All right, well thank you for this opportunity to present a case. This is a conditional recommendation with a decision to close and it's based with decompression illness. I have no financial affiliations to report. And the guidelines are in scuba divers with prior decompression illness and without a prior PFO associated stroke. The SCAI guideline panel suggests against the routine use of PFO closure to prevent decompression illness, but in patients who place a high value on continuing to scuba dive and the potential but uncertain benefits of having their PFO closed and a lower value on risks may reasonably choose PFO closure. This is the patient's history. He's a 38-year-old engineer, a technical scuba diver. He was diving in Micronesia to 140 feet on shipwrecks when he developed decompression illness. One hour after ascending, developed itching and rash on his abdomen with pain. No neurologic symptoms. He was treated with 100% oxygen for an hour. The rash lasted for two days. He stopped diving for one month, then dove to 120 feet for 40 minutes, went through decompression stops, but despite that was straining on board with his equipment, which is very heavy, one hour later felt clammy. Abdomen became red and tender. He used oxygen at home and called the diver's network, referred to a local emergency room and treated with oxygen, but there was no decompression chamber, and they recommended more conservative diving. A transthoracic echo bubble study showed right-to-left shunting, and he was referred to UCLA. Of interest in his past medical history, he had migraines two days a week, but more recently they were occurring a few times a year. They were almost always associated with visual aura manifested as fortification spectra and scotomata. No brain MRI or TEE was performed. At age 16, he had acute lymphoblastic leukemia and treated with chemotherapy for three years. A protein S deficiency was identified, and he had portal vein thrombosis and subsequent splenomegaly with thrombocytopenia of about 50,000 platelets, but no bleeding episodes, and so that was at the time when he was a teenager. In 2009, he had aseptic necrosis of both hips, presumably from the chemotherapy, and had bilateral hip replacements. We recommended that he have a TEE to assess the anatomy. There was no atrial septal aneurysm. There was a small PFO with two bubbles in the left atrium, and we recommended a brain MRI to look for prior silent strokes, but the patient refused, and that was never done. These are the observational studies that were chosen by the committee, which suggest that PFO closure and decompression illness is helpful, but these are not randomized clinical trials, and so there was a weak recommendation, a weaker recommendation made by the guidelines committee. The possible recommendations that I gave to the patient were you could give up scuba diving, you could dive more conservatively, or we could close your PFO. The patient was equally concerned about preventing a stroke because of his hypercoagulable history, and thrombosis, prior thrombosis, as he was with recurrent decompression illness. So he elected to close his PFO, and the insurance companies agreed to that. So the PFO was closed with a device, 25 millimeter device. And he continued to dive to depths greater than 100 feet, and had no recurrent symptoms of decompression illness, and he had only one migraine in the past year. Thank you.

scuba diving

decompression illness

PFO closure

migraines

hypercoagulable history