Interview with my Cardiologist on PFO related issues!

[Alan]

I took this from my email exchange with him, I am so tired I can't reformat it but I think its a unique insight into PFO related issues.


1. Have you ever dived? Had to ask, being a diving article. YES - I USED TO BE AN ENTHUSIASTIC SPORTS DIVER. I TRAINED WITH A DIVE CLUB IN CHELSEA. I HAVE DIVED IN THE UK (YES - STONEY COVE !!, SWANAGE, POOLE ETC), ISRAEL / EGYPT (EILAT / SHARM / RAS MUHAMMED) AND AUSTRALIA (BARRIER REEF)

SADLY I HAVE LITTLE TIME TO DIVE NOW !

2. What percentage of divers make up the group of those you have
treated for PFO? ABOUT 10%-20%

3. Is it fair to say that most non-stroke related patients are
divers? YES

4. How many procedures have you performed? OVER 300


Some Medical related questions:

1. Some people in the medical profession have tried to draw
> conclusionsfrom the fact that because some divers do not
> experience a DCS event for
> sometime (1000+ dives), then do and discover they have a PFO,
> suggestingpossibly a worsening of the condition as a result of diving.
>
>
> Details in this article:
> HYPERLINK
> "http://www.healthypages.net/newspage.asp?newsid=4996"http://www.healthy
> pages.net/newspage.asp?newsid=4996
>
> Can/have you an opinion on this!
THE PAPER DOES NOT SUGGEST THAT PFO'S OPEN UP AFTER YEARS OF DIVING, BUT IT MAY BE THAT THEY STRETCH A LITTLE. THIS IS PURE SPECULATION WITH REALLY RATHER POOR EVIDENCE TO SUPPORT IT SO I CANT SUBSCRIBE TO THE THEORY. HOWEVER IT IS INTRIGUING AND INTUITIVE THAT REPETITIVE AND FREQUENT VALSALVA MANOEVRES MAY ENCOURAGE A SMALL PFO TO STRETCH










2. Why does there seem to be a general lack of knowledge,
specificallyin NHS (without wanting to stereotype) about the
condition, were the
mindset that PFO’s are fixed in children at birth and as a play no
partin the patients medical well being? There are cases of divers,
weretheir NHS trust won’t believe them that anything is wrong,
even with
medical referrals which have diagnosed a PFO!


THE REASON IS THAT THE RELATIONSHIP OF PFO TO CLINICAL PRESENTATIONS INCLUDING STROKES, IS STILL AN AREA WHERE THERE IS A RANGE OF OPINION AMONG CARDIOLOGISTS AND NEUROLOGISTS. THE ISSUE OF DIVING RELATED SYNDROMES IS EVEN MORE COMPLEX. THERE IS LITTLE IF ANY TEACHING AT MEDICAL SCHOOL ON THE SUBJECT OF DIVING MEDICINE. THERE IS ALMOST NO POINT GOING TO A GENERAL PRACTITIONER AS THEY HAVE LITTLE OR NO KNOWLEDGE OF DIVING MEDICINE. MY ADVICE IS TO GO INITIALLY TO A DIVING PHYSICIAN IE A DOCTOR WHO DEALS WITH THESE SYNDROMES. (THIS WILL ALMOST CERTAINLY BE A PRIVATE DOCTOR). HE CAN THEN WRITE A LETTER TO THE GP SUGGESTING REFERRAL TO A SPECIFIC NHS UNIT. THE GP THEN SIMPLY BECOMES THE FACILITATOR. MOST CARDIOLOGISTS KNOW ONLY THE RUDIMENTS OF DIVING RELATED ILLNESS SO YOU HAVE TO GET REFERRED TO ONE THAT UNDERSTANDS ABOUT THE RELATIONSHIP BETWEEN DCS AND PFOS






> 3. Another example of the ignorance of some GPS:
>
> Diver Comment:
> I had to harass my GP for weeks to get a referral to Wilmshurst.
> The GP
> sounded my heart on 4 different occasions and told me “If you had
> a hole
> in your heart I would be able to hear it”, totally ignoring all the
> migraine symptoms id had all my life, coupled with the bend last
> year. I
> even made appointments with one of his colleagues for a second
> opinion,Same result.
>
> I think in the end he referred me just to get me off his back. Lucky
> really cos at 26mm diameter, to quote Wilmshurst, "Never mind DCS,
> you'dhave had heart failure in your 40's".
>
>
> What advice would you give divers in similar situations and can you
> explain why this proves to be such a common area of mis-diagnosis?


PFOS DO NOT HAVE ANY PHYSICAL SIGNS THAT CAN BE PICKED UP. MY ADVICE IS AS IN THE ANSWER ABOVE


> 4. Has the size of the PFO have a linear relation with the effects of
> shunts which cause so many problems for divers. The reason I ask
> is that
> I seemed to have a large PFO based on my initial test from the
> amount of
> bubbles observed by the Ultra sound. I was also acutely sensitive to
> sudden change in ambient pressure when diving, and felt very tired
> afterevery dive (experiencing mild forms of DCS) but had a
> relatively small
> PFO.
>
>

THE RELATIONSHIP BETWEEN SIZE OF PFO AND THE NATURE AND SEVERITY OF DCS IS COMPLEX AND NOT STRICTLY LINEAR. HOWEVER - THE BIGGER THE PFO THE BIGGER THE RISK - UP TO A CERTAIN POINT.




