Continue or stop diving with a PFO?

[scubaozy]

I don't try to prevent anything. The doctor does if he thinks there is a need.

The benefits of prevention are significant only in the case of mandatory accelerated deco diving. The DAN guidelines are for rec divers (they cite studies about recreational diving).

Different doctors may have different opinions on same input. That is why there are guidelines. Doctors are service providers as well, I doubt someone would refuse you doing a PFO test if you asked for it but again if a doctor advises you for a closure without you ever being diagnosed with DCS I would think this is out of guidelines and I would immediately get a second or third opinion.
Technical diving is also recreational diving, unless you are a commercial diver that is. Where exactly you see that they are excluded in this report? Traditionally DAN includes all type of divers in their reports.
Anyway I recommend you have a look at this post.

 

[tridacna]

In the US, what is the position of Health Insurance companies in this regard? It’s one thing to “want” a test vs a medical need for a test for a recreational activity. I’m guessing that a prior auth will be required.

 

[ginti]

Different doctors may have different opinions on same input. That is why there are guidelines. Doctors are service providers as well, I doubt someone would refuse you doing a PFO test if you asked for it but again if a doctor advises you for a closure without you ever being diagnosed with DCS I would think this is out of guidelines and I would immediately get a second or third opinion.

I am not a doctor, so I am not able to answer all your questions (not even mine); and I am surprised you are so sure of what you are saying, except if you are a cardiologist specialising in diving medicine. This is why I asked some physicians here on the forum.

Regarding tec and rec divers, I have no idea of what these terms mean according to DAN. Are you sure 100% that in their definition rec comprises also tec divers? Anyway, even if you were right, the statistics would be biased because the decompression risks and stress are different between these two groups.

I am not saying that they are wrong: definitely, they have more data than the one shown on the website. I am saying that maybe those guidelines are not intended for divers like me. **Maybe**.

 

[ginti]

Anyway I recommend you have a look at this post.

I had, and @Dr Simon Mitchell agrees that for tec divers, the situation is borderline, and the main problem why the medical community does not suggest mandatory checks is about the cost/risk factor in the case of tec divers. He also says that depending on the diver he may accept or even suggest a preventive screening.

Please, I would like to point out that the cost has great variation across countries. I did the test for 220€, but the doctor who visited me did a full (general) medical check-up, plus a specialized test for my heart (I have a condition - I think it was an echography), plus an effort test. Relatively cheap when you compare it with the 800$ you need in Australia ONLY for the bubble test. Let me be clear: I wouldn't do it for 800$ without a previous accident, except if a doctor advocates for it. Also, before taking the test, I discussed with the doctor how I feel after the dives (often I am tired) and that I want to start deep tec diving relatively soon. He thought that, in my case, it made sense.

I agree that for a vast majority of divers, it is unnecessary, but I still believe that it can be helpful for tec divers, especially in places where the cost is not high. I am curious to see what other doctors think about it.

EDIT: "being helpful" and "should be mandatory" are very different things.

 

[scubaozy]

I had, and @Dr Simon Mitchell agrees that for tec divers the situation is borderline, and the main problem why the medical community does not suggest mandatory checks is about the cost/risk factor in the case of tec divers. He also says that depending on the diver he may accept or even suggest a preventive screening.

Please, I would like to point out that the cost has huge variation across countries. I did the test for 220€ but the doctor who visited me did a full (general) medical check-up, plus a specialized test for my heart (I have a condition - I think it was an echography), plus an effort test. Rather cheap when you compare it with the 800$ you need in Australia ONLY for the bubble test. Let me be clear: I wouldn't do it for that price without a previous accident. Also, before taking the test I discussed with the doctor how I feel after the dives (often I am tired) and that I want to start deep tec diving rather soon. He thought that in my case it made sense.

I agree that for a vast majority of divers it is unnecessary, but I still believe that for tec divers it can be helpful, especially in places where the cost is not high. I am curious to see what other doctors think about it.

Again, you are free to do whatever you want to do. I am not criticizing your choices and it is not a crime to know about your PFO status. You seemed to focus on new/other areas in that post. I never discussed cost or mandatory checks. Let me share again some statements from that post.
3. A positive test after an episode of DCS does not guarantee that the PFO was the cause of the DCS.

4. As a corollary to point 3, repairing a PFO discovered after an episode of DCS does not guarantee that another event will not occur.

5. A negative test does not mean that the diver is “resistant” to DCS as many seem to believe.

But at this time the expert medical community does not believe that pre-participation screening is justified purely on a risk / cost vs benefit basis.

Above are no different from roughly what I wrote of which, most of them were actually direct quotations to DAN.
Risk: probability of dcs vs impact of dcs - I believe I wrote that dcs has low probability of occurrence even with presence of pfo and relatively high recovery chances
Cost vs benefit: What benefit is exactly achieved if points 3.4.5 are true even you are able to cover the costs..
If you test positive, you will be offered 3 options and you will be asked to choose between them. Its not your doctor, it is you who chooses. In the light of other information such as presence of headaches or tiredness, perhaps you might choose a closure hoping that there might be other benefits as it will not give much certainty into your diving,

 

[Dr Simon Mitchell]

Thanks a lot. It would be nice to know what experts think about your explanation - if it's aligned with current scientific knowledge or not

@Duke Dive Medicine @Dr Simon Mitchell

Hello,

It is difficult to be definitive on this, and much depends on how you define fast and slow tissues, but I don't think Angelo's theory is strictly correct. The danger implied by a PFO arises from the fact that it allows venous bubbles to enter the arterial circulation. The question is 'where do these venous bubbles come from'? They almost certainly form in the capillary beds of supersaturated tissues, and migrate into the venous blood from there. Very fast tissues are quantitively small, don't remain supersaturated long, and probably contribute little to a sustained venous bubble load after surfacing. On the other hand, slower tissues with a large capacity for dissolving nitrogen (such as fat, possibly skin) almost certainly contribute to sustained release of venous bubbles that we see after diving. These tissues are probably more relevant to the danger imposed by a PFO. However, I would stop short of categorically claiming that fast tissues are never relevant.

