Pediatric Cardiology (2018) 39:1031–1035

https://doi.org/10.1007/s00246-018-1857-0

ORIGINAL ARTICLE

The Significance of Crochetage on the R wave of an Electrocardiogram

for the Early Diagnosis of Pediatric Secundum Atrial Septal Defect
Lei Shen1 · Jian Liu2 · Jin‑kang Li2 · Meng Xu1 · Lang Yuan2 · Guo‑qin Zhang2 · Jian‑yi Wang1 · Yu‑juan Huang2

Received: 15 August 2017 / Accepted: 3 March 2018 / Published online: 22 March 2018
© Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
The purpose of this study was to test the hypothesis that the incidence of crochetage on the R wave in inferior limb leads can
be used for the diagnosis of pediatric secundum atrial septal defect (ASD). Two hundred fifty-six children with secundum
ASD (case cohort) and 256 age- and gender-matched children without heart disease (control cohort) were included in the
study. Statistical analyses were performed to test the relationship between the ASD and the crochetage on the R wave with
a single lead and three leads, respectively. The impact of incomplete right bundle branch block (IRBBB) and ASD diameter
(≥ 5 and < 5 mm) on ASD diagnosis were also explored. Crochetage on the R wave was observed in all three inferior limb
leads on 28.13% (72/256, 28 with IRBBB) of subjects with secundum ASD, while it was seen in only 2.73% (7/256, one with
IRBBB) of control subjects (P < 0.001). Subgroup analysis showed that the incidence of R wave crochetage correlated with
ASD size in both the single inferior limb lead (26.14%, 23/88 on ASD ≥ 5 mm vs. 10.71%, 18/168 on ASD < 5 mm; P = 0.001)
and all three inferior limb leads (44.32%, 39/88 on ASD ≥ 5 mm vs. 19.64%, 33/168 on ASD < 5 mm; P < 0.001). Our find-
ings suggest that crochetage on the R wave in inferior limb leads can serve as an independent marker for ASD diagnosis.

Keywords  Crochetage on R wave · Inferior leads · Secundum atrial septal defect · Pediatric

Introduction
Atrial septal defect (ASD) is one of the most common types
of congenital heart diseases, and 70–80% of ASD are secun-
dum ASD. Early diagnosis and timely medical and surgical
interventions can benefit ASD management and prognosis.
Missed diagnosis, however, is a major problem in ASD
administration, probably due to the asymptomatic phase of
the disease. Many cases of ASD fail to be identified until
late stages, when severe complications such as arrhythmia,
pulmonary hypertension, or Eisenmenger syndrome occur,
which reduce the effectiveness of surgical therapy, reduce
Lei Shen and Jian Liu are co-first authors; Jian-yi Wang and Yu-
juan Huang are co-last authors.
* Yu‑juan Huang
huangyj@shchildren.com.cn
1
Department of Cardiology, Shanghai Children’s Hospital,
Shanghai Jiao Tong University School of Medicine,
Shanghai 200040, China
2
Department of Emergency, Shanghai Children’s Hospital,
Shanghai Jiao Tong University School of Medicine,
Shanghai 200040, China
quality of life, and increase the risk of mortality [1, 2]. While
the confirmatory diagnosis of ASD is made by echocardi-
ography, electrocardiogram (ECG) screening is still widely
applied in clinical settings as an efficient, low-cost method
[3, 4]. Crochetage has frequently been observed near the
peak area of the R wave captured by inferior limb leads of
ECG in patients with secundum ASD. The incidence of the
so-called crochetage pattern was found in close correlation
with secundum ASD in many studies [5–8]. In this study,
we analyzed the correlation between the crochetage sign on
the R wave and secundum ASD by comparing the ECGs of
hospitalized pediatric patients with secundum ASD to those
with no heart defect. The size of ASD and incomplete right
bundle branch block (IRBBB) were taken into account in the
analyses. We hypothesized that the incidence of R wave cro-
chetage could differentiate pediatric secundum ASD cases
from controls.

