Did you know that heart disease is the leading cause of death globally? On 11 November 2023, Asian Heart & Vascular Centre held Heart to Heart Talk 2023, organized by MediaCorp, official media partner, CNA, at Suntec Convention Centre. We hope to bring awareness and get everyone to recognize the symptoms of common heart and related diseases, and understand the treatments available. Here's the presentation shared by Dr Cliff Wong Chun Pong. Dr Cliff Wong is an echocardiologist trained in imaging of the heart. He specializes in cardiac imaging (echocardiography and cardiovascular computed tomography). Experienced in managing cardiomyopathy, heart failure, valvular heart diseases and cardio-oncology. For more info, visit www.ahvc.com.sg

1. Silent Hole
Lethal Flaw
Dr. Cliff Wong Chun Pong 黄振邦医
生
MBBS (HK), MRCP (UK), FAMS
Certified Cardiac Rehabilitation Professional
(American Association of Cardio-Vascular & Pulmonary Rehabilitation)
Diplomate of the Certification Board of Cardiovascular Computed Tomography (CBCCT)
Diplomate of National Board of Echocardiography in Adult Comprehensive Echocardiography (ASCeXAM)
Fellow of the American Society of Echocardiography (FASE)

3. Patent Foramen Ovale (PFO)
• Present in 25% of the adult population.
Homma S, Sacco RL. Patent foramen ovale and stroke.
Circulation. 2005 Aug 16;112(7):1063-72.
doi: 10.1161/CIRCULATIONAHA.104.524371. PMID: 16103257.

4. Stroke
• Hemorrhagic vs. Ischemic
• Hemorrhagic
• Bleeding
• Ischemic
• Blood clot
• Brain vessel blockage

5. Cryptogenic Stroke
• An imaging-confirmed stroke with unknown source
despite thorough diagnostic assessment.
• The cause of a stroke cannot be determined.
Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF,
Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC Jr, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke
and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2021 Jul;52(7):e364-e467. doi:
10.1161/STR.0000000000000375. Epub 2021 May 24. Erratum in: Stroke. 2021 Jul;52(7):e483-e484. PMID: 34024117.

6. Cryptogenic Stroke
• ~35% of ischemic strokes are cryptogenic.
• Approximately 1 in 4 stroke survivors will likely have
another stroke.
Source: https://www.stroke.org/-/media/Stroke-Files/Cryptogenic-Patient-Facing-Resources/A-Patient-Guide-to-Understanding-Strokes-of-Unknown-
Cause-PDF-ucm477655.pdf?
_gl=1*1y5i884*_ga*MTg2NjY2MDM0My4xNjg1NjI2MTkw*_ga_THX2C0D2X1*MTY4NzUyNzE1Ny4zNC4xLjE2ODc1MzIyMDQuMC4wLjA.

7. Association between PFO and cryptogenic stroke
• Adults under 55 years old with ischemic stroke and a normal
cardiac examination.
• 40% vs. 10% (P<0.001)
Lechat P, Mas JL, Lascault G, Loron P, Theard M, Klimczac M, Drobinski G, Thomas D, Grosgogeat Y.
Prevalence of patent foramen ovale in patients with stroke. N Engl J Med. 1988 May 5;318(18):1148-52.
doi: 10.1056/NEJM198805053181802. PMID: 3362165.

8. Association between PFO and cryptogenic stroke
• Patients presenting with non-haemorrhagic stroke or transient
ischaemic attacks under the age of 40 years.
• Right-to-left shunting
• 20 (50%) vs. 6 (15%) [p < 0.001]
Webster MW, Chancellor AM, Smith HJ, Swift DL, Sharpe DN, Bass NM, Glasgow GL.
Patent foramen ovale in young stroke patients. Lancet. 1988 Jul 2;2(8601):11-2.
doi: 10.1016/s0140-6736(88)92944-3. PMID: 2898621.

