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(Stroke. 1998;29:1393-1397.)
© 1998 American Heart Association, Inc.

Original Contributions

An Electrocardiographic Criterion for Diagnosis of Patent Foramen Ovale Associated With Ischemic Stroke

Hakan Ay, MD; Ferdinando S. Buonanno, MD; Stephen A. Abraham, MD; J. Philip Kistler, MD; Walter J. Koroshetz, MD

From the Departments of Neurology (H.A., F.S.B., J.P.K., W.J.K.) and Cardiology (S.A.A.), Massachusetts General Hospital, Stroke Service, Boston, Mass.

Correspondence to Dr Ferdinando S. Buonanno, MD, Stroke Service, VBK-802, Massachusetts General Hospital, 32 Fruit St, Boston, MA 02114. E-mail buonanno{at}helix.mgh.harvard.edu

Background and Purpose—An M-shaped bifid notch on the ascending branch, or on the zenith, of the R wave in inferior ECG leads (II, III, aVF), so called "crochetage," is an indicator of ostium secundum atrial septal defects. The pathophysiology underlying this finding remains unknown. A crochetage pattern has not been previously reported in patients with patent foramen ovale (PFO); however, the location of this defect and the secundum atrial septum are similar. The purpose of this study was to determine the prevalence of crochetage in cryptogenic stroke patients with or without PFO.

Methods—A conservative selection scheme was used to identify patients likely to have had PFO-associated strokes (ie, cryptogenic) and to exclude any structural, functional, or vascular heart disease responsible for ECG changes. All patients had a standard 12-lead ECG. The prevalence of crochetage in each group was determined.

Results—Sixty consecutive patients were studied (28 with echo-documented PFO and 32 echo-negative control subjects). The crochetage pattern was present in at least 1 inferior limb lead in 10 of 28 PFO patients (36%) and 3 of 32 control subjects (9%) (P<0.05). The sensitivity and specificity of the crochetage pattern for diagnosis of PFO in cryptogenic stroke cases were 36% and 91%, respectively; positive predictive value was 77%.

Conclusions—The finding of an ECG crochetage pattern may help to identify stroke patients with PFO, may help to streamline their diagnostic workup, and may warrant future studies to determine its value in stratifying stroke risk in patients with PFO.

Key Words: cerebral ischemia • cerebral infarction • electrocardiography • foramen ovale, patent

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