Crochetage sign in atrial septal defect

Crochetage sign in atrial septal defect

Crochetage sign in atrial septal defect
Crochetage sign in atrial septal defect

First available report on “crochetage” of the QRS in ECG of secundum atrial septal defect dates back to 1959 [1]. “Crochet” is a French word which Google translates to “hook” and “crochetage” to “lock picking”. Heller J et al in 1996 reported on “crochetage” (notch) on R wave in inferior leads as a new independent electrocardiographic sign in atrial septal defect [2]. They mentioned that “crochetage” is French equivalent of notch while citing the 1959 study of 11 patients. Heller J et al noted a sensitivity of about 73% and specificity of 92% if the sign was present in all the three inferior leads. Early disappearance of the crochetage sign after surgical correction of atrial septal defect was found in 35% of cases even when the incomplete right bundle branch block (RBBB) pattern was persisting. They found that the incidence of the crochetage sign increased with larger anatomic defects or greater left to right shunt. Their study cohort had 1560 older children and adults, of which 532 had secundum atrial septal defect, 266 had ventricular septal defect, 146 pulmonary stenosis, 110 mitral stenosis and 47 cor pulmonale. 459 were normal subjects. They noted this finding in only 7.4% of the normal subjects, one third of those with other congenital heart disease and one tenth of those with acquired heart disease.

A retrospective study of 314 patients who underwent percutaneous device closure of secundum atrial septal defect suggested that crochetage sign may be used to predict the risk of late atrial arrhythmia development [3]. 57 patients in their cohort presented with late atrial arrhythmias. Of these 30 had new onset atrial fibrillation or flutter. 27 patients with pre-procedure paroxysmal atrial flutter or fibrillation had recurrence during follow up. The authors noted that the presence of crochetage sign and older age at the time of closure of the atrial septal defect were independent predictors for late atrial arrhythmia. They thought that the crochetage sign represented heterogenous ventricular depolarization due to long term hemodynamic overload.

The ECG illustrated above shows the notch at the apex of the R wave in leads II and aVF and a notch in the ascending limb of R wave in lead III.

This ECG also shows right atrial overload as evidenced by P wave amplitude of 0.3 mV in lead II. Incomplete RBBB pattern is seen as slurred S waves in lead I and rSrS pattern in V1.

References

  1. Rodriguez-Alvarez A, Martinez De Rodriguez G, Goggans AM, Holsapple CK, Etier EL, Marietta JS, Wilson SW, Kelly GB. The vectorcardiographic equivalent of the “crochetage” of the QRS of the electrocardiogram in atrial septal defect of the ostium secundum type. Preliminary report. Am Heart J. 1959 Sep;58:388-94. doi: 10.1016/0002-8703(59)90155-3. PMID: 14438235.
  2. Heller J, Hagège AA, Besse B, Desnos M, Marie FN, Guerot C. “Crochetage” (notch) on R wave in inferior limb leads: a new independent electrocardiographic sign of atrial septal defect. J Am Coll Cardiol. 1996 Mar 15;27(4):877-82.
  3. Celik M, Yilmaz Y, Kup A, Karagoz A, Kahyaoglu M, Cakmak EO, Celik FB, Sengor BG, Guner A, Izci S, Kilicgedik A, Candan O, Kahveci G, Gecmen C, Kaymaz C. Crochetage sign may predict late atrial arrhythmias in patients with secundum atrial septal defect undergoing transcatheter closure. J Electrocardiol. 2021 Jul-Aug;67:158-165. doi: 10.1016/j.jelectrocard.2021.06.010. Epub 2021 Jul 3. PMID: 34246066.