Percutaneous closure of patent foramen ovale for the secondary prevention of decompression illness in sports divers: mind the gap

Abstract

Objective: To evaluate the efficiency of percutaneous patent foramen ovale (PFO) closure on the recurrence of decompression illness (DCI). Design: Retrospective, observational study with interview and questionnaire Setting: Tertiary referral center. Population: 59 scuba divers with a history of DCI who received a percutaneous PFO closure. Main outcome measurements: Questionnaire about health status, dive habits and recurrence of DCI after PFO closure. Results: A total of 59 divers with DCI were included. The most common manifestations of DCI were cutaneous or vestibular DCI. Procedural complications occurred in four patients but none with long-term consequences. Four patients had recurrence of DCI after closure during a 10-year follow-up. In three of these cases there was residual shunting, all of which were initially considered closed. The fourth patient had aggravating factors for his recurrent DCI. A quarter of the patients stated to have changed their diving habits. Four patients quit diving. Conclusion: Percutaneous PFO closure for secondary prevention of DCI is associated with few, but not negligible, complications. As a large portion of our cohort changed their diving habit after closure it is difficult to ascertain the efficiency of PFO closure for secondary prevention of DCI. However, the study shows that PFO closure does not fully protect against DCI, emphasizing that the relationship between PFO and DCI is but an association. As such it is imperative that divers be counseled to ensure they understand the risks as well as the benefits of percutaneous PFO closure in their specific case.

The management of patent foramen ovale in divers: where do we stand?

“…Interestingly, three of them had residual shunt, which is probably linked with the recurrence. 48 Pristipino et al 29 highlighted the necessity for the entire closure of shunt; otherwise, unrestricted diving should be avoided. Smart et al advise divers not to return back in their exercise until the confirmation of satisfactory PFO closure.…”

European position paper on the management of patients with patent foramen ovale. Part II - Decompression sickness, migraine, arterial deoxygenation syndromes and select high-risk clinical conditions

“…In these people, PFO closure may be proposed based on observational data suggesting that PFO closure is associated with reduced DCS incidence in divers 5 and prevents arterialisation of VGE [31][32][33] . However, since recurrent DCS has also been observed after PFO closure in some studies, it should be remembered that diving may be a cause of DCS even without a PFO [33][34][35] . Current recommendations are that diving should be resumed only in the presence of a sealed PFO 30,36 .…”

“…However, the number of subjects was low and there was significant dropout. Some case reports have been published on divers who suffered recurrent DCS after PFO closure [33][34][35]. Although a residual shunt was detected in some of these patients, it is possible that, in others, a provocative dive profile caused high VGE loads, resulting in recurrent DCS, even with a successfully closed PFO.…”

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).…”

“…A recent study (Vanden Eede et al, 2019) describing the follow-up of 59 PFO closures over a 10-year period in a Belgian diving population has reported a significant number of recurring DCS (15%) despite the PFO closure. These occurred either because the PFO had not been completely closed, or because of extremely provocative dives.…”