Possible PFO- would you still get certified? with what precautions?

[drbill]

I certainly understand where D_B is coming from since we are both aware of the same sad incident. However, I am relieved to read Doug's advice regarding the treatment of PFOs.

I used to push the envelope quite hard in my diving, although in the past two years I've dived far more conservatively (I no longer have the reason for pushing the envelope that I had two years ago). My body is an older model and I do try to treat it as conservatively as I can by being well hydrated, well rested and avoiding alcohol the day before and of a dive.

 

[Scubagolf]

There is an excellent very recent (June 2010) interview with Dr. Ebersole about this very topic on the podcast PODDIVER RADIO The ScubaCast, Episode 110.

http://itunes.apple.com/us/podcast/pod-diver-radio-2010/id270165444

 

[drbill]

As Lynne (LCF) pointed out in a similar thread, Doug makes his living dealing with PFOs and if he is recommending against treatment it is obviously objective advice he is giving. Some day I'll make it back to Florida so we can actually meet and dive together, Doug. Really appreciate your expert information on this subject (and others).

 

[limeyx]

As an interventional cardiologist, I close PFOs for a living. I definitely would NOT be checked for a PFO just because you are thinking about getting certified. And I practice what I preach. I am a CCR trimix diver and routinely do decompression dives to 300 fsw. I have never been checked for a PFO. Now if I ever have recurrent "undeserved" DCS I'll probably get a TEE.


Doug

Doug,

what are your thoughts on the TCD test for PFO ?
Nick

 

[Dr. Doug Ebersole]

Thanks, Bill. I hope to dive with you either here in Florida or out in Catalina some day!

Nick -- TCD is a very sensitive test for detecting a shunt and as so is a reasonable screening tool, but it doesn't localize where the shunt is occurring. Bubbles are injected into a peripheral vein. Those bubbles should be cleared by the lungs and not reach the arterial circulation. You then doppler over the artery and if you hear signals from bubbles you know that the bubbles crossed over -- possibly from a PFO or possibly from an intrapulmonary shunt. IMHO, a TEE is a much better test as it is equally sensitive and much more specific for PFO. Additionally, you can identify the size of the PFO and if there is an associated atrial septal aneurysm which is a high risk marker for stroke. Hope this helps.

Doug

 

[limeyx]

Thanks, Bill. I hope to dive with you either here in Florida or out in Catalina some day!

Nick -- TCD is a very sensitive test for detecting a shunt and as so is a reasonable screening tool, but it doesn't localize where the shunt is occurring. Bubbles are injected into a peripheral vein. Those bubbles should be cleared by the lungs and not reach the arterial circulation. You then doppler over the artery and if you hear signals from bubbles you know that the bubbles crossed over -- possibly from a PFO or possibly from an intrapulmonary shunt. IMHO, a TEE is a much better test as it is equally sensitive and much more specific for PFO. Additionally, you can identify the size of the PFO and if there is an associated atrial septal aneurysm which is a high risk marker for stroke. Hope this helps.

Doug

Thanks Doug. Very informative. I chose to have the TCD a few years ago because despite it being "anecdotal" I have heard of too many people taking severe DCS hits and having PFO's (yes only low numbers but enough for me)

I understand that just because there was no evidence of a shunt at that point in time, that doesn't mean one wont develop or somehow be missed, and that there are other major factors in DCS risk that may be even more important.

 

[Dr. Doug Ebersole]

You are right that a single negative TCD is not a definitive answer that you don't have a PFO, but it is quite reassuring.

 

[SDiverJim]

I have a PFO but I'm lucky enough not to have a Hx of migraines. My cardiologist has assured my there is nothing to be concerned about "in my case". I agree with the others, hold of on certification and get more testing done. Maybe even by a specialist with diving knowledge to be sure. Call DAN for a recommendation.

 

[SLAMdiver]

With the advent of Transcranial Doppler (TCD) and the even newer transcatheter (nonsurgical) procedure of PFO closure, the risks of open heart surgery are even further removed from this equation. That said, the critical decision to undergo any invasive procedure is not one to take lightly, and the question becomes risk Vs. benefit. What I see missing from the discussion, is the information that the TCD is capable of "grading" a PFO on a 1 to 5 scale, with closure only recommended for grade 4 and 5 in the clinical setting. Historically, PFO closure was only accredited by the FDA under a humanitarian exemption to the normal validation process and could only be considered after a second embolic stroke, often after considerable function was lost. The procedure has been so widely accepted in the medical community that full accreditation has be given theis procedure and is routinely being performed in roughly 100 centers natiowide and internationally. As a diver, with a higher than average potential for a widely (4 or 5) patent PFO to precipitate embolic events, my thought turns to presevation of function and avoidance of a potentially catastrophic event. I would suggest that the TCD is a small inconvenience to assess the potential for a life altering outcome. A google search of PFO will yield a plethora of information (that how I found Scubaboard) about the condition and a number of links to physicians and other can can provide personalized recommendations.