Persistent foramen ovale closure in divers with a history of decompression sickness

Abstract

ObjectiveTo study the effect of percutaneous patent foramen ovale (PFO) closure in divers with a history of decompression sickness (DCS).Study design(1) Retrospective study of patient records and (2) telephonic follow-up. Patients with unexplained decompression sickness, who were referred to a cardiologist with a focus on diving medicine between 2000 and 2017, were included in the studyResultsA total of 62 divers with DCS were included. In all cases transoesophageal echocardiography (TEE) was performed, showing 29 PFOs and 6 atrial septum defects (ASDs) in total n = 35 (56%). The highest prevalence was found in divers with cutaneous and vestibular DCS. At follow-up (mean follow-up duration 6.8 years), 21 PFOs/ASDs were closed using a percutaneous procedure. One diver was lost to follow-up. One diver quit diving. The remaining divers were able to resume unrestricted diving; there was no recurrence of major DCS. Of the divers with an open PFO or ASD, 14 were included of whom 7 are currently diving. All (except one diver with a small PFO) divers are using a conservative diving profile to reduce nitrogen load and the appearance of venous nitrogen bubbles. There was no recurrence of major DCS in this group.ConclusionPercutaneous PFO closure may be an effective and safe treatment for divers who have suffered a major DCS to return to unrestricted diving. Alternatively, conservative treatment seems safe when divers refrain from unrestricted diving and use a conservative technique in order to reduce nitrogen load.

Mind the gap: closure of right to left shunts for rare indications

“…The findings of the current study by Koopsen et al. [ 1 ] indicate that it may be time to change our opinions about diving in the presence of a right-to-left shunt. Their results clearly demonstrate that it may be time for a paradigm shift.…”

“…In the current issue of the Netherlands Heart Journal , Koopsen et al. [ 1 ] describe the mid-term follow-up of a series of divers that suffered from decompression illness (DCI) and assessed how closure of the right-to-left heart shunt influenced the recurrence of DCI.…”

“…For divers, the presence of a right-to-left shunt carries an increased risk for DCI [ 1 , 5 ]. Although the incidence of DCI is low, there is a 5-fold increased risk in the presence of a right-to-left shunt [ 5 ].…”

Increased Risk of Decompression Sickness When Diving With a Right-to-Left Shunt: Results of a Prospective Single-Blinded Observational Study (The “Carotid Doppler” Study)

“…In other studies it was also reported that even though the PFO was closed, a significant number of divers adopted a more conservative diving attitude (Koopsen et al, 2018;Anderson et al, 2019;Vanden Eede et al, 2019). A recent report (Anderson et al, 2019) described a better reduction of DCS incidence after PFO closure compared to "conservative diving, " but major methodological flaws have been pointed out by an accompanying editorial (Wilmshurst, 2019).…”

Patent Foramen Ovale—A Not So Innocuous Septal Atrial Defect in Adults

“…So-called minor DCS (i.e., DCS type I) is caused by the local formation of bubbles and presents with skin and/or musculoskeletal symptoms, such as itching, skin rash, and joint pain. Major DCS, or type II, is due to the formation of venous bubbles that induce neurological, vestibular (dizziness/vertigo), or pulmonary symptoms in the presence of a right-to-left shunt caused by PFO [44].…”