PFO - Diving with more conservatism, specifically CCR

Please register or login

Welcome to ScubaBoard, the world's largest scuba diving community. Registration is not required to read the forums, but we encourage you to join. Joining has its benefits and enables you to participate in the discussions.

Benefits of registering include

  • Ability to post and comment on topics and discussions.
  • A Free photo gallery to share your dive photos with the world.
  • You can make this box go away

Joining is quick and easy. Log in or Register now!

To the OP:
I'm not going to go far into the PFO stuff or answer all of your questions because I had mine fixed and you want answers from people without them fixed. But I didn't have it fixed until after I was already diving CCR. I got similar symptoms on CCR as I did in OC. I can not say if the hits were more or less frequent because I dove OC much longer with a pfo than on ccr.
I understand the idea that maybe a CCR will help, but at the end of the day if you have a pfo (small or large) you could have a bubble go to your brain and kill or paralyze you. Think of your dive buddy, your family, and your friends. Fixing it makes the most sense.
I had Dr Ebersole fix mine and it was an excellent experience and the best time and money I've ever put towards my diving career.

Even if a CCR gets you bent a little less, you may regret it when it doesn't and you're left a drooling vegetable.
 
Not exactly your question but after several skin hits (no chamber rides) I had a study done that showed a PFO. Could not find a cardiac surgeon that wanted to do my surgery. This was about 10 years ago (by the way-I also have migraines with aura).

So I considered CCR but instead went with Advanced Nitox and starting diving on highly conservative algorithms using 100% at my safety stops on my more aggressive dives in Florida. I had been interested in tech diving and was currently pursuing cave. But still having problems so a few years after finding the PFO I tried the surgical repair route again. After making my case the surgeon agreed but of course he wanted his own study. This one did not show the opening (it was a TEE and I was sedated). So once again surgery was not an option for me. Thus ending cave and tech.
Go see Ebersole. The reason I went years getting bent was the first Cardiologist couldn't find it. Mind you like with most cardiologists, the bubble study was done by a nurse and an ultrasonographer with no cardiologist around. They didn't see it and told me something else was bending me. I did all sorts of stuff such as changing GFs and how I dive. It helped, but didn't stop the issue. I went to see Dr Ebersole and he found it. Unlike the first cardiologist he was there for the bubble study. Initially they didn't see it, but right at the end of the study it became obvious. It appeared to be a small pfo, but when the amplatzer was placed it seems it was much bigger than could be visualized on ultrasound.
 
Thanks for the replies so far.

As mentioned previously, I don't want this to turn into another topic discussing PFOs - those topics already exist on ScubaBoard.

If you are all curious about my symptoms - it's mostly been feeling tired / ill after diving, and more recently aching joints. I have had an issue with what I can only describe as hissing from deep in my head at the back, not quite the same as tinnitus, however this might have been down to a previous middle ear infection progressing to inner ear (we aren't sure). I don't get migraines, or skin marbling etc.

With regards to the bubble study, if any experienced cardiologists / hyperbaric doctors on here would like to reach out to me in private, I have reports / ultrasound videos etc of which I'm happy to have additional opinions.
 
I've spoken to the odd member (and experts) about this already via PM, but wanted to ask a wider audience about their experiences as I couldn't see this specific question being asked. After visiting the chamber multiple times with DCS issues, I finally carried out a bubble study the other day where a PFO was discovered with R/L shunt. I'm aware of the fact that it's not guaranteed to be causing issues with my diving - however the PFO is not the subject of the question I would like to ask. I'm already diving conservatively in line with DANs recommendations, EN32 is the highest nitrox we have available here. Again, this isn't the subject of discussion however.

I'm looking to hear from members who have been diagnosed with a PFO (after having had DCS issues), and decided not to opt for surgery, but instead switched to CCR in order to run a high setpoint (say 1.3) and hence reduce Nitrogen saturation / improve tissue off gassing gradients, in the hope of preventing bubble formation. For now I'm talking within recreational limits, but mixed gas stories would be interesting.

In particular, I'm interested in:
The size of your PFO
The symptoms you were experiencing before switching to CCR
How switching to CCR (hopefully) reduced future instances of DCS
Your end Surface GF from CCR dives
Symptom-free average dive times (CCR)
What setpoint you run for the majority of the dives
Your ascent rate for the last 6m (20ft)

Please remember that I don't want this topic to turn into a discussion about PFOs. I'd simply like to hear from people who have taken the CCR route due to previous issues with PFO on open circuit and had success with symptom free diving. I'm also not looking for medical advice, nor will I base any decisions on information we talk about here.

Scuba Lad
Just had a chat about this in a webinar with the Norwegian Baromedical Association last night. Two CCR divers with a history of DCS hits (with no PFO proven) shared their own conservative rules for diving to achieve symptom-free diving. I know it's not directly applicable since PFO was not proven in these cases (one diver with a negative test and one diver with no testing done), but maybe it would be helpful?