10. Song JK. Pearls and Pitfalls in the Transesophageal Echocardiographic Diagnosis of Patent
Foramen Ovale. J Am Soc Echocardiogr. 2023 Sep;36(9):895-905.e3. doi: 10.1016/
j.echo.2023.05.004. Epub 2023 May 15. PMID: 37196905.
Table 2 Summary of RCTs that evaluated the efficacy of percutaneous device closure over medical treatment: impact of the
anatomical features of PFO
Trial name
(year)reference
Patient
no.
Overall
results PFO subtype (n, %)
PFO closure
(no. of events/total)
Medication
(no. of events/total)
Hazard ratio*
(95% CI)
P value by
log-rank test
CLOSURE I
(2012)14
909 Negative High-risk (388, 42.7) 5/198 3/190 1.48 (0.36 to 6.14) .532
Non-high-risk (415, 45.6) 6/194 8/221 0.85 (0.30 to 2.45) .740
PC (2013)15
414 Negative High-risk (154, 37.2) 1/78 2/76 0.59 (0.06 to 6.15) .558
Non-high-risk (233, 56.3) 0/114 5/119 0.09 (0.00 to 2.12) .024
RESPECT
(2017)18
980 Positive High-risk (619, 63.2) 7/318 21/301 0.29 (0.13 to 0.69) .002
Non-high-risk (353, 36.0) 11/178 7/175 1.36 (0.53 to 3.50) .493
REDUCE
(2017)19
664 Positive High-risk (273, 41.1) 1/193 6/80 0.08 (0.01 to 0.52) <.001
Non-high-risk (302, 45.5) 5/195 6/107 0.46 (0.14 to 1.51) .180
CLOSE
(2017)17
653 Positive High-risk (653, 100) 0/238 17/415 0.05 (0.00 to 0.88) .002
DEFENSE-
PFO
(2018)20
120 Positive High-risk (120, 100) 0/60 6/60 0.07 (0.00 to 0.26) .013
CLOSE, Patent Foramen Ovale Closure or Anticoagulants Versus Antiplatelet Therapy to Prevent Stroke Recurrence; CLOSURE I, Evaluation of the
STARFlex Septal Closure System in Patients With a Stroke and/or Transient Ischemic Attack to Presumed Paradoxical Embolism Through a Patent
Foramen Ovale; DEFENSE-PFO, Device Closure Versus Medical Therapy for Cryptogenic Stroke Patients with High-Risk Patent Foramen Ovale;
Gore REDUCE, GORE HELEX Septal Occluder/GORE CARDIOFORM Septal Occluder for PFO Closure in Stroke Patients; PC, Clinical Trial
Comparing Percutaneous Closure of PFO Using the Amplatzer PFO Occluder With Medical Treatment in Patients With Cryptogenic Embolism;
RESPECT, Randomized Evaluation of Recurrent Stroke Comparing PFO Closure to Establish Current Standard of Care Treatment.

11. • Prevent 1 recurrent stroke in 131 during 1 person-year of follow-
up
• Prevent 1 recurrent stroke in 13 during 10 person-years of
follow- up
• Clinically important in this generally young population.
Kleindorfer DO, et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American
Heart Association/American Stroke Association.
Stroke. 2021 Jul;52(7):e364-e467. doi: 10.1161/STR.0000000000000375. Epub 2021 May 24.
Erratum in: Stroke. 2021 Jul;52(7):e483-e484. PMID: 34024117.

12. 2a B-R
2. In patients 18 to 60 years of age with a nonla-
cunar ischemic stroke of undetermined cause
despite a thorough evaluation and a PFO with
high-risk anatomic features,* it is reasonable
to choose closure with a transcatheter device
and long-term antiplatelet therapy over anti-
platelet therapy alone for preventing recurrent
stroke.552–557
2b C-LD
3. In patients 18 to 60 years of age with a nonla-
cunar ischemic stroke of undetermined cause
despite a thorough evaluation and a PFO
without high-risk anatomic features,* the ben-
efit of closure with a transcatheter device and
long-term antiplatelet therapy over antiplatelet
COR LOE Recommendations
Kleindorfer DO, Tow
fi
ghi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O,
Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC Jr, Turan TN, Williams LS.
2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart
Association/American Stroke Association.
Stroke. 2021 Jul;52(7):e364-e467. doi: 10.1161/STR.0000000000000375. Epub 2021 May 24. Erratum in: Stroke. 2021 Jul;52(7):e483-e484.
PMID: 34024117.

14. Right Left

17. Case Study

18. Case Study
• 21 year old lady
• University team netball player
• Non-smoker, non-drinker
• Good past medical health
Source: https://openhousenygh.com/cca-showcase/
netball/#jp-carousel-3991

19. Case Study
• Presented to Neurologist
• Few times after squat and
jump

20. Case Study
• Few seconds of syncope
• Few hours of numbness over
1 side of the body

21. Case Study
• Initial diagnosis
• Transient Ischemic Attack (TIA)

22. Case Study
• All the diagnostic assessments are essentially normal.

23. Case Study
Cryptogenic Stroke

24. Right
Left