A young woman with epigastric pain. ECG Crochetage sign? What is the significance?

A former resident texted me this ECG, done for epigastric pain in an 18 year old.  The pain resolved immediately with treatment for acid reflux, and in the clinician's opinion was clearly GI in origin, but he wanted to know what the strange waves in the QRS were:See the unusual notching in II, III, aVF, and V2-V4.I had no idea what they were.  They reminded me of theDelayed Activation Wave associated with circumflex acute MI.See this case: https://hqmeded-ecg.blogspot.com/2018/05/is-there-delayed-activation-wave.html.But they are clearly different from this.I put it on Facebook EKG club and this is the response:No one knew for certain what that was, butKen Grauer suspected artifact (due to lead placement over an artery) or aCrochetage sign, which is strongly associated with atrial septal defect.  I looked up Crochetage sign and it sure does look like it!You can always rely on Ken.I told my former resident:The latter (Crochetage) is important because it is seen in atrial septal defect.  I not sure the cardiologist will know this.  You should make certain she gets an echo specifically looking for ASD (especially if still present on a repeat ECG).  Let the referral cardiologist know.  He will notify the patient but, unfortunately,  because she will follow up in a different system, he will not have follow up.Crochetage signYou can see many more images of the Crochetage sign here.See the 5 articles below.“...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs

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Authors: Saito I PMID: 32493882 [PubMed - as supplied by publisher]
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Conclusion: Direct compression of ICA is rare complication of pituitary apoplexy, which caused cerebral ischemia. Conventional angiography should be necessary for accurate diagnosis and prompt surgical decompression should be the treatment of choice. PMID: 32494388 [PubMed]
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