> 5. Can the risks to the individual patient be ascertained before the
> procedure, does age, size of the PFO or fitness of the patient
> play a
> role in risk assessment? What cases would a patient we advised not to
> have the procedure?
>

THERE ARE FEW IF ANY ABSOLUTE CONTRAINDICATIONS TO THE PROCEDURE. INABILITY TO TAKE ASPIRIN OR CLOPIDOGREL WOULD BE A PROBLEM. THE RISKS ARE GENERALLY VERY SMALL. MOSY DIVERS TEND TO BE YOUNG AND OTHERWISE FIT SO THE RISKS OF THE PROCEDURE AND ANY GENERAL ANAESTHETIC ARE VERY SMALL. THE SIZE OF THE PFO DOES NOT INCREASE THE RISK.




> 6. The most frequent response to the article I wrote in HYPERLINK
> "http://www.travel-dive.com/"www.travel-dive.com concerned the
> Risks to
> the patient long term after having a PFO device fitted? There are
> statistics which show that the Amplatzer device is much more reliable
> than previous devices. Have there been any documented issues
> relating to
> long term affects of having such a device, and how do they relate
> to the
> device in question?
>

YOU ARE QUITE RIGHT - THE AMPLATZER HAS THE MOST LONG TERM FOLLOW UP AND SEEMS TO BE THE DEVICE ASSOCIATED WITH FEWEST PROBLEMS. HOWEVER EVEN THE AMPLATZER CAN , VERY RARELY HAVE DELAYED PROBLEMS. I HAVE USED AT LEAST THREE OTHER DEVICES, BUT USE ONLY ONE OTHER (THE HELEX) WITH ANY REGULARITY. THE KEY IS THAT THE DEVICE IS LOW PROFILE (THIN) AND NON THROMBOGENIC (IE DOES NOT ATTRACT BLOOD CLOT). SOME OF THE OTHER DEVICES HAVE BEEN ASSOCIATED WITH BLOOD CLOTS IN THE LONG TERM. MANY THOUSANDS OF AMPLATZER DEVICES HAVE BEEN IMPLANTED WORLDWIDE. THERE HAVE BEEN A VERY FEW CASES OF EROSION REPORTED (IS THE DEVICE ERODES THE WALL OF THE HEART) BUT THESE HAVE BEEN IN CASES OF ATRIAL SEPTAL DEFECT (A MUCH LARGER HOLE AND MUCH LARGER DEVICE). THANKFULLY DESPUET MANY HUNDRED CASES IN OUR HANDS WE HAVE NOT HAD THIS COMPLICATION.






> 7. As a PFO patient with a special heart, I am happy to take part
> in any
> studies for the condition, but unaware of anyone doing any
> research. Are
> you aware of any ongoing research, or yourself completing research
> related to the condition and divers!
>

THE MOST ACTIVE RESEARCHER IN THIS AREA IN THE UK (AND PROBABLY THE WORLD) IS PETER WILMSHURST - A WORLD REKNOWNED EXPERT IN DIVING RELATED DISEASES, A CARDIOLOGIST , AND A DIVER - I GUESS THE IDEAL COMBINATION. I HAVE KNOWN PETER FOR 20 YEARS - HE IS A FRIEND AND COLLEAGUE I RESPECT ENORMOUSLY. IT WAS HIS ENTHUSIASM IN THIS FIELD WHICH INSPIRED ME.




> 8. After the procedure I had some Arrhythmia problems, is their anyway
> to lesson the affects of this which were quite uncomfortable at the
> time, and involved me taking a few trips to the A/E for
> monitoring. I
> attributed this to being forced to go back to work before I was ready
> due to my tyrant of a boss.


THIS SIDE EFFECT IS WELL RECOGNISED BUT AFFECTS ONLY A SMALL PERCENTAGE OF PATIENTS HAVING THE PROCEDURE. THE ONLY TREATMENT IS A BETA BLOCKER.




> 9. Has the Transesophageal Echo been superseded by a much less
> uncomfortable procedure for identification of the PFO?


THE PROCEDURE CAN BE GUIDED BY AN INTRACARDIAC ECHO (ULTRASOUND PROBE PLACED IN THE HEART VIA THE FEMORAL VEIN). A TRANSOESOPHAGEAL ECHO IS STILL EXTREMELY USEFUL FOR THE PLANNING STAGE OF THE PROCEDURE AND I STILL FAVOUR IT AS A PRE-CLOSURE TEST - TO DEFINE THE PFO COMPLETELY




> 10. What are your views on cryptogenic strokes related to PFOs? (These
> can be high level) I am personally interested since I based part
> of my
> decision to having the procedure on the inherent long term risks.


THE INCIDENCE OF PFOS WITH BIG SHUNTS IS MUCH HIGHER IN THE YOUNG CRYPTOGENIC STROKE POPULATION THAN NORMAL SUBJECTS AND I FEEL, IN THE ABSENCE OF OTHER RISK FACTORS, THAT THE PFO HAS TO BE TAKEN SERIOUSLY IN SUCH PATIENTS.

[Larry Hadley]

Hi Alan,
I've been waiting for this and look forward to reading it slowly and carefully. Many thanks for all your input on PFOs. I'm hoping for a scan soon and all this info is very reassuring.
Regards
Larry

[Hellvet]

much as the research i have trawled through has made me feel, and much as the discussion i have had with wilmshurst and other cardiologists has concluded.

good post! have a green!