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Physiological Murmur in a Pregnant WomanA Catch in the Notch

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To identify the key insights or developments described in this article
1 Credit CME

A 29-year-old primigravida woman presented to the outpatient obstetric clinic for a routine antenatal checkup. Cardiovascular system examination revealed a systolic murmur in the left upper parasternal region, which was initially thought to be a physiological murmur of pregnancy. There was no history of dyspnea, chest pain, palpitation, or lower limb swelling. Her vital parameters were within normal limits. The 12-lead electrocardiogram (ECG) is presented in the Figure.

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Atrial septal defect is the most common congenital disease encountered in adults. The ECG changes in ASD depend on the type of defect, degree of shunt severity, and presence of pulmonary hypertension. The most common type of ASD is the OS subtype, which typically demonstrates rSr′ or rsR′ QRS configuration in right precordial leads.1 This reflects right ventricular volume overload rather than a conduction delay. Prolongation of the PR-segment may be seen in 6% to 19% of patients, which rarely progresses to high-degree atrioventricular block. Right-axis deviation is commonly seen in OS-ASD, whereas left-axis deviation is rare but has been described in hereditary forms of ASD, such as Holt-Oram syndrome and ostium primum ASD.

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Article Information

Corresponding Author: Abhishek Thakur, MD, DM, Department of Cardiology, National Cardiac Centre, Kathmandu 44600, Nepal (abhishekthakur1039@gmail.com).

Published Online: July 5, 2022. doi:10.1001/jamainternmed.2022.2512

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
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Khairy  P , Marelli  AJ .  Clinical use of electrocardiography in adults with congenital heart disease.   Circulation. 2007;116(23):2734-2746. doi:10.1161/CIRCULATIONAHA.107.691568PubMedGoogle ScholarCrossref
2.
Toscano Barboza  E , Brandenburg  RO , Swan  HJ .  Atrial septal defect; the electrocardiogram and its hemodynamic correlation in 100 proved cases.   Am J Cardiol. 1958;2(6):698-713.PubMedGoogle ScholarCrossref
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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(4):877-882. doi:10.1016/0735-1097(95)00554-4PubMedGoogle ScholarCrossref
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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(7):1393-1397. doi:10.1161/01.STR.29.7.1393PubMedGoogle ScholarCrossref
5.
Celik  M , Yilmaz  Y , Kup  A ,  et al.  Crochetage sign may predict late atrial arrhythmias in patients with secundum atrial septal defect undergoing transcatheter closure.   J Electrocardiol. 2021;67:158-165. doi:10.1016/j.jelectrocard.2021.06.010PubMedGoogle ScholarCrossref
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