PFO and repair process

[boomx5]

As an interventional cardiologist, I thought I should pipe in. There is an association of PFO (patent foramen ovale) and cryptogenic stroke, meaning no other cause can be found. The suspicion is that small blood clots can travel across from the right side of the heart (where these small clots would be filtered by the lung) to the left side where they can embolize to the brain and cause stroke. PFO has also been implicated in dcompression illness in that small bubbles (which also might be cleared by the lungs) can cross over to the left side and embolize to the brain or elsewhere.

In the past the only way to fix a PFO required heart surgery. For stroke prevention the alternative to surgery was anticoagulation therapy with Coumadin. While this is helpful in decreasing clot problems, it would have no effect on bubble issues. There are now two different devices approved by the FDA for PFO closure percutaneously (catheter based like a heart cath and not with surgery). This procedure usually only requires a one day hospital stay and very little in terms of "recovery" time. It is an invasive procedure, however, and does involve small risks. I'm sure there is a cardiologist in your area who is experienced in using these devices who could render an opinion as to whether this would be an option for you.

The risk of the PFO with diving depends on what kind of diving you are doing and is based on the likelihood of bubble formation. Very shallow recreational diving is much lower risk than prolonged deep dives requiring long deco stops. However, as we all know even the most conservative profiles have some risk of DCS. Therefore, while it is reasonable to advise divers with PFO not to be technical or commercial divers, this doesn't completely remove the risk.

If you have any other questions, feel free to PM me.

Are there any other tests out there that will work as good as a TEE but are not as invasive?

 

[RTodd]

Are there any other tests out there that will work as good as a TEE but are not as invasive?

The doc can better speak to this, but yes there is a better alternative. TEE is generally overkill. It can be done externally too. The only discomfort there is it is cold and slimy. It just isn't quite as good of a picture. But, if you are just trying to see if you are at risk, it is really all you need. Sorry, I don't know the technical lingo for the test name. I do believe there is a third test that is not as good.

 

[jbd]

Kraken,
For some reason I'm thinking Detroit Diver had a PFO repair. I think he posted about it. He might be able to provide you with some personal info or insight.


Yep! Here it is http://www.scubaboard.com/showthread.php?t=49396&highlight=patent+foramen+ovale

 

[Dr. Doug Ebersole]

The post by Detroit Diver (link courtesy of jbd) is an excellent description of the problem and treatment. Yes, the diagnosis can be made by a TTE (transthoracic echocardiogram) where the transducer is on the chest and agitated saline ("bubbles") are injected to look for flow across the atrial septum. However, one of the imaging principles of ultrasound is that it takes longer wavelengths to penetrate deeper but shorter wavelengths to have good resolution (better quality pictures). Hence, TEE (transesophageal echocardiogram) where the ultrasound probe is put into the esophagus ("food tube") so that it the ultrasound only has to travel a few millimeters to get to the heart instead of the several centimeters through the chest wall in traditional TTE. This results in excellent resolution and much clearer pictures. Who cares? The better quality images allows the physician to plan the closure procedure better -- i.e. surgery versus percutaneous (non-surgical) closure, what size device is needed, etc. To the patient, a TEE is not a big deal. You are sedated and it's similar to having a doctor look into your stomach for an ulcer. The whole thing takes about 15 minutes and the patient usually doesn't even remember having the test. As a diving doctor, if the issue of a PFO came up for me I'd definitely go with a TEE followed by a closure device!!!

 

[lamont]

transesophageal echocardiography (TEE). The one where they shove and I mean shove this huge tube down your throat. It was a bad experience (nice people at the hospital), but I believe it violated the geneva conventions. It was cool to watch my heart.

The bubble portion of the test came back negative, but when I coughed (have a cold), you could see the flap open up a little.

so, i thought that for TEEs you were supposed to be sedated (valium and versed/fentanyl) and not remember anything of the procedure?

i had a nasogastric tube once, and based on that, i definitely don't wouldn't want to be conscious for a TEE...

 

[kraken]

Regarding the ease of the test, NOT, it felt uncomfortable and my throat still hurts 14 hours later and I was told that is to be expected. If you deco dive get the test, and then decide if you will quit that or have the procedure.

Yes, I was sedated, but not knocked out. It felt like I something stuck in my throat for 20 minutes, gaged a lot, at one point I wanted to pull the stupid tube out, felt like I was choking... wanted to scream. Is it the worst thing I have ever had done? nope, not even close to the hit. I would easily do the TEE (invasive one) every day for a week to not have gone through the hit... had nightmares for a few days after the hit. Couldn't walk straight for 6 months afterwards, my handwriting is still junk (oh, wait it was never that good to start with, but still worse than before).

The non-diving cardiologist who did the test recommended closure for the clot reason mentioned above.

Thanks everyone for the advice, I think I'm going to talk to the cardiologist and really understand the risks and see if my insurance will cover it. If the risks are acceptable I will probably have the procedure done.

Thanks for the link, I'll check it out later tonight

 

[boomx5]

Regarding the ease of the test, NOT, it felt uncomfortable and my throat still hurts 14 hours later and I was told that is to be expected. If you deco dive get the test, and then decide if you will quit that or have the procedure.

Yes, I was sedated, but not knocked out. It felt like I something stuck in my throat for 20 minutes, gaged a lot, at one point I wanted to pull the stupid tube out, felt like I was choking... wanted to scream. Is it the worst thing I have ever had done? nope, not even close to the hit. I would easily do the TEE (invasive one) every day for a week to not have gone through the hit... had nightmares for a few days after the hit. Couldn't walk straight for 6 months afterwards, my handwriting is still junk (oh, wait it was never that good to start with, but still worse than before).

The non-diving cardiologist who did the test recommended closure for the clot reason mentioned above.

Thanks everyone for the advice, I think I'm going to talk to the cardiologist and really understand the risks and see if my insurance will cover it. If the risks are acceptable I will probably have the procedure done.

Thanks for the link, I'll check it out later tonight

Is it possible to post a summary of the dive prior to the hit? Times, gas, deco gas deco profile and after dive activites? You can PM me if you want.

Thanks,

 

[Dr Deco]

Hello kraken:

PFO

In general, the simple presence of a PFO does not correlate well with the occurrence of DCS. If this were the case, a large percentage of divers would have a problem since about 25% of divers have a PFO with Valsalva and 10% have an open PFO without Valsalva.

It is not generally recommended, therefore, that one have it closed solely from the standpoint of scuba diving. Closure because of the reoccurrence of a stoke [as mention by the physician above] is a different matter and is separate from diving.

Ouch - Climbing the Stairs

I hope that many readers would have noted this comment about “climbing five flights of stairs.” This procedure is not only a generator of micronuclei in the legs, it causes straining and often times a Valsalva-like maneuver.

My oft-quoted injunction against heavy lifting, straining, and climbing following diving is because these can be factors in stress-assisted (hydrodynamic cavitation) nucleation.

Dr Deco :doctor:

 

[kraken]

Wish I knew about hte stairs ahead of time, I could hav paid someone to carry me in a royal coach :11:

I sat in on my gf's OW course after my accident, they only talked about DCS at a high level... I think the training agencies should be more up front, if you violate the rules it could hurt real bad..

Dave

 

[GoBlue!]

You did not have adequate sedation.

Jim