Previous symptoms: skin bends, lymphatic bends, no neurological hits as far as I know

Some key points for avoiding DCS incidents for these divers:
- Ascent speed: 1 minute per meter from 6m
- O2/high PPO2 on 6m stop
- Reduced physical strain immediately after diving
- GF 40/60 for one diver with usual Surfacing GF of <50% after the last slow ascent, other diver at 30/70

Another thing to note was that for one diver it was long dives within recreational depths that lead to symptoms, not deeper mixed gas dives with adequate deco.

PS
Don't know if @Imla has anything to add here?
 
Thanks for the replies so far.

As mentioned previously, I don't want this to turn into another topic discussing PFOs - those topics already exist on ScubaBoard.

If you are all curious about my symptoms - it's mostly been feeling tired / ill after diving, and more recently aching joints. I have had an issue with what I can only describe as hissing from deep in my head at the back, not quite the same as tinnitus, however this might have been down to a previous middle ear infection progressing to inner ear (we aren't sure). I don't get migraines, or skin marbling etc.

With regards to the bubble study, if any experienced cardiologists / hyperbaric doctors on here would like to reach out to me in private, I have reports / ultrasound videos etc of which I'm happy to have additional opinions.
Just so it's out there, PFO is associated with severe, sudden-onset neurological DCS, inner ear DCS, and cutis marmorata. The hissing could conceivably be attributable to inner ear DCS but it sounds like you and your providers are leaning more toward another mechanism. At what point in your dives did the hissing start, and did it resolve with hyperbaric oxygen treatment? You mentioned that you don't get marbling/cutis. Have you ever had severe neurological DCS symptoms?

Best regards,
DDM
 
Just had a chat about this in a webinar with the Norwegian Baromedical Association last night. Two CCR divers with a history of DCS hits (with no PFO proven) shared their own conservative rules for diving to achieve symptom-free diving. I know it's not directly applicable since PFO was not proven in these cases (one diver with a negative test and one diver with no testing done), but maybe it would be helpful?

Previous symptoms: skin bends, lymphatic bends, no neurological hits as far as I know

Some key points for avoiding DCS incidents for these divers:
- Ascent speed: 1 minute per meter from 6m
- O2/high PPO2 on 6m stop
- Reduced physical strain immediately after diving
- GF 40/60 for one diver with usual Surfacing GF of <50% after the last slow ascent, other diver at 30/70

Another thing to note was that for one diver it was long dives within recreational depths that lead to symptoms, not deeper mixed gas dives with adequate deco.

PS
Don't know if @Imla has anything to add here?
Not sure I recognize those cases. Assume I am "the other diver". I dive both OC and CCR, and didn't cross to CCR because of skin-bends, I mostly crossed because of deeper wrecks and sick of being cold. I also usually dive 40/80.
However... tricks to minimise gas tissue tension. Slow shallow ascent speed (IE NEVER more than 1m/min), well hydrated with the use of a pee-valve, focus on retaining normal body temperature and use of heated undergarments if available, avoid physical strain immediately after (decompression) dives, avoid valsalva on ascent.
I do firmly believe that a slow shallow ascent rate is the single most beneficial change I made to my diving.
 
Not sure I recognize those cases. Assume I am "the other diver". I dive both OC and CCR, and didn't cross to CCR because of skin-bends, I mostly crossed because of deeper wrecks and sick of being cold. I also usually dive 40/80.
However... tricks to minimise gas tissue tension. Slow shallow ascent speed (IE NEVER more than 1m/min), well hydrated with the use of a pee-valve, focus on retaining normal body temperature and use of heated undergarments if available, avoid physical strain immediately after (decompression) dives, avoid valsalva on ascent.
I do firmly believe that a slow shallow ascent rate is the single most beneficial change I made to my diving.
Yeah, I guess I fumbled the GF in your case, my memory is not what it used to be... And like I said not directly related, but I thought there was some parallel, at least in terms of ascent speed and adding conservatism after DCS incidents.
 
I have to agree at least with regard to 100% deco gas for recreational dives. I am not sure it did much. And there is no proof as DDM pointed out that my skin reactions (even less so the lymphedema) are even related to the PFO.

A combination of depth and time seems the deciding factor in most cases. Florida/Grand Cayman/ Cozumel all with deeper dives to 4 to 5 minute shallow safety stops. One episode in Cozumel occurred after spending a very hot afternoon strolling through town.

Never once in Bonaire despite some deepish dives and 3 to 4 dives a day over a week or more. The difference? The last half of all my dives are spend at 30 or less.

