TEE, PFO, and "Undeserved Hits"

[Lopaka]

I know this has been thrashed out here many times, but this is my episode and I now think there are divers out there that should be requesting PFO screening.

I posted my recent episode with what could have been barotrauma or an "undeserved" DCS hit:
http://www.scubaboard.com/forums/diving-medicine/230884-2nd-ear-vertigo-episode-six-years.html

After numerous visits to an ENT (hearing is still mostly zip), a MRI was done. No tumors, but it did spot a couple stroke areas. Off to a neurologist. MRA to image blood vessels, harness to record heart for 24 hours, echo cardiogram, etc. Echo did show I have a "moderate " PFO, Hell, I could see a small stream of bubbles getting across without evern doing a valsalva.

Back to the neuro guy, who by now has my MRI films from six years ago. He is pissed, because the signs of the small stroke was there back then, and no one said anything about it. So, more tests. Check for blood clots and just this morning had the triple whammy TEE with the hose down the throat.

The TEE is not nearly as spooky as some make it out to be, and it gave the cardiologist a much better picture. He confirmed that the hole was open most of the time, which was why he did not bother to ask me to cough or anything.

Now I will be dealing with the cardio and neuro guys. I want this thing fixed if they can convince insurance to pay for fixing the hole as I have already had one or more small strokes.

The neuro does not want to make a pronouncement, but I think he is leaning toward a bubble causing the havoc in the brain, possibly in the region supplying blood to the nerves from the right ear. No evidence of clotting, veins looked ok for my age, the relation of this happening after diving, etc.

Now that I got this off my back, my point is anyone that has had the symptoms of sub-clinical DCS (fatigue, dizziness, whatever) should get their heart checked out and if need be, modify their diving. Might cost you out of pocket, but a full blown stroke could be in the works if you push it. Taking Plavix or other blood thinner and going conservative might be all that needs to be done to protect yourself.

I figure going deaf in one ear might be a blessing in disguise: might never know that I had had a couple small strokes otherwise.

Having a PFO does leave you more vulnerable to a stroke from loose plaque pieces, blood clots (fly long distance a lot?), not to mention diving. A massive stroke is a nasty thing, so it behooves anyone that might suspect having a PFO because of after-dive oddness to get checked out.

Sorry for the long post, but this is serious and I get the impression people are spooked by the tests that spot the PFO.

 

[DocVikingo]

Fascinating finds, Lopaka, and thanks for the update.

Please keep us posted as to how the repair issue unfolds.

Best of luck.

DocVikingo

 

[nereas]

...Taking Plavix or other blood thinner and going conservative might be all that needs to be done to protect yourself.

...

Aspirin is a good over-the-counter product as well.

Diving conservatively, with nitrox, and always shallower than 100 ft, together with a 1 min 50 ft stop, and egressing in 10 ft increments of 1 min each from there, has worked really well for my diving, combined with aspirin dosages before the dive. No more fatigue now after diving.

I do not have a PFO, but I believe that diving needs to be taught to be done much more conservatively than it now is.

Tech-deco diving introduces the notion of aspirin dosages together with nitrox decompression and slow ascents and egressions, with the first deep stop at 1/2 of the max depth of the dive, and 10 ft increments of ascent from there.

Unfortunately the basic training courses do not introduce this, yet. Maybe someday they will. For now, however, they all seem to think that the 3 min 15 ft stop is sufficient.

NAUI has begun to introduce the notion of the 50 ft 1 min stop for NDL diving, but as far as I know, NAUI is still alone in this.

Sorry to hear about your PFO and your hearing loss from the DCI hit. Thanks for sharing your experience. It reinforces what I have always suspected, that modern diving instruction is still too aggressive for all but a few, and I do not include myself in that few. I would prefer a more conservative approach for everyone.

 

[Saturation]

I am happy there is a path to resolution for you.

For a PFO its clear the size of the hole matters.