13
Vol.:(0123456789)

1032 Pediatric Cardiology (2018) 39:1031–1035

Materials and Methods
Study Population
Patients who visited the heart center of Shanghai Chil-
dren’s Hospital from January 1, 2012, to December
31, 2015, were included in this study. The case cohort
(n = 256; 160 male and 96 female) was assembled with
pediatric patients who were diagnosed with simple secun-
dum ASD by echocardiography, and with no other cardio-
vascular defect. Control cohort (n = 256; 160 male and 96
female) included age- and gender-matched patients who
had no history of cardiovascular diseases and had normal
results of echocardiography tests during hospitalization.
All the patients had complete documentation of ECG. The
study was approved by the institutional review board (IRB)
committee of Shanghai Children’s Hospital.
ASD usually occurred in the middle of the atrial septum
[10].
Statistical Analysis
All analysis was conducted using SPSS 19.0 software (IBM
Corp., Armonk, NY, USA). The χ2 test was used to compare
the results between groups.
Results
Baseline Characteristics
The mean age in months was 35 ± 13 in the case cohort and
34 ± 12 in the control cohort. The two cohorts were age- and
gender-matched (P > 0.5). The baseline characteristics of the
subjects are listed in Table 1.

Definition of Crochetage Signs on the R Wave Crochetage on the R Wave in Case and Control
in Inferior Limb Leads Cohorts

The standard 12-lead ECG was recorded using an MECG-
200 12-lead synchronous handheld ECG monitor (MedEx
Tech-Trade Corp., Beijing, China), with sensitivity of 10
mv/cm and paper speed of 25.0 mm/s. Crochetage on the
R wave in the inferior limb leads of the ECG was defined
as a notch appearing at the rising edge or peak of the R
waves in leads II, III, and aVF [9]. Crochetage on the R
wave in a single lead referred to a notch appearing at only
one lead, and crochetage on the R wave in three leads
referred to a notch appearing at all inferior limb leads.
Crochetage on the R wave with incomplete right bundle
branch block (IRBBB) was defined as notches appearing
on the ascending limb or peak of the R wave of the QRS
complex with IRBBB in one or more inferior limb leads.
ECG with IRBBB had the following features: interval of
QRS complex < 0.12 s; R wave in the right chest leads is
rsr′, rsR′, rSR′ or M-shaped QRS complex. Crochetage on
the R wave sometimes appeared on ECG with IRBBB, at
the end of the QRS complex.
Examples of crochetage on the R wave observed in one
lead, three leads, and three leads with IRBBB are shown in
Fig. 1. The results for R wave crochetage in case and control
cohorts are shown in Table 2. In the case cohort, 41 subjects
exhibited crochetage signs on the R wave in a single inferior
limb lead, and 72 subjects in three inferior limb leads. In the
control cohort, 30 subjects exhibited crochetage signs on
the R wave in a single inferior limb lead, and seven subjects
in three inferior limb leads. The percentages of three-lead
crochetage on the R wave, single-lead crochetage on the R
wave with IRBBB, and three-lead crochetage on the R wave
with IRBBB were all significantly higher in the case cohort
than the control cohort (P < 0.001). The crochetage-based
diagnosis of ASD h a sensitivity of 28.1%, specificity of
94.5%, and a positive predictive value (PPV) of 91.1% using
Table 1  Baseline characteristics of the case and control cohorts
Baseline characteristics Case cohort Control cohort

Number 256 256

Diagnosis of ASD Using Echocardiography Age, mean ± SD, months 35 ± 13 34 ± 12
Sex
A iE33 (Philips, Yorba Linda, CA, USA) color Doppler  Male 160 160
ultrasound diagnostic apparatus (probe frequency: 6.0 MHz)  Female 96 96
was used to observe the parasternal and subxiphoid four- Age at diagnosis (mean ± SD, 15 ± 11 N/A
chamber section, short axis section of the aorta, subxiphoid months)
superior vena cava and inferior vena cava, interatrial septal ASD size
section. Maximal diameters of defects were measured. The  ≥ 5 mm 88 N/A
absence or interruption of atrial septal echo was a direct sign  < 5 mm 168 N/A
for diagnosis of ASD. The absence of echo with secundum N/A not available

