Key result
Multi-lead crochetage is linked to ~2-fold higher odds of stroke-associated PFO.
Why the study?
The crochetage sign has been associated with patent foramen ovale (PFO), but its relationship with stroke-associated PFO remains unclear, including whether multi-lead involvement shows a stronger association than single-lead involvement after accounting for established echocardiographic risk features.
Does the presence of multi-lead crochetage on a 12-lead ECG, compared to no crochetage or single-lead crochetage, independently associate with stroke-associated patent foramen ovale in adults with TEE-confirmed PFO?
Case-Control (n=937)
Blinded outcome assessment (two electrophysiologists blinded to clinical characteristics, echocardiographic findings, and cerebrovascular event status)
Yes
Does the presence of multi-lead crochetage on a 12-lead ECG, compared to no crochetage or single-lead crochetage, independently associate with stroke-associated patent foramen ovale in adults with TEE-confirmed PFO?
The presence of the electrocardiographic crochetage sign in two or more inferior leads—unlike single-lead crochetage—is independently associated with stroke-associated PFO even after adjusting for high-risk echocardiographic features, offering a non-invasive marker to aid in risk stratification.
Multi-lead crochetage may support PFO-related stroke risk assessment; hypothesis-generating and requires prospective validation before clinical adoption.
Background The crochetage sign has been associated with patent foramen ovale (PFO), but its relationship with stroke-associated PFO remains unclear. We investigated whether this association persisted after accounting for established echocardiographic risk features and whether multi-lead crochetage showed a stronger association than crochetage confined to a single inferior lead. Methods This retrospective multicenter study included 937 patients with PFO from four tertiary centers: 511 with cryptogenic ischemic stroke or transient ischemic attack and 426 controls without a history of cerebrovascular events. Standard 12-lead electrocardiograms were independently reviewed by two blinded electrophysiologists. Crochetage was categorized as single-lead when confined to one inferior lead and as multi-lead when present in two or more inferior leads, with the categories defined as mutually exclusive. Multivariable logistic regression models were adjusted for clinical characteristics and high-risk PFO status. Results Single-lead crochetage did not differ between stroke-associated and non-stroke-associated PFO and was not significant in multivariable analysis. In contrast, crochetage involving two or more inferior leads remained independently associated with stroke-associated PFO after multivariable adjustment (OR 2.01, 95% CI 1.24–3.26; p = 0.005). High-risk PFO status showed the strongest independent association with stroke-associated PFO (OR 5.33, 95% CI 3.83–7.43; p < 0.001); older age and hypertension were also independently associated. Multi-lead crochetage was strongly associated with atrial septal aneurysm or interatrial septal hypermobility. Conclusions The association between crochetage and stroke-associated PFO appears to depend on the number of involved inferior leads. Crochetage involving two or more inferior leads was independently associated with stroke-associated PFO, whereas single-lead crochetage was not. Clinical trial number Not applicable.
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Çelık et al. (2026) conducted a case-control in Patent foramen ovale (PFO) with or without cryptogenic ischemic stroke or transient ischemic attack (n=937). Multi-lead crochetage sign (≥2 inferior ECG leads) vs. No crochetage sign (or single-lead crochetage) was evaluated on Stroke-associated patent foramen ovale (cryptogenic ischemic stroke or transient ischemic attack) (OR 2.01, 95% CI 1.24-3.26, p=0.005). Crochetage in two or more inferior ECG leads was independently associated with stroke-associated patent foramen ovale (OR 2.01, 95% CI 1.24–3.26; p = 0.005), whereas single-lead crochetage was not.
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