Patent foramen ovale and the risk of paradoxical embolization of venous bubbles in divers-cave for foam sclerotization of varicose veins
Abstract
Introduction: Foam sclerotization of varicose veins may cause paradoxical embolization through patent foramen ovale (PFO). The aim of our study was to: 1) select an optimal screening method for the detection of PFO; 2) determine the prevalence of PFO in a nonselected population; and 3) test the risk of paradoxical embolization of venous bubbles in patients with PFO.
Materials and methods: A diver after decompression is a suitable model for determining the risk of paradoxical embolization of venous gas bubbles. 329 Czech divers were screened for PFO. In a pilot study, we compared Transcranial Doppler Sonography (TCD) with Transesophageal Echocardiography (TEE) in 100 patients.
TCD alone was used for further screening. In 31 divers with PFO, nitrogen bubbles were detected after simulated dives.
Transthoracic Echocardiography (TTE) was used to detect venous bubbles in rightsided heart chambers; TTE and TCD were used to detect arterial bubbles. The right-to-left shunt was rated as non-significant (=20 arterial bubbles).
Different decompression regimens were compared. Results: In the pilot study, TCD was compared with the gold standard in PFO detection - TEE.
The negative predictive value of TCD was 100%, positive predictive value was 92%. Screening was performed in a total of 329 divers, PFO was detected in 85 (25%), significant R-L shunt in 45 (14%).
In simulated dive to 50 m maximum depth, venous nitrogen bubbles were detected in 7/8 (88%) divers. In 6/8 (75%) divers, paradoxical embolization was confirmed - nitrogen bubbles were detected in the systemic circulation.
Conclusion: PFO prevalence with significant R-L shunt was 14% in the non-selected population of Czech divers. Simulated dives indicate that PFO represents a risk factor for paradoxical embolization of gas bubbles.
TCD is a suitable screening method for the detection of PFO and the evaluation of R-L shunt significance. These results are indicative of a possible high risk of paradoxical embolization of gas bubbles and the trombogenic substance in patients with a larger PFO and significant R-L shunt undergoing foam sclerotization of varicose veins.