13
Pediatric Cardiology (2018) 39:1031–1035 1033

Fig. 1  Capture of crochetage
in one lead (top), three leads
(middle), and three leads with
IRBBB (bottom), respectively

Table 2  Crochetage on the R Group Single lead Three leads Single lead with Three leads
wave in inferior leads of ECG in IRBBB with IRBBB
case and control groups
Control, n = 256 30 (11.72) 7 (2.73) 3 (1.17) 1 (0.39)
Case (ASD), n = 256 41 (16.02) 72 (28.13) 39 (15.23) 28 (10.94)
χ2 1.986 72.022 39.370 33.013
P 0.159 < 0.001 < 0.001 < 0.001

Values are presented as no. (%). χ2 = chi-square statistic

Table 3  Crochetage on the R wave in subgroups with ASD ≥ 5 and in the < 5 mm subgroup had single-lead crochetage on the
< 5 mm R wave (P < 0.01), and 44.32% (39/88) of subjects in the
Group Crochetage on the R Crochetage on the R ≥ 5 mm subgroup and 19.64% (33/168) in the < 5 mm sub-
wave on a single lead wave on three leads group had three-lead crochetage on the R wave (P < 0.01).
< 5 mm, n = 168 10.71 (18/168) 19.64 (33/168)
A Follow‑Up Analysis of Crochetage on the R Wave
≥ 5 mm, n = 88 26.14 (23/88) 44.32 (39/88)
in the Subgroup with ASD ≥ 5 mm
χ2 10.212 17.394
P 0.001 < 0.001
Follow-up ECG data were recorded in the subgroup with
Values are presented as no. (%). χ2 = chi-square statistic ASD ≥ 5 mm (n = 88). Twenty-eight of 88 subjects had sur-
gical treatments, 44 of 88 subjects had interventions, and 16
of 88 subjects had no treatment or intervention. ECGs were
three-lead crochetage on the R wave as a classifier; sensi- recorded twice, at the time of the treatment or intervention,
tivity of 15.2%, specificity of 98.8%, and a PPV of 92.9% and at 1 month later (Table 4). Crochetage pattern on the R
using single-lead crochetage on the R wave with IRBBB as a wave disappeared for 15 subjects in the surgical subgroup,
classifier; and sensitivity of 10.9%, specificity of 99.6%, and and for six subjects in the intervention subgroup. No signifi-
a PPV of 96.6% using three-lead crochetage with IRBBB as cant difference in the incidence rates of R wave crochetage
a classifier. was observed between the surgery/intervention groups and
the no-treatment group.
Crochetage on the R Wave in Subjects with Different
ASD Sizes
Discussion
The case cohort (n = 256) was further divided into two
subgroups: one had 88 cases (34.38%, 88/256) with ASD ASD is one of the most common congenital heart dis-
size ≥ 5 mm, and the other had 168 cases (65.63%, 168/256) eases overall, and is the most common type in adults.
with ASD size < 5 mm. As shown in Table 3, 26.14% (23/88) Without timely and proper treatments, it can result in
of subjects in the ≥ 5 mm subgroup and 10.71% (18/168) arrhythmic complications, heart failure, and paradoxical

