morais MJ, Nikus K, Marcus FI. Epsilon wave: A review of historical aspects. Indian Pacing Electrophysiol J. 2019 Mar-Apr;19(2):63-67.
• The Standard 12 Lead ECG. ECG learning center
• Cadogan M. History of the Electrocardiogram. LITFL
• Cadogan M. ECG Lead positioning. LITFL

Mike Cadogan

Associate Professor Curtin Medical School, Curtin University. Emergency physician MA (Oxon) MBChB (Edin) FACEM FFSEM Sir Charles Gairdner Hospital.  Passion for rugby; medical history; medical education; and asynchronous learning #FOAMed evangelist. Co-founder and CTO of Life in the Fast lane | Eponyms | Books | Twitter |