Journal of the Practice of Cardiovascular Sciences

: 2022  |  Volume : 8  |  Issue : 2  |  Page : 115--116

Crochetage sign – A signature electrocardiographic sign of atria septal defect

Anamika Giri1, Sourya Acharya1, Sandeep Kamat2, Gajendra Agrawal3,  
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

Correspondence Address:
Anamika Giri
Department of Medicine, Jawaharlal Nehru Medical College, Sawangi, Meghe, Wardha, Maharashtra

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;8:115-116

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 Mar 25 ];8:115-116
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Full Text

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}{Figure 2}

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}


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.


1Sarma A. Crochetage Sign: An invaluable independent ECG sign in detecting ASD. Indian J Crit Care Med 2021;25:234-5.
2Heller 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.
3Toscano 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.