13

1034
Table 4  Incidence of crochetage on the R wave and IRBBB before and after treatment
Group Crochetage on a single lead
At diagnosis 1 month later
Surgery, n = 28 11 (39.29) 6 (21.43)
Intervention, n = 44 7 (15.91) 5 (11.36)
No treatment, n = 16 5 (31.25) 5 (31.25)
χ2 0.564
P 0.754
Values are presented as no. (%). χ2 = chi-square statistic
embolism-related morbidity or mortality. Early diagnosis
of ASD is thus very important. Confirmatory diagnosis is
made by transthoracic echocardiography, but the high costs
associated with this method limit its application in clini-
cal settings. ECG, on the other hand, is a low-cost testing
method, but has shown low specificity in the diagnosis of
ASD, because ECGs of patients with ASD can be normal,
or exhibit a large right atrium, large right ventricle, IRBBB,
extended PR intervals, right axis deviation, or atrial arrhyth-
mia [11–13]. Heller et al. in 1996 advanced the notion that
crochetage on the R wave may be a specific sign of ASD,
and the higher the incidence of a three-lead R wave with
crochetage patterns, the higher the diagnostic specificity [8].
In the current study, we analyzed ECG crochetage on the R
waves in 256 pediatric patients with simplex secundum ASD
and 256 controls. We found that the percentages of patients
exhibiting crochetage signs on the R wave in all three infe-
rior limb leads, one or more inferior limb leads with IRBBB,
or all three inferior limb leads with IRBBB were all higher
than patients without cardiac defects. These results show that
R wave crochetage in inferior limb leads can be considered
a sign of pediatric ASD.
Subgroup analysis indicated a correlation between R
wave crochetage and ASD size (Table 2). The results showed
that the incidence of crochetage was higher in the group with
≥ 5 mm ASD size (26.14 vs. 10.71% on a single lead; 44.32
vs. 19.64% on three leads). The results were consistent with
Heller’s study, in which crochetage signs were found to be
more obvious in patients with larger ASD or larger bypass
from left to right, indicating that crochetage on the R wave
may correlate with the type of ASD and amount of bypass.
Crochetage on the R wave, therefore, was considered a sign
of large bypass from left to right on ASD patients. Some
studies further proposed that there might be a correlation
between the R wave with crochetage patterns and dysfunc-
tion such as pulmonary hypertension or conduction disor-
ders [7, 8]. Investigation of crochetage on the R wave offers
an opportunity to gain deeper insight into the underlying
mechanisms of ASD and other heart-related defects.
We also measured the impact of IRBBB on crochetage-
based diagnosis of ASD. Significant differences in the
13
Pediatric Cardiology (2018) 39:1031–1035
Crochetage on three leads IRBBB
At diagnosis 1 month later At diagnosis 1 month later
19 (67.86) 11 (39.29) 15 (53.57) 15 (53.57)
13 (29.55) 9 (20.45) 22 (50.00) 22 (50.00)
7 (43.75) 7 (43.75) 9 (56.25) 9 (56.25)
0.697 0.000
0.706 0.999
incidence of crochetage were found with single- and three-
lead IRBBB between the case and control cohorts (Table 2).
Crochetage patterns typically appear at the starting point
of the QRS wave within 80 ms, while IRBBB abnormality
often appears at the end part of QRS. Thus, there would
be no problem with overlap in differentiating crochetage
from IRBBB abnormalities on ECG. Various studies have
reported that the diagnostic specificity of ECG for ASD is
improved in the case of R waves with crochetage patterns
and IRBBB [4, 7, 8].
The follow-up analysis showed that the crochetage pat-
terns disappeared on ECG of secundum ASD patients after
surgical treatment, while IRBBB was still present (Table 4).
Compared with the pre-operation period, crochetage on the
R wave disappeared in 15 subjects in the surgical subgroup
and six in the intervention subgroup 1 month after surgi-
cal treatment or intervention, while there were no changes
in IRBBB on ECG 1 month after treatment. Such results
indicate that crochetage was an independent diagnostic sign
for ASD. Similar results have been reported in other stud-
ies: crochetage on the R wave disappeared 10–15 days after
surgical treatment in 35% of ASD subjects, while IRBBB
lasted for a longer period due to the mechanism caused by
an overloaded right ventricle [8].
