Can you dive with a PFO?
This article is about my actual case of discovering that I was diving with PFO and finally having it closed. I have met some other cases as well in the last years. PFO (Patent Foramen Ovale) is very real, and yes, many people have it.
What is a PFO?
The PFO is an opening in the heart which makes it possible to actually be alive. Before birth, since the foetus doesn’t use the lungs (obviously), this opening ensures that the blood can flow through all organs supplying the necessary oxygen. After being born, the pressure increase due to blood circulation causes this “flap” to close. However, in about 25% of cases, this does not happen properly.
What does it cause?
Many people will never realise that they have a PFO. You can live your life without any symptoms. However, in some cases, it can increase the risk of stroke, heart attack, and migraine.
It can also be partially closed and only open due to increased pressure caused by coughing, sneezing, and in case of divers equalising your ears, or heavy exertion such as lifting heavy equipment like twinsets.
Why is it a problem for divers?
During the dive, there are small bubbles in the venous portion of blood circulation, which get “filtered” out in the lungs. Technically if you have a PFO, these bubbles can pass to the arterial circulatory flow and start growing, likely causing decompression sickness.
However, it is not 100% certain that this will happen, hence doctors don’t recommend to screen every diver for PFO.
Since about a quarter of the population has this opening, and events of decompression sickness are still rare compared to a number of dives conducted, just because you have one, it doesn’t mean you will get DCI.
Personally, I had about 2,500 dives and worked as a dive instructor for a decade, sometimes doing 4 dives a day, liveaboards, technical dives, before experiencing the first symptoms. So you really don’t need to run to the doctor’s right now to get tested 😀
You can read more about this from actual professionals in the area here. I have found this article very detailed and useful.
How did my symptoms start?
I remember that day very well. I had finished my trimix course, and this was the first dive on the Le Polynesien… it was super exciting. Planned a conservative dive, only 15 m bottom time on 60m average depth. Before the dive I didn’t want others to wait for me, so I got into my drysuit at the same time the first group did. It was a hot summer day, and the boat was busy. We were the last pair in, and I helped everybody with stages before jumping in. I kept drinking water to keep hydrated, but honestly, I was still boiling.
We had some current on the dive, so my buddy turned the dive at 12 minutes. We did all deco stops as planned, got back on the boat, then loaded all tanks together on the truck to go back to the dive centre.
I already felt really tired, but as it happens, denied that anything is wrong. I then felt the skin on my arms become a sort of “thick”.
Undeterred, I then helped to fill all tanks for the next day. Only the next day, when my face was also slightly swollen, (looked really funny) did I go to get checked. The diagnosis was a very mild case of lymphatic DCS, and since no other symptoms were present, a trip to the chamber was not required. It took days until all swelling disappeared.
After that event, I didn’t have any issues for a while, so I thought it was just a one-off accident. But then the second episode happened. Double dive down to 34 m, on air, with some decompression stops. (All divers in the group were techies) Fatigue, itching, rash… Bollocks, I can’t deny it, yes, I got bent. So I immediately went to the hospital and was directed to the chamber right away.
Two and a half hours later all symptoms had subsided except a mild pain under the skin. Think of when you bang into the table edge and it’s sore for days. Ouch.
This was when I heard about the PFO for the first time. My doctor recommended I get tested. I thought come on, I have so many dives, it is impossible, I can not have such a thing. I insisted in my mind that it was just a hot day and I was dehydrated.
Teaching a tec 45 course, the plan was to do 2 dives, the first a practice dive with simulated deco to 28m, and the second an actual deco dive. The exit at the chosen site is not easy, climbing up a long ladder kitted up and then carrying equipment back. Rash and itching. I knew the drill by now and I was more prepared. If you ever end up in the pot, grab some food, warm clothes, and maybe a book. After this third event, I was scheduled for a PFO screening. Unfortunately, this was months away.
Let’s call it the first test. It is called a transesophageal echocardiogram (TEE) which sounds worse than it is.
