About right now, about 80 percent of you are saying to yourself
"What's a PFO and who is George", 10 percent are saying, "Oh, someone
else trying to kiss GI's butt", and the rest saying "This should be
interesting". Or at least that's my perception.

So why am I writing this letter? I'm writing this because it is my
impression that most of you have never heard of a PFO and what can
happen to you as a diver if you do have one. I'd like to explain by
separating this into 3 parts. 1. What is a PFO? 2. Why does it matter
to diving and 3.My experience in repairing the PFO.

What is a PFO?

A little story about how I became aware of the whole PFO issue. When I
began diving about 4 years ago, I was introduced to the DIR concepts
by my open water instructor, Brandon Schwartz  (www.scubaguys.com). I
assure you that this is not going to become a DIR rant. I am just
filling in some holes in the story. Anyway, Brandon's emails to me
included some interesting (if not colorful!) issues that George Irvine
of the WKPP said about diving in general. Some of it was way over my
head as I was just certified. Nevertheless, as a student of diving, I
found great information among the noise. One of the things I picked up
on was this thing called a PFO. George forcefully suggested that any
diver should find out if he had this PFO. I believe, in fact, that it
was required of all WKPP divers (of which he was director
www.wkpp.org). It was mentioned numerous times in his writing. I later
came to find out that it stood for Patent Foramen Ovale.

When you are a fetus in your Mother's womb, your mother's body does
the job of filtering out all of the harmful pieces of material that
float around in the blood supply. The BIG reason for the flap is so
the blood purposely bypasses the lungs because the fetus's use of the
mother's oxygenated blood is how the baby (in effect ) breaths. Your
heart has a hole (actually a flap) between the left and right side
chamber so that this filtered blood can supply your (the fetus's)
brain. Immediately after birth, this flap is supposed to close. The
newborns body is now filtering the "dirty" blood. I say "supposed"
because about 30 percent of the population still has this flap or
hole. That means that of yourself and your 2 other dive buddies, odds
are that 1 of you has this PFO (okay, I'm rounding the numbers).

Why does it matter to a diver?

Remember all those things you learned about safety stops and slow
ascents? Well folks, this is where things get tricky if you have a
PFO. Let's say you've been down diving for about a half hour or 45
minutes on a pretty reef in the Caribbean. I'm taking strictly
recreational diving. After you are done with your bottom time, you
have accumulated a fair bit of nitrogen, as I'm sure you remember from
your OW class. So you're told to ascend slowly and do a 3-5 minute
safety stop to allow the nitrogen to filter out of your system via the
lungs. This nitrogen-laden blood flows thru the left chamber of your
heart. There is a wall separating the left and right chambers, and the
wall keeps the unfiltered nitrogenous blood from traveling to the
right side, which supplies your brain. The problem arises when you
have a PFO. The flap I previously spoke about is in this separating
wall and is normally kept closed by your blood pressure, but during
periods of exertion- like coughing, strenuous movement, or climbing
the ladder of a boat- this blood pressure reduces on the right side
for a brief moment and can open the flap that was supposed to close
naturally. This can allow small nitrogen bubbles to pass to the right
chamber of the heart and be fed to the brain. As you can remember from
OW class, Boyles Law takes over here. So as you ascend, those bubble
grow in size due to the reduce pressure. Large bubbles in the brain
material are not good for anyone, and can cause strokes and paralysis.
For some this means death.

My experience in repairing the PFO

You might ask-how did I find out that I had a PFO? During a routine
cardiology exam, I asked my cardiologist to check for a PFO because of
what I had read from George Irvine's writings. My cardiologist looked
at me really funny and asked how I knew what a PFO was, and why it
mattered to me. I explained to him what I had learned, and that I did
a lot of scuba diving. Then he smiled and began to speak about the
implications of the PFO in diving and other sports. He related some
stories about previous patients that were not divers, but weight
lifters. Some are paraplegics now because of PFOs. It seems that
during the lifting phase, the exertion caused the flap to open, and
it's presumed that a piece of plaque or cholesterol passed thru the
opening and into the brain. We're talking a kid in his mid-twenties.
Really sad. Getting back to my story, I asked him what it would take
to test for this anomaly, thinking there was no way that I would have
one of these things. It only happens to other people of course. He
suggested an echocardiogram with bubble study. This is a fairly benign
test. You lay down and an IV is inserted into your arm. A "wand" is
run across your chest that creates ultrasound waves. These are then
seen on a monitor by a trained technician. Dyes are injected into the
IV and the technician follows the dye into the heart. They then ask
you to cough, and try to find out whether the dye went across the
wall. Then they inject very small bubbles into your bloodstream and
repeat the coughing process. In my case, they could see a few bubbles,
but not until after they reviewed the tape later on.