Our study had several limitations. First, the follow-up
analysis covered a period of only 1-month post-surgery or
intervention. Further analysis such as changes in dilation
after 6 months of post-ASD closure and their impact on cro-
chetage were not included. Second, the relationship between
the hemodynamics and crochetage statistics was not ana-
lyzed, due to the lack of data.
In conclusion, crochetage on the R wave in inferior limb
leads of ECG has clinical significance in early diagnosis
of secundum ASD at the asymptomatic stage. Our findings
support the hypothesis that the presence of crochetage pat-
terns can assist in identifying ASD candidates and can aid
in decision making at an early point, benefiting resource
utilization and intervention delivery. A future study with a
larger sample size and longer follow-up period is in prepara-
tion to further explore the impact of R wave crochetage on
ASD diagnosis and its underlying mechanism.
Pediatric Cardiology (2018) 39:1031–1035 1035
Compliance with Ethical Standards  5. Kuijpers JM, Mulder BJ, Bouma BJ (2015) Secundum atrial sep-
Conflict of interest  The authors declare that they have no conflict of
interest.
Ethical Approval  All procedures performed in studies involving human
participants were in accordance with the ethical standards of the insti-
tutional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
Informed Consent  Informed consent was obtained from all individual
participants included in the study.
References
1. Saritas T, Yucel IK, Demir IH, Demir F, Erdem A, Celebi A
(2016) Comparison of transcatheter atrial septal defect closure
in children, adolescents and adults: differences, Challenges and
short-, mid- and long-term results. Korean Circ J 46(6):851–861.
https​://doi.org/10.4070/kcj.2016.46.6.851
2. Behjati-Ardakani M, Golshan M, Akhavan-Karbasi S, Hosseini
SM, Behjati-Ardakani MA, Sarebanhassanabadi M (2016) The
clinical course of patients with atrial septal defects. Iran J Pediatr
26(4):e4649. https​://doi.org/10.5812/ijp.4649
3. Ucak A, Temizkan V, Ugur M, Yedekci AE, Uz O, Selcuk A,
Yilmaz AT (2016) Comparison of primary repair and patch
plasty procedure on the P wave in adult atrial septal defect clo-
sure. Cardiovasc J Afr 27(4):285–261. https​://doi.org/10.5830/
CVJA-2016-013
4. Bayar N, Arslan S, Koklu E, Cagirci G, Cay S, Erkal Z, Ayoglu
RU, Kucukseymen S (2015) The importance of electrocardio-
graphic findings in the diagnosis of atrial septal defect. Kardiol
Pol 73(5):331–336. https​://doi.org/10.5603/KP.a2014​.0240
tal defect in adults: a practical review and recent developments.
Neth Heart J 23(4):205–211. https​: //doi.org/10.1007/s1247​
1-015-0663-z
6. Somura J, Nakagawa M, Ukiami M, Sagawa H, Furukawa O,
Hoshino S, Fujino H, Takeuchi Y (2015) Relationship between
electrocardiographic signs and shunt volume in atrial septal defect.
Pediatr Int 57(4):535–540. https​://doi.org/10.1111/ped.12569​
7. Bhattacharyya PJ (2016) ‘Crochetage’ sign on ECG in secun-
dum ASD: clinical significance. BMJ Case Rep. https​://doi.
org/10.1136/bcr-2016-21781​7
8. Heller J, Hagege AA, Besse B, Desnos M, Marie FN, Guerot C
(1996) “Crochetage” (notch) on R wave in inferior limb leads: a
new independent electrocardiographic sign of atrial septal defect.
J Am Coll Cardiol 27(4):877–882
9. Cohen JS, Patton DJ, Giuffre RM (2000) The crochetage pattern
in electrocardiograms of pediatric atrial septal defect patients. Can
J Cardiol 16(10):1241–1247
10. Dillon JC, Weyman AE, Feigenbaum H, Eggleton RC, Johnston
K (1977) Cross-sectional echocardiographic examination of the
interatrial septum. Circulation 55(1):115–120
11. Schiller O, Greene EA, Moak JP, Gierdalski M, Berul CI (2013)
The poor performance of RSR’ pattern on electrocardiogram
lead V1 for detection of secundum atrial septal defects in chil-
dren. J Pediatr 162(2):308–312. https​://doi.org/10.1016/j.jpeds​
.2012.07.017
12. Wang MX, Wu GF, Gu JL, Li L, Lu K, Yang D, Chen L, Zhang
X, Luo FT, Michaels AD, Ma H (2012) Defective T wave com-
bined with incomplete right bundle branch block: a new electro-
cardiographic index for diagnosing atrial septal defect. Chin Med
J 125(6):1057–1062
13. Davies DH, Pryor R, Blount SG Jr (1960) Electrocardiographic
changes in atrial septal defect following surgical correction. Br
Heart J 22:274–280
13