Key result
Multi-lead inferior crochetage sign is linked to ~2.1-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 after accounting for established echocardiographic risk features and the number of involved inferior leads remained unclear.
Is the electrocardiographic crochetage sign in multiple inferior leads independently associated with cryptogenic stroke or TIA in patients with a patent foramen ovale after accounting for high-risk echocardiographic anatomy?
Case-Control (n=937)
Standard 12-lead electrocardiograms were independently reviewed by two blinded electrophysiologists
Yes
Is the electrocardiographic crochetage sign in multiple inferior leads independently associated with cryptogenic stroke or TIA in patients with a patent foramen ovale after accounting for high-risk echocardiographic anatomy?
Crochetage sign present in two or more inferior ECG leads—but not a single lead—is independently associated with cryptogenic stroke in patients with PFO even after adjusting for high-risk echocardiographic anatomy, offering a simple electrocardiographic marker to aid in PFO risk stratification.
Multi-lead crochetage was associated with stroke-PFO; extends prior ECG links but leaves open incremental value over echo features.
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 anatomy. 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 2.081, 95% CI 1,283-3,376; P = 0.003). High-risk PFO anatomy was the strongest predictor (OR 6.482, 95% CI 4,796-8,762; P < 0.001); older age and hypertension were also independent predictors. 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.
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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 (involving two or more inferior ECG leads) vs. Absence of crochetage sign (and single-lead crochetage sign) was evaluated on Stroke-associated patent foramen ovale (cryptogenic ischemic stroke or transient ischemic attack) (OR 2.081, 95% CI 1.283-3.376, p=0.003). Crochetage sign in two or more inferior ECG leads was independently associated with stroke-associated PFO after multivariable adjustment (OR 2.081, 95% CI 1.283-3.376; P = 0.003).
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