PFO closure/insurance coverage

[michael-fisch]

Thank you all for the response! Is the fact that the TTE was negative and TEE was positive a possible indication that it is a smaller PFO? Also could it be and indication of size by another hit not happening with me having done long and very deep dives since? I am still under the impression the TTE was done improperly to check as there was no bubble test done but I certainly have no merit to conclude that as fact. My next appt isn't until November 1 so we'll see what they have to say. As far as diving goes, I've been diving for a year and a half with no other problems. However wreckless it may seem I will continue to dive but keep the deco to a minimum and will not do any trimix diving. The image shows the profile of that dive.

Don't share your belief that the Shunt could be small, since the OP also mentions that he has Migranes. AFAIK most people who suffer from migranes also have a PFO. Getting your PFO closed also usually eliminates the reoccurance of migranes, and also significantly reduces the risk of suffering a stroke.
Doesn't matter what it costs, have the shunt fixed.

Michael

[Pullnglide]

Did I miss something or misread your post sir? I AM the OP and asked a legitimate question aimed at Dr. Ebersole and whomever else may have significant experience with PFO size and closure. I am having it closed regardless, just trying to consider my options with information from those who have experienced the process from DCS to having it closed. Thank you.

[rddvet]

What is the accuracy of a tte with bubble test? I had two hits on very mild dives One skin/mild neuro and one only skin. My bubble test was negative. I did seek a cardiologist recommended by DAN. I would assume the sensitivity to be high but also dependent on the ultrasonographer. Would the recommendation be if another hit occurs, have a tee performed?

[lv2dive]

It was my understanding there is a correlation with migraines with aura only - not migraines without aura. If my understanding is incorrect I would very much like to know. Dr Ebersole?

Don't share your belief that the Shunt could be small, since the OP also mentions that he has Migranes. AFAIK most people who suffer from migranes also have a PFO. Getting your PFO closed also usually eliminates the reoccurance of migranes, and also significantly reduces the risk of suffering a stroke.
Doesn't matter what it costs, have the shunt fixed.

Michael

[Pullnglide]

My migraines are always with aura. The aura usually starts a little bit before the pain really comes on. They kind of come in spells. Sometimes I will have a couple a month and sometimes go 6 months without having one. I was prescribed Relpax at one time that would help relieve the symptoms but for the most part the only way to get rid of them for me would be to try and sleep.

[debersole]

michael-fisch -- I don't know of any data that "most" people with migraine headaches also have PFO, but there is a correlation. And for people who have never had a stroke there is no data that closing the PFO with decrease the risk of stroke. For patients who have already suffered a cryptogenic stroke (no other source found) it is controversial as to how much benefit there is for closing the PFO.

lv2dive -- Yes the correlation between PFO and migraine headache is for migraine headaches with aura. Anecdotally, patients who had their PFO closed for other reasons such as cryptogenic stroke reported a decrease in the frequency of their migraine headaches. A randomized study was performed to see if closing PFOs could eliminate the headaches. That trial was negative so the procedure was not approved for that indication. However, in that trial there was a significant decrease in the frequency of migraines. So, while not a definitive treatment for migraine with aura, we frequently see a significant decrease in headache burden once the PFO is closed for other reasons -- DCS, cryptogenic stroke, etc.

rddvet -- If you were to have more episodes of DCS (cerebral, spinal, inner ear, skin) with low risk dives, I would definitely recommend getting a TEE with a bubble study at an experienced site because there are some technical issues with getting a high quality study.

[lv2dive]

Thank you for the clarifications. I think it is critical to be very specific when discussing topics such as these!

From someone who gets migraines without aura

michael-fisch -- I don't know of any data that "most" people with migraine headaches also have PFO, but there is a correlation. And for people who have never had a stroke there is no data that closing the PFO with decrease the risk of stroke. For patients who have already suffered a cryptogenic stroke (no other source found) it is controversial as to how much benefit there is for closing the PFO.

lv2dive -- Yes the correlation between PFO and migraine headache is for migraine headaches with aura. Anecdotally, patients who had their PFO closed for other reasons such as cryptogenic stroke reported a decrease in the frequency of their migraine headaches. A randomized study was performed to see if closing PFOs could eliminate the headaches. That trial was negative so the procedure was not approved for that indication. However, in that trial there was a significant decrease in the frequency of migraines. So, while not a definitive treatment for migraine with aura, we frequently see a significant decrease in headache burden once the PFO is closed for other reasons -- DCS, cryptogenic stroke, etc.

rddvet -- If you were to have more episodes of DCS (cerebral, spinal, inner ear, skin) with low risk dives, I would definitely recommend getting a TEE with a bubble study at an experienced site because there are some technical issues with getting a high quality study.

[Johnoly]

.... The insurance is BCBS and is very good but I'm just not sure they will cover it....

Many time the skill of a doctor is not only how good their sutures are, but also how good their insurance procedure approvals are. Good doctors have incredibly talented billing staff that gets things done.

[bigdave]

3. Close the PFO -- This should only be done (expert consensus) for recurrent unexpected bouts of DCS. And the symptoms should be types of DCS known to be associated with a PFO -- namely cerebral, spinal, inner ear, or skin bends.

There you go, that's what I have wanted to say all along. I read posts from folks who have one occurrence of DCS and want to go have it "fixed". The tables and DC models are not perfect, and folks are going to get bent now and then. Especially on some of the aggressive tech profiles.

bigdave -- of course there are risks. Every procedure has its risks and benefits. The key is to have an informed discussion with each individual patient about their individual situation and the inherent risks to them by the procedure.

But I think the risks need to be discussed here as well when folks are asking about the options. It should be part of the discussion.

The science is not definitive and never will be. The last thing you want in any scientific study is a self-selecting sample, but that's what we have with divers. Even a big study doesn't always work out - the RESPECT study started with almost 1000 patients and was down to 30 at ten years. That's pretty dismal.

Thank you,

David

[Pullnglide]

What I'm seeing is advice to wait until I'm bent a couple more times before deciding to have it fixed. No thanks!! Not saying I wouldn't get bent after having it closed but I'd rather not go through that again if there is something I could do to reduce my risk. Not too much like my brain telling my arms to move and they refuse to do as I say while an elephant stands on my chest and my vision obscured with spots and jagged lines among others, I understand the reference to being "bent". I will be in contact Dr. Ebersole, thank you!