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Table of Contents
Year : 2017  |  Volume : 20  |  Issue : 4  |  Page : 475-476
Think beyond right bundle branch block in atrial septal defect

1 Department of Cardiac Anesthesiology, Sir Ganga Ram Hospital, New Delhi, India
2 Department of Thoracic Surgery, Sir Ganga Ram Hospital, New Delhi, India
3 Department of Cardiac Surgery, Sir Ganga Ram Hospital, New Delhi, India

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Date of Web Publication9-Oct-2017

How to cite this article:
Raut MS, Verma A, Maheshwari A, Shivnani G. Think beyond right bundle branch block in atrial septal defect. Ann Card Anaesth 2017;20:475-6

How to cite this URL:
Raut MS, Verma A, Maheshwari A, Shivnani G. Think beyond right bundle branch block in atrial septal defect. Ann Card Anaesth [serial online] 2017 [cited 2022 Aug 14];20:475-6. Available from:

The Editor,

A 48-year-old woman presented with shortness of breath on routine activities for 6 months. On cardiac auscultation, an ejection systolic murmur was heard at the upper left sternal border with wide and fixed splitting of the second heart sound. Electrocardiogram (ECG) was suggestive of normal sinus rhythm with right-axis deviation, incomplete right bundle branch block (RBBB), and crochetage sign (notch near the apex of R-wave) [Figure 1]. Transthoracic echocardiography was performed which revealed large ostium secundum atrial septal defect (ASD) of size 28 mm with large left-to-right shunt (Qp: Qs – 2.2:1) [Figure 2]. Coronary angiography of the patient was normal. The patient underwent cardiac surgery, and ASD was closed using the Dacron patch. No residual shunt across interatrial septum was observed after the surgery. Postoperative ECG showed disappearance of crochetage pattern [Figure 3].
Figure 1: Electrocardiogram showing crochetage sign marked by red arrow in inferior leads

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Figure 2: Transesophageal echocardiographic bicaval view showing large atrial septal defect

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Figure 3: Electrocardiogram showing disappearance of crochetage pattern

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Normal axis or right-axis deviation and incomplete RBBB are the most commonly observed ECG findings in patients of ostium secundum ASD.[1] Incomplete RBBB is due to delayed depolarization of the thickened right ventricular outflow tract and possibly right ventricular volume overload.[2] RSR' pattern in lead V1 carries the specificity of 80%, sensitivity of 36.1%, positive predictive value of 14.7%, and negative predictive value of 92.9% for the diagnosis of ASD. Hence, incomplete RBBB alone is inadequate to diagnose ASD.[3] Sinus venosus ASDs may show ectopic atrial activity or inverted P-waves in the inferior leads suggestive of absent or deficient sinus node function.[4],[5] Left-axis deviation and atrioventricular nodal delay may be observed in ostium primum ASDs.[6]

The presence of crochetage pattern has been reported to have very well correlation with the degree of left-to-right shunting and with the size of the ASD.[7] A notch near the apex of the R-wave in inferior limb leads resembles the work of a crochet needle, hence it is called “crochetage” sign. Crochetage pattern if present in only one lead has a specificity of 92.6% and sensitivity of 73.1% with a positive predictive value of 69% for the diagnosis of ostium secundum ASD. Specificity becomes 100% if the pattern is observed in all the three inferior leads.[7] Crochetage pattern in all inferior limb leads along with RBBB is suggestive of specific ECG diagnosis of ASD.[7] Patients with patent foramen ovale (PFO) and crochetage sign are more prone to suffer from cerebral infarction than the PFO patients without crochetage. Crochetage sign has a specificity of 91% and a positive predictive value of 77% in recognizing PFO patients prone to paradoxical embolism.[8] After surgical correction of ASD, crochetage pattern disappeared in 35.1% of patients while RBBB pattern persisted. Crochetage sign can be a good and useful ECG marker in recognizing ASD and predicting stroke risk.

Wang et al. used the defective T-wave pattern which was defined as “inverted or horizontal displacement of the proximal T-wave limb in the right precordial leads.”[9] Incomplete RBBB along with the presence of defective T-wave had 100% specificity and 87.1% sensitivity for the diagnosis of ASD.[2],[9] These ECG findings can potentially help clinicians diagnose ASD and assess the risk of transient ischemic attack even before confirming the diagnosis on echocardiography.

Declaration of patient consent

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

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Conflicts of interest

There are no conflicts of interest.

   References Top

de Oliveria JM, Zimmerman HA. The electrocardiogram in interatrial septal defects and its correlation with hemodynamics. Am Heart J 1958;55:369-82.  Back to cited text no. 1
Bayar N, Arslan S, Köklü E, Cagirci G, Cay S, Erkal Z, et al. The importance of electrocardiographic findings in the diagnosis of atrial septal defect. Kardiol Pol 2015;73:331-6.  Back to cited text no. 2
Schiller O, Greene EA, Moak JP, Gierdalski M, Berul CI. The poor performance of RSR' pattern on electrocardiogram lead V1 for detection of secundum atrial septal defects in children. J Pediatr 2013;162:308-12.  Back to cited text no. 3
Attenhofer Jost CH, Connolly HM, Danielson GK, Bailey KR, Schaff HV, Shen WK, et al. Sinus venosus atrial septal defect: Long-term postoperative outcome for 115 patients. Circulation 2005;112:1953-8.  Back to cited text no. 4
Davia JE, Cheitlin MD, Bedynek JL. Sinus venosus atrial septal defect: Analysis of fifty cases. Am Heart J 1973;85:177-85.  Back to cited text no. 5
Fournier A, Young ML, Garcia OL, Tamer DF. Electrophysiologic cardiac function before and after surgery in children with atrioventricular canal. Am J Cardiol 1986;57:1137-41.  Back to cited text no. 6
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. 7
Ay H, Buonanno FS, Abraham SA, Kistler JP, Koroshetz WJ. An electrocardiographic criterion for diagnosis of patent foramen ovale associated with ischemic stroke. Stroke 1998;29:1393-7.  Back to cited text no. 8
Wang MX, Wu GF, Gu JL, Li L, Lu K, Yang D, et al. Defective T wave combined with incomplete right bundle branch block: A new electrocardiographic index for diagnosing atrial septal defect. Chin Med J (Engl) 2012;125:1057-62.  Back to cited text no. 9

Correspondence Address:
Monish S Raut
Department of Cardiac Anesthesiology, Sir Ganga Ram Hospital, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aca.ACA_5_17

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  [Figure 1], [Figure 2], [Figure 3]