Definition

  A notch near the apex of the R wave in inferior limb leads.



Crochetage Sign and Atrial Septal Defect (ASD)

  involves at least one inferior limb lead in 73% of the ASD patients.

  involves all 3 inferior leads in 27% of the ASD patients.

  Two weeks after closure of the atrial septal defect, Crochetage sign disappears in approximately

      50% of the patients.

  Crochetage pattern is independent of the incomplete right bundle branch block frequently seen

      in patients with ASD.

  Crochetage pattern correlates with shunt severity in patients with ASD.




Crochetage Sign and Ventricular Septal Defect (VSD)

  involves at least one inferior limb lead in 35% of the VSD patients.

  involves all 3 inferior leads in 2% of the VSD patients..




Crochetage Sign and Pulmonary Stenosis

  involves at least one inferior limb lead in 23% of the pulmonary stenosis patients.

  involves all 3 inferior leads in 0.7% of the pulmonary stenosis patients..




Reference

  J Am Coll Cardiol 1996;27:877.





ECG 1a. The compact ECG above is from a 46 years-old man with a large ostium secundum type atrial septal defect
and left to right shunt. ECHOcardiography showed a dilated right ventricle and a dilated right atrium.
The QRS width is 94 milliseconds.
Inferior leads show notched R waves: Crochetage sign.




ECG 1b. The compact ECG above belongs to the same patient.
It was recorded 30 days after surgical closure of his large secundum ASD.
Right ventricular volume overload is not present anymore. The QRS width has decreased to 84 milliseconds.
The notched R waves in inferior leads are not so prominent.





ECG 2. The ECG above belongs to a 18 years-old girl with congenital pulmonary stenosis. The maximum systolic gradient at the
level of pulmonary valve was 90 mmHg and the mean gradient was 60mmHg. The ECG shows right axis deviation and
right ventricular hypertrophy.
Crochetage sign is seen in lead aVF.

Click here for a more detailed ECG





ECG 3. The ECG above belongs to a 3.5 years-old boy who has both pulmonary stenosis and an 18mm wide non-restrictive type
ASD. The peak systolic gradient at the pulmonary valve was measured 60mmHg by echocardiography and 40mmHg by right
heart catheterization. Echocardiography showed dilation of right heart chambers. This patient has both right ventricular (RV)
volume overload due to non-restrictive type ASD and RV pressure overload due to pulmonary stenosis.
The heart rate is 118/min. (normal for his age). There is right axis deviation.
The increased amplitude of R' wave in C1 suggests RV hypertrophy.
Crochetage sign in leads III and aVF is the other abnormality in the above ECG.
Pediatric cardiologist Dr. Mahmut Gokdemir has donated this ECG to our website.

Click here for a more detailed ECG





ECG 4. The ECG above shows right bundle branch block pattern.
It belongs to a 6 months-old infant with a 7 mm wide, unoperated Atrial Septal Defect.
Her pulmonary valve systolic gradient was measured as 15 mmHg.
Crochetage sign in lead aVF is another abnormality in the above ECG.

Pediatric cardiologist Dr. Mahmut Gokdemir has donated the above ECG to our website.

Click here for a more detailed ECG





ECG 5. The above ECG is from a 5 years-old girl with a large sinus venosus type ASD and pulmonary stenosis.
Crochetage sign ise seen in leads III and aVF.

Pediatric cardiologist Dr. Mahmut Gokdemir has donated the above ECG to our website.

Click here for a more detailed ECG





ECG 6. The above ECG is from a 16 years-old girl with a large secundum ASD (3 cm width), left to right shunt.
Her right atrium and right ventricle were dilated.
Crochetage sign is seen in lead aVF.

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ECG 7. The above ECG is from a 8 months-old infant with a large secundum ASD.
Subtle Crochetage sign is seen in leads III and aVF.

Pediatric cardiologist Dr. Mahmut Gokdemir has donated the above ECG to our website.

Click here for a more detailed ECG





ECG 8. The above ECG is from a 6 years-old girl with secundum ASD.
Subtle Crochetage sign is seen in leads III and aVF.

Pediatric cardiologist Dr. Mahmut Gokdemir has donated the above ECG to our website.

Click here for a more detailed ECG





ECG 9. The above ECG is from a 14 years-old girl with a secundum ASD.
Subtle Crochetage sign is seen in leads III and aVF.

Pediatric cardiologist Dr. Mahmut Gokdemir has donated the above ECG to our website.

Click here for a more detailed ECG





ECG 10. The ECG above is from a 47 years-old man with a normal ECHOcardiogram and a normal treadmill exercise test.
Crochetage sign is positive in lead aVF, but he does not have ASD.
Crochetage sign is neither 100% specific nor 100% sensitive for the diagnosis of ASD.

Click here for a more detailed ECG