Patent Foramen Ovale and Divers

  • Carla Canniffe
  • Kevin P. Walsh


A patent foramen ovale (PFO) occurs in approximately 27–30 % of the population (Thompson and Evans, Q J Med 23:135–52, 1930; Hagen et al. Mayo Clin Proc 59:17–20, 1984) and has been linked to paradoxical embolism, cryptogenic stroke, migraine and an increased risk of decompression illness (DCI) in divers.

Recent estimates have suggested that over 15 million people worldwide are participating in recreational diving, with greater than 250,000 dives per year (UN atlas of the Oceans. 2006. Decompression sickness is estimated to occur in one per every 6,369 dives deeper than 30 m of sea water (St Leger Dowse et al., Aviat Space Environ Med 73:743–9, 2002). However, those with PFOs have been shown to have a fivefold increase in the risk of experiencing decompression illness (Torti et al., Eur Heart J 25:1014–20, 2004). This, and recent studies describing a higher incidence of subclinical cerebral damage in divers with PFOs has led to increasing numbers of divers seeking out screening for the presence of a PFO and elective PFO closure.

In the absence of definitive practice guidelines, the clinical management of such patients remains challenging. In this chapter we review the pathophysiology of diving and PFOs, the potential risks associated with the presence of a PFO in divers, as well as some proposed methods of screening and managing this patient group.


