Cost of PFO testing

[befee]

I am currently interested in diving into the realm of technical diving. My instructor informed me to get myself tested for PFO. After reading around and trusting his opinion, I decided to go along with it. Being a student, I am under tight finances; however I do have health insurance. I was wondering around how much the tests might run (TEE/TTE/TCD) in case the insurance doesn't cover it.

Thanks in advance.

 

[Bubbletrubble]

There's an estimated 10-30% chance that you have a PFO.
There isn't a proven causal 1:1 relationship between the presence of PFO + bubbles and DCS occurrence.

• What course of action did your instructor recommend should you get a positive result by whatever method that you select?
• If the result is positive, would the size of the PFO determine whether you choose surgical/percutaneous closure, make accommodations to minimize venous bubble load on deep dives, or decide to give up tech diving altogether?
• In the event of a negative result, how often (months, years, decades) does he recommend getting retested?

It's good to be informed and to think about these issues ahead of time...prior to testing.
It's also worthwhile to consider whether you should be taking more "chances" DCS risk-wise, i.e., adopting aggressive profiles, even if you get a negative result.

TCD will probably be the most affordable option. Estimated cost is probably in the hundreds of dollars. Shop around since it probably won't be covered by your health plan.

 

[DocVikingo]

Hi befee,

In the absence of any signs, symptoms or serious suspicions of PFO, the chances are about nil that your health insurance will cover an echocardiogram for the sole purpose of safety in pursuing technical diving training. Plan on paying out of pocket.

Most experts consider contrast transesophageal echocardiography (TEE) to be the current gold standard for this type of evaluation, although contrast transcranial Doppler of certain cerebral vessels runs a very close second, and has the benefit of being ever so much less expensive than TEE.

This will give you an idea of costs for TEE, which of course is somewhat dependent upon location/facility/practice --> Transesophageal Echocardiography Cost Comparison | NewChoiceHealth.com

The cost of contrast transcranial Doppler, which of course also is somewhat dependent upon location/facility/practice, should run in the $300-$500 range.

Regards,

DocVikingo

 

[Dr Deco]

As said, insurance will not pay for "curiosity prior to diving."

In general, there is not a good correlation between PFO and DCS. That is actually very good!

 

[N2DeepInAz]

It was recommended by my doc that I have an Echo done when I went to have my primary care physician sign off on my tech diving medical forms. It was not covered by my insurance and cost me $700.

Oddly, they couldn't tell me beforehand what the cost was going to be so I kindof rolled the dice and justified it by knowing that no matter what the cost my health was what mattered. Better to be safe than sorry.

Hope this helps.

 

[Duke Dive Medicine]

Befee,
There's no good clinical rationale to get tested for a PFO just to rule it out prior to taking a diving class. Unless it's a course requirement (and I'm not sure why it would be - the Navy doesn't do it, and neither do any commercial companies that I'm aware of), you're better off spending you're money on some good equipment. If you do decide to go ahead with it, we use transthoracic echocardiography with bubble contrast. Color flow echocardiography will also work, but our ultrasound techs and radiologists prefer the bubble contrast. Transcranial doppler will detect shunted bubbles but will not distinguish between a PFO and another type of shunt (intrapulmonary, for example), so a PFO cannot be positively diagnosed using transcranial doppler alone.
Best regards,
DDM

 

[DocVikingo]

Hi DDM,

Befee, There's no good clinical rationale to get tested for a PFO just to rule it out prior to taking a diving class.

As also can be implied by the posts of Bubbletrubble and Dr Deco, IMHO this absolutely is the case.

Transcranial doppler will detect shunted bubbles but will not distinguish between a PFO and another type of shunt (intrapulmonary, for example), so a PFO cannot be positively diagnosed using transcranial doppler alone.

Excellent additional comment.

Since we're off to extended clarifications here, I'd also mention that if TCD proves negative, and that is the very strong expectation in the asymptomatic individual, in the vast majority of cases the search is over. And you'll have spent only a small fraction of what a contrast TEE (especially) or TTE typically costs and avoided the unpleasantness many experience from TEE.

Moreover, if bubbles are apparent on TCD as best as I know other types of shunting (e.g., intrapulmonary, other ASDs) are significantly less likely to be the cause than is PFO.

Color flow echocardiography will also work, but our ultrasound techs and radiologists prefer the bubble contrast.

Please free to correct me, but wouldn't it be more accurate and clear to say that the research on color flow v bubble contrast echocardiography generally indicates the diagnostic superiority of the latter technique?

Regards,

Doc

 

[DocVikingo]

Hi Befee,

I suspect you'll find the following recent Alert Diver magazine articles to be quite informative:

Alert Diver | PFO and Decompression Illness in Recreational Divers

Alert Diver | Divers with Holes in their Hearts

Regards,

DocVikingo

 

[Duke Dive Medicine]

Hi DDM,
Since we're off to extended clarifications here, I'd also mention that if TCD proves negative, and that is the very strong expectation in the asymptomatic individual, in the vast majority of cases the search is over. And you'll have spent only a small fraction of what a contrast TEE (especially) or TTE typically costs and avoided the unpleasantness many experience from TEE. (Me: cut cut paste paste) Moreover, if bubbles are apparent on TCD as best as I know other types of shunting (e.g., intrapulmonary, other ASDs) are significantly less likely to be the cause than is PFO.

Hi Doc,
I agree that if the TCD is negative, that probably rules out clinically significant PFO and maybe saves Befee some money. A positive test is another story; that's where Bubbletrubble's insights come in. TCD is not specific for PFO. If a TCD shows bubble shunting, since his (or rather his instructor's) goal is to rule out a PFO, does he pay for another test with more specificity to get a positive diagnosis? Then, more importantly, if he does have a PFO, what's he going to do about it? If he wants to have it fixed, he'll need either a TEE or an MRI (or both) to define the borders and determine the repair method to be used. Or, does he pay the extra money for a TEE in the first place? That's not the way our diagnostic cardiology lab normally proceeds but somebody might be willing to do that for him.

Please free to correct me, but wouldn't it be more accurate and clear to say that the research on color flow v bubble contrast echocardiography generally indicates the diagnostic superiority of the latter technique?

Can you just tack that onto the end of my post for me?

Long answer: yes. I've had some great talks with one of our diagnostic/interventional cardiology fellows about this, and one of our cardiologists has done considerable research on bubble contrast. TTE with bubble contrast has higher sensitivity and specificity for PFO, which is why that's our preferred testing method.

Thanks for your post. Hopefully between all of us Befee and anyone else who's reading this will get a solid take-home message.

Best regards,
DDM

 

[befee]

Firstly,thanks to all that responded. This was just the info and responses I was looking for.

PS I was trying to find those Dan articles but couldn't find the issues home. Thanks agaon