What is the current thinking on having a PFO closed to reduce the risk of DCS? I have been diving for 35 years, primarily in shallow water, with 60 dives in the last 18 months after a long break. I've never had DCS but expect my diving to increase. I have had < 5 migraines or TIAs in that time, which is how I know about the PFO, so prevention of those is a consideration as well, but opinions and guidelines on closures seem to change with time and specialty.
Question PFO Closure advice
- Thread starter Rokky
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Capt Jim Wyatt
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These two guys will be able to answer your question better than anyone else here. IMO
@rsingler
These two guys will be able to answer your question better than anyone else here. IMO
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Call and Consult with UCLA Health here in Los Angeles.
As an active Tech Diver frequently diving mandatory decompression profiles, I had my Transcranial Doppler Scan Screening for PFO (negative result from 2009) at the UCLA Medical Center:
www.uclahealth.org
As an active Tech Diver frequently diving mandatory decompression profiles, I had my Transcranial Doppler Scan Screening for PFO (negative result from 2009) at the UCLA Medical Center:
Patent foramen ovale: Heart ‘tunnel’ linked to stroke, migraines
Up to a quarter of the population has this passageway between the heart’s upper chambers.
www.uclahealth.org
In a diver with an asymptomatic PFO, the statistical risk of closure-related complications is higher than that of DCS, so we generally advise against closure and instead recommend diving conservatively, e.g. diving nitrox and using the air setting on the computer and not diving to the edge of the no-stop limit.
I'm reading that your health care team has linked your migraines and TIAs to your PFO. If so, this suggests a clinically significant shunt. Depending on how you define shallow and what your future diving plans are, it seems reasonable to explore closure in your case along with a cardiac and hematologic workup if your care team thinks you're shunting microembooli (small clots), if you haven't already had that done. Where in Utah are you?
Also @Dr. Doug Ebersole - would be interested to hear your perspective.
Best regards,
DDM
SpaceX Aquanaut
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Close to where you’re at and another resource (or to have the procedure):
healthcare.utah.edu
Patent Foramen Ovale (PFO)
A patent foramen ovale (PFO) is a hole in the heart that doesn’t close as expected after birth. Most PFOs don’t require treatment.
Capt Jim Wyatt
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@Dr. Doug Ebersole for sure.
I agree completely. I would NOT recommend PFO closure for an asymptomatic diver just because a PFO was found on echo imaging. Additionally, I would only recommend closure for (1) cryptogenic stroke/TIA (stroke with no other obvious source) or for (2) recurrent decompression sickness of the types associated with PFO which would be cerebral (stroke like symptoms), spinal (paralysis, urinary retention), inner ear (vertigo), and cutaneous (skin bends) despite diving "conservatively". Conservative diving practices would include diving only 1-2 dives per day, no dives greater than 100 fsw, no decompression diving, diving nitrox on air profiles, performing long safety stops (say, 5-7 minutes, rather than the typical 3 minutes), and doing no strenuous exercise for several hours after diving. The issue with DCS is the inert gas load not the PFO per se. The diving practices above limit inert gas loading and, thus, will decrease the risk of DCS whether or not a PFO is present. Obviously, there are exceptions to this recommendation such as people who dive professionally and cannot follow these recommendations due to their occupation or technical divers.
So, I would not see PFO closure simply to decrease your risk for DCS as a good idea as you have been asymptomatic diving. As was pointed out, while PFO is a very safe procedure, it has a complication rate higher than risk of DCS in asymptomatic recreational divers with PFO. The best guess we can make is that having a PFO increases the risk of DCS by about 5 fold. The risk of DCS in recreational diving is around 2 episodes per 10,000 dives. Therefore, a recreational diver with a PFO has about a 1 in 1000 dives risk of having DCS. The complication rate for PFO closure is very low, but is higher than 1 in 1000!
On the other hand, PFO closure is known to improve migraine headaches though, in the USA, migraine headache is not an approved indication for PFO closure. However, you did mention suffering TIAs. If your neurologist feels you were having cryptogenic TIAs and you are in the approved age group of 18-65 years, PFO closure may be indicated.There is a scoring system called a ROPE score. Scores of 7 or higher are felt to suggest PFO closure would be of benefit. Your score can be calculated by the following:
No history of hypertension = 1 point
No history of diabetes mellitus = 1 point
No history of stroke/TIA = 1 point
Nonsmoker = 1 point
Age in years
18-29 = 5 points
30-39 = 4 points
40-49 = 3 points
50-59 = 2 points
60-69 = 1 point
70 or greater = no points
I hope that is helpful.
Douglas Ebersole,MD
Cardiology Consultant, Divers Alert Network
Chief, Structural Heart Program, Lakeland Regional Health
Interventional Cardiologist, Watson Clinic LLP
SpaceX Aquanaut
Contributor
Patent Foramen Ovale (PFO)
Patent foramen ovale is a heart defect that may contribute to a higher risk of DCI. Read about several options for managing the condition while diving.
dan.org
The effectiveness of risk mitigation interventions in divers with persistent (patent) foramen ovale - PubMed
PFO closure should be considered on an individual basis. In particular, individuals who are healthy, have a significant DCS burden, a large PFO or seek to pursue advanced diving may benefit from closure.
pubmed.ncbi.nlm.nih.gov
My motivation, the simple issues, and final non-equivocating argument -from the Point-of-View as an active Tech Diver:
The point to be aware of is- there's a dilemma in considering the low statistical incidence of DCI in the general diver population versus the high morbid consequences of suffering a type II DCS/AGE in specialized technical decompression diving, with a PFO as a possible contributing -or "associated" condition. So you have a low probability event vs a severe health & welfare outcome if you unluckily suffered such an occurrence.
It may seem like a fallacy apples & oranges comparison, but it actually turns out to be a continuum of personal risk management: In other words, the chances are low of contracting DCI in regular NDL recreational diving, but on the other hand, would you do 3hr runtime, saw-tooth profile, decompression cave dives in hypothermic stress if you knew you had an underlying PFO condition to begin with?
Now together with OP Patient’s History of TIA/Migraine:
Tough Choice -but I would recommend further in-person consultation with a local Cardiologist there in Utah- leaning toward having the PFO procedure done. . .
Lastly, the best practical advice in light of the OP’s desire to dive in the meantime, I would strongly advise diving near a location that has a staffed Hyperbaric Chamber 24/7/365, like we do here in offshore Southern California:
USC Catalina Hyperbaric Chamber - USC Catalina Hyperbaric Chamber
USC Catalina Hyperbaric Chamber
dornsife.usc.edu
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