Admittedly though, it is not a good feeling having an ultrasound device down your throat to see whether the injected saline passes from one side of the heart to the other.
Some sedatives may have been involved, but I swear I didn’t feel a thing. The result: NO PFO! Yaay, I was super happy, went back diving and boom! Round 4, and another skin bend. Damn. The second test showed a small PFO under heavy exertion, which according to the cardiologist shouldn’t cause any issues. This was in 2016. I thought ok, then I will just stay hydrated, keep sporty, healthy, and get on conservative dive profile… Had many dives throughout 2 years without incident, used 50/60 gradient factors on tec dives, plus overstayed my last stops as much as I could (usually 10-15 minutes). But then, once again.
The (hopefully) last incident
In 2018, on a beautiful autumn day, we planned a dive to the Um El Faroud, a 110m long tanker which is not too deep at 36m max depth. The average depth of the deep portion of the dive is around 30m.
It was a long dive, however, almost 3 hours in total. After the dive, I felt fine and jumped on the truck to lift everybody’s stages on. It was a big group, and sure enough, about halfway through loading, I felt something was wrong.
I did it again. Hoping I was wrong, I waited, but the usual burning, itchy feeling was back. Back to the hospital, and the hyperbaric chamber. It was a very mild case of DCI, with the symptoms subsiding after being administered oxygen, but for precaution, I was still in the chamber for two and a half hours.
The test when the PFO finally showed
After this accident, I had another appointment booked for yet another PFO test, as that was still the most probable cause of all my troubles.
The main difference was this and my previous two tests were that this time the cardiologist injected the bubbles through the femoral vein on the leg instead of my arm.
Sure enough, the bubbles were flying through the hole without much effort! To be honest, it was a relief, knowing for certain the cause of my problems. I had three options: 1. Stop diving (good one!) 2. Dive to a maximum of 15 m (you’re kidding, right?) or 3. close it. Obviously I went for the third option.
After diving for almost three years with a PFO just feeling something is wrong, and not knowing what the issue was, I was very excited for the procedure. This is a good video showing how it is done.
It was all smooth, arriving at the hospital at 9 am and by 4 pm I was ready to go home!
Then came the hardest part of all: no diving at all for 3 months. After this period came another 3 months of restricted diving. I have to say never enjoyed so much teaching beginner courses. The important thing was I was back in the water!
The final test
After six months I had the appointment for the final checkup. The PFO was now fully closed, no leaks, and cleared for diving! This was in November 2019. Three years since the first DCI and diving with a PFO for another two and a half years, finally it seemed like it was case closed.
Obviously, I will continue diving conservatively.
Closing the “flap” does not mean I cannot get DCI anymore but have reverted to a “normal” level of risk.
Diving with PFO is not impossible, probably thousands of divers do it unknowingly. However, conservative diving practices are recommended for a reason!
I didn’t know that I had any issue for years and thousands of dives, many of them technical dives.
While I was lucky, and my DCI events were not serious, I have seen other divers who weren’t so fortunate. If you get any DCI symptoms, get yourself checked.
If you get into technical diving especially, limit yourself to one deep dive a day. Staying hydrated is incredibly important! Don’t try to fit everything in one holiday, diving during the day, going out in the evening, drinking alcohol, then back in the water the next morning.
Divers on holidays should take time to acclimatise, travelling to a warmer climate will increase the stress on your body.
If you don’t feel well, or haven’t slept that well at night, or even got sunburnt, do consider cancelling the dive even if you lose money. It will still be miles better than getting into trouble. A hospital visit would probably mess up your holiday even more.
Avoid hard work after diving. But what can you do if the dive site requires work? For example, have to walk back to the truck uphills? Just extend your last stop, or in case of recreational dive, do a longer safety stop.
You have been in the water for a while already, that few minutes extra won’t hurt. And do take it easy with the lifting and carrying.
Let me know your thoughts
Please feel free to add your comments or questions. I read through many articles before my procedure but it was nice to hear about other divers who went through the same and got back to diving after!