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Physiological Murmur in a Pregnant WomanA Catch in the Notch

Educational Objective
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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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.

Questions: What is the abnormality in the ECG, and what is the likely diagnosis?

The ECG in the Figure shows normal sinus rhythm with heart rate of 70 beats/min. There is complete right bundle-branch block with normal PR interval. There are no significant ST-T segment changes. However, on closer inspection, fragmented QRS segment with a notch on the R wave of inferior leads can be noticed. This sign, also eponymously known as crochetage sign, is relatively specific for ostium secundum (OS) atrial septal defect (ASD). Transthoracic echocardiography revealed a dilated right atrium and right ventricle with a large 21-mm OS-ASD, with left-to-right shunt.

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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
3.
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
4.
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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Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
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  • 1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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