2 DCS hits and a PFO closure

[kensuf]

If I remember correctly you have not had another incident since the closure. From what I understand my PFO was large. I don't know how it compares to most the Dr. sees as far as size goes but I know the same size device was used as used in the majority of closures.

Yup, that's true.

Pre-surgery -- between 2011 when I resumed cave diving and 2014 when I had the closure, I averaged one skin hit a month, frequently on ~60-70 minute dives and had one massive type 2 after a 4 hour dive in Indian and another very minor neurological hit on a 3 hour dive in Indian.

Post-surgery -- in the 27 months since resumption of diving post-surgery, one skin hit, zero other hits. Several dives in 6-7 hour range, including 3 hour bottom times at 150' and 90 minute bottom times at 250'.

The one skin hit came during a 4 hour dive (max depth 120') on a hot summer day (mid-August), we got a late start and I was drenched in sweat before hitting the water and was shivering during deco. Within two minutes of surfacing I hauled all of my gear out of the water (no surface stop) and humped it a half-mile back to where my car was parked. Most people I know would have gotten some sort of hit from doing that.

 

[kensuf]

I should add, while it appears that surgery helped me, those results may not be typical.

 

[Pullnglide]

I should add, while it appears that surgery helped me, those results may not be typical.

Very true.

 

[Duke Dive Medicine]

Tell this to the OP @Pullnglide :
@debersole and @Duke Dive Medicine :
In making the diagnosis of the cause of illness in an individual case, calculations of probability have no meaning. The pertinent question is whether the disease [or disorder] is present or not. Whether it is rare or common does not change the odds in a single patient. ... If the diagnosis can be made on the basis of specific criteria, then these criteria are either fulfilled or not fulfilled. — [A. McGehee Harvey, James Bordley II, Jeremiah Barondess]

If you knowingly undertake decompression diving with a PFO, then you are at least aware of what the potential risks are. Take extra precautions like plannng your deco profiles very conservatively, and making sure there is immediate access to a Recompression Chamber nearby -or else give up technical diving altogether especially if there is no Chamber Facility nearby (i.e. North Florida Cave Country). . .

Ditto @mattia_v re: your quote. It's irrelevant in this situation because it's talking about the "cause of illness". PFO does not cause DCS. It is associated with DCS, and there is a large difference. It makes logical sense that venous gas emboli can be arterialized through it and cause symptoms, but for all we really know (and I've heard this debated by people with far better minds than mine), there's another as-yet-undiscovered factor that increases the risk of DCS in divers with PFO that has nothing to do with the PFO. This may change as researchers like Drs. Ebersole and Denoble accumulate data on divers who've had PFO closure.

Again, (merging your other post here) you are assuming that TCD is diagnostic for PFO and you've just had an interventional cardiologist/tech diver/rebreather diver who does PFO research tell you that it isn't. I don't speak for North Florida cave divers, but I don't imagine too many would give up tech diving if they found out through a TCD screening that they had a right-to-left shunt.

I will at this point tip my hat to you and wish you a happy and safe New Year, and let the future readers of this thread do what they will with the information contained here.

Best regards,
DDM

 

[Anny Art]

Well I actually think that after having my pfo closed in March last year it has made no difference at all. I still get skin bends on a regular basis, with neurological side effects that can take about 5 days to subside, despite being conservative.
You know there's something wrong but do nothing about it for years as a normal GP doesn't encounter these problems as they don't seem to be a problem in day to day living. Blimey I could run 15 miles and cycle 60 before the closure. And still can now.
Well after getting bend after bend my decision was to pay private for a bubble echo scan which was of course showed a large PFO. I was told that I could carry on diving but limit myself to 15meter dives with extra conservative settings. This made very little difference to getting bent.
Decision..... Stop diving till the PFO had been closed before I had done some irreversible damage to myself.
6 months later job done hole sealed with very little disruption and thought that I would give it another 3 months to heal. The surgeon said that I could resume diving straight away.
3 months later great no bends for the 1st 12 dives to a maximum depth of 15 meters, hooray problem solved, but then I got bent and have been on a regular basis ever since... Just like before when my normal diving resumed but with added conservatism. Eg longer safety/deco stops and conservative settings on computers.

Maybe there is something else that makes certain people more susceptible to getting the bends other than PFO's?

 

[Pullnglide]

Well I actually think that after having my pfo closed in March last year it has made no difference at all. I still get skin bends on a regular basis, with neurological side effects that can take about 5 days to subside, despite being conservative.
You know there's something wrong but do nothing about it for years as a normal GP doesn't encounter these problems as they don't seem to be a problem in day to day living. Blimey I could run 15 miles and cycle 60 before the closure. And still can now.
Well after getting bend after bend my decision was to pay private for a bubble echo scan which was of course showed a large PFO. I was told that I could carry on diving but limit myself to 15meter dives with extra conservative settings. This made very little difference to getting bent.
Decision..... Stop diving till the PFO had been closed before I had done some irreversible damage to myself.
6 months later job done hole sealed with very little disruption and thought that I would give it another 3 months to heal. The surgeon said that I could resume diving straight away.
3 months later great no bends for the 1st 12 dives to a maximum depth of 15 meters, hooray problem solved, but then I got bent and have been on a regular basis ever since... Just like before when my normal diving resumed but with added conservatism. Eg longer safety/deco stops and conservative settings on computers.

