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 Table of Contents  
Year : 2022  |  Volume : 8  |  Issue : 2  |  Page : 115-116

Crochetage sign – A signature electrocardiographic sign of atria septal defect

1 Department of Medicine, Jawaharlal Nehru Medical College, Wardha, India
2 Department of Cardiology, Topiwala National Medical College and B. Y. L. Nair Charitable Hospital, Mumbai, Maharashtra, India
3 Department of Cardiology, Jawaharlal Nehru Medical College, Wardha, India

Date of Submission16-Jul-2022
Date of Decision21-Jul-2022
Date of Acceptance25-Jul-2022
Date of Web Publication19-Aug-2022

Correspondence Address:
Anamika Giri
Department of Medicine, Jawaharlal Nehru Medical College, Sawangi, Meghe, Wardha, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpcs.jpcs_32_22

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How to cite this article:
Giri A, Acharya S, Kamat S, Agrawal G. Crochetage sign – A signature electrocardiographic sign of atria septal defect. J Pract Cardiovasc Sci 2022;8:115-6

How to cite this URL:
Giri A, Acharya S, Kamat S, Agrawal G. Crochetage sign – A signature electrocardiographic sign of atria septal defect. J Pract Cardiovasc Sci [serial online] 2022 [cited 2023 Feb 3];8:115-6. Available from: https://www.j-pcs.org/text.asp?2022/8/2/115/354136

Dear Editor,

A 46-year-old female presented to hospital with chief complaints of breathlessness associated with chest pain for the past 4 months. The patient was apparently alright 4 months ago when she started experiencing breathlessness which increased to NYHA grade 2 at present. The patient also complained of dull, diffuse, nonradiating intermittent chest pain which was not associated with palpitations. The patient had no comorbidities.

On examination, the patient was conscious and cooperative. The patient had a heart rate of 88 beats per minute. Blood pressure was 110/70 mmHg taken in the right arm supine position. The patient's saturation was 98% on breathing ambient air. Hepatojugular reflux was positive.

On cardiovascular system examination, the first heart sound was normal, while a wide, fixed splitting of the second heart was heard along with an ejection systolic murmur in the upper left sternal border.

Electrocardiography (ECG) revealed sinus rhythm with right-axis deviation. The inferior leads (II, III, and aVF) showed a notching of R wave, suggestive of the “Crochetage sign” [Figure 1]. Chest X-ray was suggestive of cardiomegaly. Transesophageal echocardiography (Echo), bicaval view revealed right ventricular overload due to a large ostium secundum atria septal defect (ASD) of 22.4 mm with left-to-right shunt along with tricuspid regurgitation [Figure 2].
Figure 1: Electrocardiography showing R wave notching in inferior leads (II, III, and avF) suggestive of Crochetage sign.

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Figure 2: Transesophageal echocardiography, bicaval view suggestive of a 22.4 mm atria septal defect.

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The patient was planned for ASD device closure, and the procedure was performed successfully. As the patient's symptoms improved, she was discharged within the next 5 days. The patient's follow-up ECG after 3 months showed complete disappearance of “Crochetage sign” [Figure 3]. Follow-up two-dimensional Echo revealed the device in situ with no signs of any residual shunting.
Figure 3: Electrocardiography in sinus rhythm with no evidence of Crochetage sign.

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  Discussion Top

Crochetage sign is characterized by notching in the apex of R waves in inferior leads that resemble a crochet needle.[1] Crochetage sign is highly sensitive for ASD. The presence of the sign in all the inferior leads increases the specificity to 92% for the diagnosis of ostium secundum ASD.[1],[2] The sign also correlates with the degree of shunting in ASD. Typically, in approximately 35% of cases, this sign disappears after ASD closure.[1],[2],[3]

The patient consent was taken before drafting this manuscript.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Sarma A. Crochetage Sign: An invaluable independent ECG sign in detecting ASD. Indian J Crit Care Med 2021;25:234-5.  Back to cited text no. 1
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;27:877-82.  Back to cited text no. 2
Toscano Barboza E, Brandenburg RO, Swan HJ. Atrial septal defect; the electrocardiogram and its hemodynamic correlation in 100 proved cases. Am J Cardiol 1958;2:698-713.  Back to cited text no. 3


  [Figure 1], [Figure 2], [Figure 3]


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