Patent foramen ovale Deep sea diving Decompression illness 



American College of Cardiology


Decompression illness


European Society of Cardiology


Magnetic resonance imaging


National Health Service


Patent foramen ovale


Transcranial doppler


Transoesophageal echocardiogram


Transthoracic echocardiogram


  1. 1.
    Thompson T, Evans W. Paradoxical embolism. Q J Med. 1930;23:135–52.CrossRefGoogle Scholar
  2. 2.
    Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc. 1984;59:17–20.PubMedCrossRefGoogle Scholar
  3. 3.
    UN atlas of the Oceans. 2006.
  4. 4.
    St Leger Dowse M, Bryson P, Gunby A, Fife W. Comparative data from 2250 male and female sports divers: diving patterns and decompression sickness. Aviat Space Environ Med. 2002;73:743–9.PubMedGoogle Scholar
  5. 5.
    Torti SR, Billinger M, Schwerzmann M, Vogel R, Zbinden R, Windecker S, Seiler C. Risk of decompression illness among 230 divers in relation to the presence and size of patent foramen ovale. Eur Heart J. 2004;25:1014–20.PubMedCrossRefGoogle Scholar
  6. 6.
    Carturan D, Boussuges A, Vanuxem P, et al. Ascent rate, age, maximal oxygen uptake, adiposity, and circulating venous bubbles after diving. J Appl Physiol. 2002;93(4):1349–56.PubMedGoogle Scholar
  7. 7.
    Vik A, Jenssen BM, Eftedal O, et al. Relationship between venous bubbles and hemodynamic responses after decompression in pigs. Undersea Hyperb Med. 1993;20(3):233–48.PubMedGoogle Scholar
  8. 8.
    Balestra C, Germonpre P, Marroni A. Intrathoracic pressure changes after Valsalva strain and other maneuvers: implications for divers with patent foramen ovale. Undersea Hyperb Med. 1998;25(3):171–4.PubMedGoogle Scholar
  9. 9.
    Wilmshurst P, Davidson C, O’Connell G, et al. Role of cardiorespiratory abnormalities, smoking and dive characteristics in the manifestations of neurological decompression illness. Clin Sci. 1994;86:297–303.PubMedGoogle Scholar
  10. 10.
    Wilmshurst P, Nightingale S. Relationship between migraine and cardiac and pulmonary right to left shunts. Clin Sci. 2001;100:215–20.PubMedCrossRefGoogle Scholar
  11. 11.
    Walsh KP, Wlimshurst PT, Morrison WL. Transcatheter closure of patent foramen ovale using the Amplatzer septal occluder to prevent recurrence of neurological decompression illness in divers. Heart. 1999;81:257–61.PubMedCentralPubMedCrossRefGoogle Scholar
  12. 12.
    Cartoni D, De Castro S, Valente G, Costanzo C, Pelliccia A, Beni S, Di Anelantonio E, Papetti F, Vitali Serdoz L, Fedele F. Identification of professional scuba divers with patent foramen ovale at risk of decompression illness. Am J Cardiol. 2004;94:270–3.PubMedCrossRefGoogle Scholar
  13. 13.
    Wilmshurst PT, Byrne JC, Webb-Peploe MM. Relation between interatrial shunts and decompression sickness in divers. In: Sterk W, Geeraedts L, editors. EUBS 1990 proceedings. London: European Undersea Biomedical Society; 1990. p. 147–53.Google Scholar
  14. 14.
    Wilmshusrt PT, Pearson MJ, Walsh KP, et al. Relationship between right to left shunts and cutaneous decompression illness. Clin Sci. 2001;100:539–42.CrossRefGoogle Scholar
  15. 15.
    Gempp E, Sbardella F, Stephant E, Constantin P, De Maistre S, Louge P, et al. Brain MRI signal abnormalities and right to left shunting in asympotmatic military divers. Aviat Space Environ Med. 2010;81:1008–12.PubMedCrossRefGoogle Scholar
  16. 16.
    Schwerzmann M, Seiler C, Lipp E, Guzman R, Lovblad K, Kraus M, Kucher N. Relation between directly detected patent foramen ovale and ischaemic brain lesions in sports divers. Ann Intern Med. 2001;134:21–4.PubMedCrossRefGoogle Scholar
  17. 17.
    Reul J, Weis J, Jung A, Willmes K, Thron A. Central Nervous system lesions and cervical disc herniations in amateur divers. Lancet. 1995;345:1403–5.PubMedCrossRefGoogle Scholar
  18. 18.
    Koch AE, Kampen J, Tetzlaff K, Reuter M, McCormack P, Schnoor PW, Struck N, Heine L, Prytulla I, Rieckert H. Incidence of abnormal cerebral findings in the MRI of clinically healthy divers: role of patent foramen ovale. Undersea Hyperb Med. 2004;31:261–8.PubMedGoogle Scholar
  19. 19.
    Moen G, Specht K, Taxt T, Sundal E, Gronning M, Thorsen E, Troland K, Irgens A, Gruner R. Cerebral diffusion and perfusion deficits in North sea divers. Acta Radiol. 2010;51:1050–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Todnem K, Nyland H, Kambestad BK, Aarli JA. Influence of occupational diving upon the nervous system: an epidemiological study. Br J Ind Med. 1990;47:708–14.PubMedCentralPubMedGoogle Scholar
  21. 21.
    Ross JA, Macdiarmuid JI, Rostron CL, Watt SJ, Crawford JR. Psychological and physical correlates of musculoskeletal symptoms in male professional divers and offshore workers. Extrem Physiol Med. 2013;2:5.PubMedCentralPubMedCrossRefGoogle Scholar
  22. 22.
    Todnem K, Nyland H, Skeidsvoll H, Svihus R, Rinck P, Kambestad BK, Riise T, Asrli JA. Neurological long term consequences of deep diving. Br J Ind Med. 1991;48:258–66.PubMedCentralPubMedGoogle Scholar
  23. 23.
    Germonpre P, Hastir F, Dendale P, Marroni A, Nguyen AF, Balestra C. Evidence for increasing patency of the foramen ovale in divers. Am J Cardiol. 2005;95:912–5.PubMedCrossRefGoogle Scholar
  24. 24.
    Thanigaraj S, Valika A, Zajarias A, Lasala JM, Perez JE. Comparison if transthoracic versus transoesophageal echocardiography for detection of right-to-left atrial shunting using agitated saline contrast. Am J Cardiol. 2005;96:1007–10.PubMedCrossRefGoogle Scholar
  25. 25.
    Wilshurst PT, Pearson MJ, Walsh KP, Morrison WL. In clinical practice transoesophageal echocardiography usually fails to detect large foramen ovale. Heart. 2003;89 Suppl 111:38–9.Google Scholar
  26. 26.
    Kerut E, Truax W, Borreson T, Van Meter KW, Given MB, Giles TD. Detection of right to left shunts in decompression sickness in divers. Am J Cardiol. 1997;79:377–8.PubMedCrossRefGoogle Scholar
  27. 27.
    NHS: percutaneous closure of patent foramen ovale for the secondary prevention of recurrent paradoxical embolism in divers. Patient version: understanding NICE guidelines.
  28. 28.
    Billinger M, Zbinden R, Mordasini R, Windecker S, Schwerzmann M, Meier B, Seiler C. Patent foramen ovale closure in recreational divers: effect on decompression illness and ischaemic brain lesions during long term follow up. Heart. 2011;97:1932–7.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London 2015

Authors and Affiliations

  1. 1.Cardiology DepartmentThe Mater Misericordiae HospitalDublin 7Ireland

Personalised recommendations