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Atrial septal defect with Crochetage sign presenting with pulmonary artery thrombosis
  1. Neerusha Kaisbain1,
  2. Wei Juan Lim1,2 and
  3. Heng Shee Kim3
  1. 1Department of Medicine, Hospital Sultanah Aminah, Johor Bahru, Johor, Malaysia
  2. 2Cardiology, Institut Jantung Negara, Kuala Lumpur, Wilayah Persekutuan, Malaysia
  3. 3Department of Cardiology, Hospital Sultanah Aminah, Johor Bahru, Johor, Malaysia
  1. Correspondence to Dr Wei Juan Lim; omegakimia{at}


Atrial septal defect (ASD) is the most common congenital heart disease observed in adult. Several ECG findings are considered sensitive for the diagnosis of ASD. We describe a 50 years old man who displayed Crochetage sign, incomplete right bundle branch block (IRBBB) and right ventricular strain pattern on ECG. Crochetage sign is highly specific for ASD and it correlates with shunt severity. The diagnostic specificity for ASD increases if the R waves have both Crochetage patterns and IRBBB. It is important not to confuse Crochetage signs with IRBBB abnormalities on ECG. Our patient was ultimately diagnosed with a large ASD measuring 3 cm with bidirectional shunt and concomitant pulmonary thrombosis. This illustrates that high suspicion of the ASD with the use of good-old ECG signs remains relevant in this modern era. This also reminds us that patients with Eisenmenger syndrome are at higher risk for pulmonary thrombosis.

  • cardiovascular medicine
  • arrhythmias
  • valvar diseases
  • venous thromboembolism

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  • Contributors NK identified this case as potential case report and was involved in the management of the case. NK also performed the literature research, drafted and revised the case report, obtained consent from the patient and obtained the images for the case report. She is the guarantor. WJL performed the literature search, revised the case report, becoming the corresponding person for this case for case report submission. HSK contributed in proofreading and revising the case report critically and gave final approval for the version being published.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.