The type described here is concerning. I'm glad the workup is proceeding, and thank you for the details provided. However, the existing information about PFOs does not warrant a workup as extensive as yours for subclinical symptoms. However, from the vertigo described on 4/08 posted at SB, it could warrant a PFO investigation after elliciting any history that discounts barotrauma.

The TEE is not nearly as spooky as some make it out to be, and it gave the cardiologist a much better picture. He confirmed that the hole was open most of the time, which was why he did not bother to ask me to cough or anything.

 

[Lopaka]

Emphasis:

I didn't really mention it clearly, but at no time when these vertigo/hearing episodes happened did I have any other symptoms of DCS. Absolutely none.

Over the years of diving, I can only recall once when I had a feeling of unusual (for me) fatigue after deep, extended dives. That was probably sub-clinical DCS, and the only time I experienced it.

 

[Saturation]

Thanks for clarification.

I'm sorry you did not get some insight from your prior posts, but many of us are diving too between April and Dec of the season. Your case is a tad complicated.

Isolated vertigo after a dive, with or without hearing loss, one has to consider perilymph fistula or inner ear DCS, likely and less likely respectively. The succeeding evaluation described on this thread is appropriate, because the symptoms you describe are quite striking, and also very unclear what it could be.

An insidious increase in vertigo sometime after a dive is more consistent with IEDCS; most PLF occur almost right after surfacing or within the dive.The ear noises you describe are suggestive of PLF or other forms of middle ear trauma.

One simple possibility to assist the diagnosis is 02; it should do little for PLF and better for IEDCS. If the symptoms improved with 02 alone, it would be clear it was IEDCS and trigger a search for a PFO.

Emphasis:

I didn't really mention it clearly, but at no time when these vertigo/hearing episodes happened did I have any other symptoms of DCS. Absolutely none.

Over the years of diving, I can only recall once when I had a feeling of unusual (for me) fatigue after deep, extended dives. That was probably sub-clinical DCS, and the only time I experienced it.

 

[Lopaka]

FYI for anyone following this, my visit yesterday with a local cardiologist resulted in a prompt recommendation to get the hole closed. If there are any cardiologists on Oahu that do it, he did not refer to them, but to a mainland guy that comes to Hawaii several times a year to do this and pediatric work. Mucho qualified. Heck, if he is an expert at working on tiny little kid's hearts, my old clunker should be a piece of cake.

I am glad there was no dithering about blood thinners first, etc. Was told if I want to continue an active life and get back in the water, closing the hole was the thing to do. And I was told the insurance coverage was not an issue.

Should get this done mid-November. Turns out this is an outpatient procedure as well, go home the same day.

Whew, almost there.....

I am happy there is a path to resolution for you.

For a PFO its clear the size of the hole matters.

The type described here is concerning. I'm glad the workup is proceeding, and thank you for the details provided. However, the existing information about PFOs does not warrant a workup as extensive as yours for subclinical symptoms. However, from the vertigo described on 4/08 posted at SB, it could warrant a PFO investigation after elliciting any history that discounts barotrauma.

 

[Kathryn_Rob]

Maybe through you're experience you could offer me some advise? I have just had Inner Ear Decompression Sickness after a 5 day dive trip. Three dives a day - all modest dives. The doctors can not explain it, let alone that it was Inner Ear, which is extremely rare in recreational diving. My major symptom was severe dizziness.

I have suffered from unexplained mild dizziness since I started diving. Even when I did my training I got out of the pool and was dizzy for a few hours. It was put down to probable dehydration. No one had really been able to explain the mild dizziness from dives. I am still suffering from dizziness since the IEDCS. I am seeing an ENT today and have been advised by my doctor I should have a test for PFO. My concern with that is that they have told me they don't usually close them and if I have one I will no longer be able to dive. They also told me that if I don't have the test and do continue diving, although at higher risk for DCS the chances also are that I could do many future dives and never have a problem. Very confusing!.....