I had left the next day to attend the DEMA show and get in a little
diving. Well, I spent about an hour at DEMA and dove the rest of the
time, but that is another story! During a surface interval at lunch
the next day, I received a phone call from my cardiologist and he told
me that upon review of the video, they had seen some bubble pass thru
the chamber. In other words, I had a PFO. He believed it was a small
one, but told me that I shouldn't be diving deep. In fact, he
suggested that I not dive at all unless I wanted to get it fixed. I
was a bit shocked to say the least.

So now what? I had a decision to make, and it involved a lot of
variables. How important was diving to me? What are the risks involved
with closing this flap? How do you close the flap? Is the surgery
worth the risk? I won't go thru all of the issues that confronted me,
but I decided to go ahead with the procedure. It reduced my risk of
stoke, regardless of the diving issue. Would I have done this if I
were not a diver? Probably not.

My cardiologist recommended a heart surgeon that had done numerous PFO
repairs. I wanted someone who was experienced in this. Probing
something into your heart is no simple matter. I interviewed the
doctor and chose him to repair my PFO. I entered the hospital
yesterday at 6am for a 7am surgery. A nurse shaved parts of my chest
for the EKG leads, and the upper part of my groin area where they
would insert the catheter for the procedure. An IV was started. And I
waited. And waited. Turns out there were a couple of emergencies that
they pushed in front of me, and I was finally taken into the Cath Lab
at 10:30am. I was moved onto the surgery table, and that's the last
thing I remember until I awoke in recovery. Here is what they used to
fix the problem: http://www.spencervascular.com/pfoclosure.htm Mine is
the device on the right.

For me, there was absolutely no pain involved, other than a slight
sore throat from the tubes they inserted during surgery. After you
awake and they take you to your room, you are required to lie flat on
your back for around 6-8 hours. After they remove the shunt from your
leg (around 2 hours), a heavy sandbag is placed over the insertion
area. Their biggest concern is that you don't bleed from the artery in
the groin that they used. I was allowed to get up after 8 pm that
nite. Today I feel wonderful. No pain, no soreness. Just some funny
looking shaved body parts!

Epilog

I wrote this because I believe that the PFO issue is ignored or
glossed over by the dive industry. If 30 percent of the population has
this anomaly, and the potential for serious injury or death is high in
the diving world, then it would be my conclusion that it should be
more in the forefront than it currently is. I can't speak of another
agency, but I know that most agencies do not even mention it in their
classes. One can speculate why, but it is my impression that we're
back to a numbers game. Imagine scaring 3 out of every 10 people that
come into your class? Worse yet, scaring those that don't even have
the PFO? Unless you test for it, there is no way to know you've got
it. You'd have people running from this industry. Not good for
business. My guess is that the industries response would be that there
is no proof that PFOs cause diving accidents. Not surprising, because
there is really no way to pinpoint the problem after it happens. How
many of the "heart attacks" or "undeserved" hits do we hear about
during the year? My guess is that a good portion of these is PFO
related. There are just too many of us PFO'ers within the dive
population. And ascent rates and buoyancy control are not often
highlighted in the industry. There are a lot of potential victims
amongst us.

So George, although I've never met you, and probably never will, I
want to thank you for your teachings and for your insight. I love this
sport, but I love my family much more. You have allowed me to enjoy
both of them for however long I'm supposed to be around. I may have
been okay otherwise, but I've now removed one potential obstacle.
Maybe thru this long report of mine, someone else who has not heard
about this can benefit also.

Thank you,

Jack

PS. If medical doctors would care to add to the description of the
anomaly, or to correct anything I've written, it would be most
appreciated.