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Congenital Defects

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

JAMA Internal Medicine

Published Online: July 5, 2022

Challenges in Clinical Electrocardiography

Article Information and Disclosures

Anamika Karn, MBBS¹;

Shital Khanal, MBBS²;

Abhishek Thakur, MD, DM²

Author Affiliations

¹Paropakar Maternity and Women’s Hospital, Kathmandu, Nepal
²Department of Cardiology, National Cardiac Centre, Kathmandu, Nepal

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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.

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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

Khairy P , Marelli AJ . Clinical use of electrocardiography in adults with congenital heart disease. Circulation. 2007;116(23):2734-2746. doi:10.1161/CIRCULATIONAHA.107.691568 PubMed Google Scholar Crossref

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.PubMed Google Scholar Crossref

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)00554-4 PubMed Google Scholar Crossref

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.29.7.1393 PubMed Google Scholar Crossref

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.2021.06.010 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
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.