I think the fact that the rashes (except perhaps the first/worst episode) never had any neurological symptoms and I never sought medical care so no documentation plays part of the role in my trouble getting it closed. Plus no proof it is the cause of my symptoms.
 
Thanks for the replies everyone.

Just so it's out there, PFO is associated with severe, sudden-onset neurological DCS, inner ear DCS, and cutis marmorata. The hissing could conceivably be attributable to inner ear DCS but it sounds like you and your providers are leaning more toward another mechanism. At what point in your dives did the hissing start, and did it resolve with hyperbaric oxygen treatment? You mentioned that you don't get marbling/cutis. Have you ever had severe neurological DCS symptoms?

Best regards,
DDM
I had also considered that the symptoms of PFO were usually reported either on ascent, or very shortly after surfacing. I'm also aware that it's not an exact science, so I'm keeping an open mind in that regards.

Usually, I'm fine on the dive, but I start to feel unwell about 2-3 hours after surfacing. The best way to describe the unwell feeling as that it is like I've been breathing car exhaust fumes or something. I'd suspected this was down to bad / contaminated tanks at first, however for the last 6 months or so, I've been renting / filling my tanks from a local reputable technical dive shop, and I test every tank I dive with the CO tester (ensuring it reads 0). My regulators are also clean after inspection (and actually only have about 50 dives on them too).

At one point, after continuing to dive despite feeling unwell, although only to depths of about 8m (26ft), the hissing got pretty loud and I developed minor muscle twitching on the right side of my face and minor vision wobble on the same side. The vision wobble would clear up after a few days of stopping diving, but the hissing would persist for much longer. I think the facial stuff could possibly be described as Hemifacial spasms, and I did have an issue with an ear infection about 12 months ago which initially went undiagnosed, but was later confirmed when I showed photos retrospectively to another ENT doc (after I had decided to try decongestants / corticosteroid treatment). Over the past 6 months, multiple ENT docs have looked into my ear canal and explained they can't see any issues. It's possible the original infection might have progressed to inner ear - I've not been diagnosed with anything however.

As I write this post, I'm at 2 weeks post Table 5 chamber ride (which was to clear up Type 1 DCS joint / MSK pain). The hissing has just yesterday, reduced to a point where I can only just hear it. I'm undecided if the chamber rides help with this. It seems to fluctuate somewhat and I've noticed stress can sometimes make it a little worse, or sometimes if I wake up in the night it can be pretty loud. Right now I'm about to try some "exercise with oxygen" therapy, as it's reported to have good results with regards to general healing. Note that I am convinced this is not the same as Tinnitus, I'm familiar with that sound / sensation. I've noticed it maybe once a year or so for most of my life, for about 10 seconds and then it stops. That can be defined as ringing and it certainly feels like it originates further out in the ear.

A potential plan this time round is to wait until the hissing completely clears before diving (In the past it didn't really clear up, despite waiting 6-8 weeks), regardless of if the hyperbaric doc clears me to dive in my evaluation visit in 2 weeks time from now. Then, I may opt to try a CCR dive with my local instructor again, this time with a high setpoint - and closely note how I feel afterwards over the coming days, without any other diving. My instructor also has the Odive system (which we forgot to use last time I did the "try CCR") so I'm also hoping this might give me some insight into my physiology. If I still have problems with this dive, I will probably give up. I'm also still waiting for opinions on the severity of my PFO, and if I would need to carry out TEE (mine was TTE) or if the videos I have from the TTE are a good enough indication of severity.
Not sure I recognize those cases. Assume I am "the other diver". I dive both OC and CCR, and didn't cross to CCR because of skin-bends, I mostly crossed because of deeper wrecks and sick of being cold. I also usually dive 40/80.
However... tricks to minimise gas tissue tension. Slow shallow ascent speed (IE NEVER more than 1m/min), well hydrated with the use of a pee-valve, focus on retaining normal body temperature and use of heated undergarments if available, avoid physical strain immediately after (decompression) dives, avoid valsalva on ascent.
I do firmly believe that a slow shallow ascent rate is the single most beneficial change I made to my diving.
With regards to the ascent speed, I just want to make sure I understand correctly. Over the entire dive - you would never exceed 1m / min? Although this seems to be contrary to the current decompression thinking (fairly quick ascents at deeper depths but progressively slower the shallower you get) - I had also considered applying the 1m / min rule to the entire dive. I'm certainly at 1m/min from 6m depth, but for depths below about 10m, I've only been sticking within about 4-8m per minute. If this turns out to help, I may speak to Shearwater and ask them about implementing a custom ascent speed alert.
 
Issue #1: Having the PFO closed is cheaper than a CCR. Even with the USA's backwards healthcare system.
Depending on your insurance provider, if you don't have a history of ischemic stroke, even with multiple occurrences of DCS...it will be a self-pay procedure. Just shy of $25,000 for me.
 

Back
Top Bottom