Yeah I've had a shoulder hit post closure, with relatively aggressive GFs, repetitive diving and a bit of swell

This is not surprising, since the occurrence of musculoskeletal DCS has never been linked to the presence of a PFO. This implies that musculoskeletal pain in DCS is one of those forms of DCS probably caused by bubbles forming within the tissues themselves; not by bubbles entering the arterial blood across a PFO.

@Frogman82 , as many have pointed out it is certainly possible to have a PFO repaired for the purpose of reducing risk in diving. Several posters on this thread have had it done. However different jurisdictions/health funding models have different perspectives on who should pay for a closure in this context.

I am surprised that a diving physician has given you a blanket 'stop diving' opinion in the absence of repair, because conservative 'low bubble' diving is a recognised option for managing the risk of a PFO in diving. That point is clearly codified in the SPUMS / UK Sport Diving Medical Committee guidelines which you can find here. The DAN / UHMS consensus says the same thing. There is also some published evidence that these strategies work, which you can find here and here. The problem with such an approach is that it is hard to achieve in technical diving, although I note at least one poster has articulated a series of steps taken in tech dives that appear to be working for him or her. Available data also suggest that a PFO closure is likely to be a more effective protective strategy. In general, if a diver on an ambitious technical diving trajectory is tested and found to have a large PFO, I would generally recommend having it closed (to accommodate that sort of diving). However, if someone only wants to dive to 15m to poke around a tropical reef the advice might be quite different.

@ginti and @Ucarkus I think you both get the idea on this debate you are having - you are just on slightly different sides of the fence. For clarity, we (and I'm virtually certain I speak for Doug Ebersole here too) do not currently recommend routine screening of technical divers for PFO. However, given that dives to progressively deeper depths are not iso-risk even if the the same decompression algorithm is followed to the letter, we also understand that there may be some technical divers performing deep decompression dives who a motivated to be tested, even if they have never suffered DCS. A theme in my long previous post that Ucarkus linked to was that most of us are not obstructive in the face of such requests, but it is beholden on us to ensure that we inform the diver fully about what they are getting into by opting for testing. I won't repeat that long post here, but after hearing the explanation described therein, there are some divers who choose not to test and some who forge ahead. Its a classic shades of grey area of medicine.

Simon M

 

[Frogman82]

Most divers hear the 3-6 month reccomendation and are back doing deco dives within 6 weeks. A buddy waited just over 2 weeks b4 doing a 3hr cave dive.

Michael

Each to their own, I'll stick to the DAN recommendations and wait 3-6 months. Also need to get off anti platelet medicine before I get back in the water.

 

[Frogman82]

@Frogman82 , as many have pointed out it is certainly possible to have a PFO repaired for the purpose of reducing risk in diving. Several posters on this thread have had it done. However different jurisdictions/health funding models have different perspectives on who should pay for a closure in this context.

I am surprised that a diving physician has given you a blanket 'stop diving' opinion in the absence of repair, because conservative 'low bubble' diving is a recognised option for managing the risk of a PFO in diving. That point is clearly codified in the SPUMS / UK Sport Diving Medical Committee guidelines which you can find here. The DAN / UHMS consensus says the same thing. There is also some published evidence that these strategies work, which you can find here and here. The problem with such an approach is that it is hard to achieve in technical diving, although I note at least one poster has articulated a series of steps taken in tech dives that appear to be working for him or her. Available data also suggest that a PFO closure is likely to be a more effective protective strategy. In general, if a diver on an ambitious technical diving trajectory is tested and found to have a large PFO, I would generally recommend having it closed (to accommodate that sort of diving). However, if someone only wants to dive to 15m to poke around a tropical reef the advice might be quite different.

Thanks @Dr Simon Mitchell for the informative publications. I luckily had my pfo closed one month ago.

 

[Duke Dive Medicine]

I don't try to prevent anything. The doctor does if he thinks there is a need.

The benefits of prevention are significant only in the case of mandatory accelerated deco diving. The DAN guidelines are for rec divers (they cite studies about recreational diving).

@Duke Dive Medicine, @Dr. Doug Ebersole what do you think about preventive PFO screening?

Like @Dr Simon Mitchell said, most diving medical professionals don't recommend routine screening for PFO in recreational divers. People who plan on engaging in deep technical diving may choose to be screened and undergo preventive closure if one is found, but approval and/or reimbursement for that could be problematic.

Best regards,
DDM

 

[Germie]

Most divers hear the 3-6 month reccomendation and are back doing deco dives within 6 weeks. A buddy waited just over 2 weeks b4 doing a 3hr cave dive.

Michael

I also read somewhere that all divers who did not wait that 2-6 months that is adviced, that none of them had problems.
I cannot find that article now. But it was interesting.

But most interesting was an article in Wetnotes, in German. There was stated that closure was not needed in most cases for technical divers as they can use oxygen at surface. That was really interesting to read.