PFO closure

[kensuf]

My skin bends hit rate was about 10% of decompression dives pre-surgery. No matter how easy I took it.

The surgeon that closed my PFO said it was one of the smallest ones he ever closed.

I had tested negative on two TEE's (the one where they shove a probe down your throat), but positive on a TTE (the one where they do an external ultrasound). Supposedly, the TEE was the gold standard and the TTE was not supposed to be reliable, but my experience is the exact opposite of that. At least one well known CCR Instructor Trainer had similar experiences with testing negative on a TEE, but had a PFO closed.

I've done over 25 dives deeper than 220, probably over 50 deeper than 150', and well over 200 dives with mandatory staged deco since having the PFO closed 20 months ago. Only one problem, which was my own stupidity.

If I practice normal "post-deco safe procedures" I don't get bent now. But I did get a small belly hit after a 4 hour dive last August -- however, immediately upon surfacing (like literally the minute I surface) I humped a rebreather, two 85's, an 80, and a 40 a half-mile in the woods back to my car -- what I did would be considered pretty stupid in most people's books, but I only took a very minor belly bend.

I wrote all this up in an article.

Insurance -- my bill was around $90k for the surgery and all the tests. My out of pocket was somewhere between $4k and $8k, I really don't remember because I just kept making payments until it was done.

[oya]

I recently managed to sort my way through getting tested for one. This was after a bit of conversation with some of the big brains on this issue including a brief exchange I was very grateful to have with Dr. Ebersole AND despite DAN's official recommendation, "Don't bother." (OK, it's a little more nuanced than that, but if you're that curious about it you can go read the report yourself.)

I wanted the test because I felt that more information is always helpful. I dive a relatively liberal GF and I figured if I knew I had a hole I'd probably tighted my GF a little more, think more carefully about hydration on days when I might be rushed or hot, just generally be armed with a bit more knowledge about what's going on inside me.

So I kept asking my GP how to make it happen and he kept blowing me off, basically. Finally, during a yearly physical he ordered an EKG. The technician reported (in an incredibly disinterested voice), "There's no evidence of shunting."

I kept insisting that I needed a bubble contrast study. I think to shut me up he finally gave me a referral to a cardiologist.

The cardiologist listened patiently to my description of why I was asking for all this and (perhaps out of curiosity more than anything else) ordered a Trans-thoracic echocardiogram (as opposed to a trans-esophageal echo which is much more accurate but also requires sticking a pole down your throat). They didn't find anything.

I KEPT insisting that the bubble contrast study needed to be applied. The cardiologist said, "OK, well you've already had an echo... what I'm going to do is order a bubble contrast study for suspected neurological factors, that way there shouldn't be too many questions."

Suspected neurological factors indeed. I think that was a polite way of saying, "You're crazy for asking me these stupid questions, this is probably the safest way to get you out of my office."

So finally I went back and got the bubble study done.

Took several annual physicals worth of asking, and the navigation of needing the study ordered by a sympathetic cardiologist who knew just what to order and how to make it happen. All that said, I have no idea how much it would cost if it wasn't covered.

Aaaaaaand... it turns out I don't have a hole. So I can keep my GFs at 95/100!!! (not really.)

https://www.facebook.com/ccrdiver/vi...type=3&theater

[bigdave]

Real-world incidence of DCS is 4 / 10,000 dives.
Before the closure, I experienced skin bends 3 out of the last 8 dives, each time more severe than the previous. And likely pre-clinical DCS many more dives before that.
After the closure, no DCS symptoms (16 post-closure dives.) Having the PFO closed has allowed me to return to diving safely. That to me is a world of difference. Diving >> No Diving.

Fair enough for your case and Ken's.

I am just taken aback by the report of divers that have never had the bends, and go take the test which turns out positive, and then have the procedure done. The procedure is not risk free. It is low risk, but there is still risk.

The science is pretty poor even on the topic of PFOs and stroke risk. There have been trials, but the samples are small and poorly controlled. And misinformation abounds, as is usually the case.

I am glad it has worked out for you and Ken.

My cardiologist says I don't have a PFO, but that was a byproduct of him doing a TEE looking for a blood clot. Fortunately I was quite unconscious at the time.

David

[Pullnglide]

I haven't talked about it other than to my dive buddies and of course my buddy that was with me when it happened. I suffered a "underserved" hit March 15 of last year. Extreme numbness in both arms, shortness of breath and blurred vision. Spent 2 days in the hospital. It was ruled DCS but their was no definitive evidence. I may have been dehydrated and possible thermal stress but it just didn't make sense. I had an external ultrasound and it came back negative but I have scheduled an appointment with a cardiologist just to make sure. The dive was a river cave with an up and down profile with a considerable amount of depth variations. Depth average was probably @ 110', total dive time 169 mins with @ 60 mins of it being deco. I have since done several 200' dives and a couple 250'-300' also @ 50 90'+ cave dives with 120 to 180 min run times and I've had no other problems. There are a few variables that could possibly have caused the hit but I'm leaning towards either AGE, PE or a PFO could have been the culprit.

[MichelleC]

I have a question for you guys with the PFOs. I had an echocardiogram and it didn't show a PFO. However, I learned there are different types of tests, and the one I had was the simplest, and it might miss a smaller PFO. Do you guys have big honking PFOs, or are they tiny?

Did you have a bubble study done along with the echo? That is where they hook you up to an IV and inject agitated saline while taking the echo. If not, they very well could have missed the shunting (blood going the wrong way through the hole.)

I'd be curious, were you able to make insurance pay for it? If not, what was the cost?

Insurance covered. Total billed for diagnosis and closure was just under $60K.

[rddvet]

I'd be curious, were you able to make insurance pay for it? If not, what was the cost?

Not sure if you meant diagnostics or surgery. I had a hit last year. I had skin bends and mild cns symptoms I actually overlooked for 24 hours because I thought the dive was too simple for me to get bent. Obviously a dumb thought. I worried I had a pfo. About 6 months later I had heart palpitations (due to work stress) and went to a cardiologist. I requested a bubble study at the time of my echo. I had no issue with insurance paying for it. I know the bubble study wasn't fool proof and the cardiologist had experience with pfo's in divers and told me the test wasn't 100% accurate as well. He had an echo tech with significant experience with bubble studies do the echo. I tested negative, but know if I have any further issues I'll get a further work up.

[cavedivingwoman]

My experience was almost the same as rdduvet's, except I did not have episodes of DCS. 'Had a workup for stress-related palpitations, including ECHO. I requested a bubble study at the time of scan. It was negative. (Insurance did pay, but YMMV).

Talk to Dr Ebersole; he probably has the most extensive database on this topic.

[Sh0use]

I wrote an article about my experience and posted it on my diving articles page.

http://www.divegainesville.org/mendi...-did-about-it/

Great write up Ken. I enjoyed the read.

[kensuf]

My cardiologist says I don't have a PFO, but that was a byproduct of him doing a TEE looking for a blood clot. Fortunately I was quite unconscious at the time.

I tested negative on two TEE's but positive on a TTE (bubble study). The best guess is that while knocked out I wasn't able to perform a deep enough valsalva to open the PFO.