Maybe there is something else that makes certain people more susceptible to getting the bends other than PFO's?

As previously stated by Dr. Ebersole and DDM, it's not the PFO causing the DCS. Hopefully I'm saying this right but it is due to the bubble load and especially for a decompression diver the off gassing is inefficient as the oxygen cannot oxygenate the blood in order to reduce the bubble load as it should. I think that's right. If your getting bent regularly at 15m I would first of all quit diving altogether until you can figure out what's going on. I'm no Hyperbaric Physician but I can confidently say that having DCS symptoms as many times as you've had and not seeking medical treatment that your causing severe and possibly irreparable damage to your body. Having DCS symptoms on a regular basis and just letting them wear off over a few days is not the way to handle it imo.

 

[Dr. Doug Ebersole]

If an individual diver wishes to pay out of pocket for a transthoracic or transesophageal echo to see if they have a PFO because it will change their behavior -- not pursuing technical diving, diving very conservatively, etc -- that is REASONABLE. However, it would have to be paid for out of pocket as no insurance company is going to pay for a diver's "screening" echocardiogram. Also, you have to remember that probably 25% of technical divers out there have an undiagnosed PFO and have never had a problem despite long deep dives and many technical divers who have had severe decompression sickness don't have a PFO. In my opinion, an asymptomatic diver would just be opening Pandora's Box by discovering something and really not knowing what to do with the information. As an example, I teach CCR trimix and regularly make long deep dives. I see lots of people who have had DCS and had PFOs closed. However, personally, I've never been tested for a PFO because I've been fortunate enough not to ever have suffered DCS. If I were to have multiple episodes of "unexpected" DCS, especially if neurologic, I'd get myself tested.

KenSuf -- That is very odd in that a TEE is MUCH better at seeing the interatrial septum and much better at imaging the bubbles in the left atrium than a TTE. However, these flaps are dynamic and volume status, etc can cause them to be more likely to shunt on one day versus another I suppose. There is also a great deal of operator dependency. You really need to look for shunting at rest, with Valsalva, "sniffing", ...... before saying there is not a PFO present. That is not usually the case in a "standard" TEE for other diagnoses, but should be when looking for PFO in the setting of DCS.

Derek -- Yes, your PFO was "large". Injection of agitated saline immediately completely filled your left atrium and at the time of the procedure the blood flow through your heart immediately directed the guidewire across the PFO with no manipulation by me whatsoever. That's why we were done in about 10-15 minutes.

 

[uncfnp]

KenSuf -- That is very odd in that a TEE is MUCH better at seeing the interatrial septum and much better at imaging the bubbles in the left atrium than a TTE. However, these flaps are dynamic and volume status, etc can cause them to be more likely to shunt on one day versus another I suppose. There is also a great deal of operator dependency. You really need to look for shunting at rest, with Valsalva, "sniffing", ...... before saying there is not a PFO present. That is not usually the case in a "standard" TEE for other diagnoses, but should be when looking for PFO in the setting of DCS.

FWIW I have had a similar experience with TTE vs TEE. My first test was the TTE and demonstrated a PFO with no valsalva needed. About 2 years later a TEE did not find a PFO.

 

[Duke Dive Medicine]

Well I actually think that after having my pfo closed in March last year it has made no difference at all. I still get skin bends on a regular basis, with neurological side effects that can take about 5 days to subside, despite being conservative.
You know there's something wrong but do nothing about it for years as a normal GP doesn't encounter these problems as they don't seem to be a problem in day to day living. Blimey I could run 15 miles and cycle 60 before the closure. And still can now.
Well after getting bend after bend my decision was to pay private for a bubble echo scan which was of course showed a large PFO. I was told that I could carry on diving but limit myself to 15meter dives with extra conservative settings. This made very little difference to getting bent.
Decision..... Stop diving till the PFO had been closed before I had done some irreversible damage to myself.
6 months later job done hole sealed with very little disruption and thought that I would give it another 3 months to heal. The surgeon said that I could resume diving straight away.
3 months later great no bends for the 1st 12 dives to a maximum depth of 15 meters, hooray problem solved, but then I got bent and have been on a regular basis ever since... Just like before when my normal diving resumed but with added conservatism. Eg longer safety/deco stops and conservative settings on computers.

Maybe there is something else that makes certain people more susceptible to getting the bends other than PFO's?

Anny Art, are you saying that you're getting "skin bends" from diving to a depth of 15 meters? Is the photo that you posted representative of that?

Best regards,
DDM

 

[Anny Art]

Yup, that's true.

Pre-surgery -- between 2011 when I resumed cave diving and 2014 when I had the closure, I averaged one skin hit a month, frequently on ~60-70 minute dives and had one massive type 2 after a 4 hour dive in Indian and another very minor neurological hit on a 3 hour dive in Indian.

Post-surgery -- in the 27 months since resumption of diving post-surgery, one skin hit, zero other hits. Several dives in 6-7 hour range, including 3 hour bottom times at 150' and 90 minute bottom times at 250'.

The one skin hit came during a 4 hour dive (max depth 120') on a hot summer day (mid-August), we got a late start and I was drenched in sweat before hitting the water and was shivering during deco. Within two minutes of surfacing I hauled all of my gear out of the water (no surface stop) and humped it a half-mile back to where my car was parked. Most people I know would have gotten some sort of hit from doing that.