Joint position statement on atrial shunts (persistent [patent] foramen ovale and atrial septal defects) and diving: 2025 update. South Pacific Underwater Medicine Society (SPUMS) and the United Kingdom Diving Medical Committee (UKDMC)

This consensus statement is the product of a workshop at the South Pacific Underwater Medicine Society Annual Scientific Meeting 2024 with representation of the United Kingdom Diving Medical Committee (UKDMC) present, and subsequent discussions included the entire UKDMC. A large right-to-left shunt across a persistent (patent) foramen ovale (PFO), an atrial septal defect (ASD) or a pulmonary shunt is a risk factor for some types of decompression sickness (DCS). It is agreed that routine screening for a right-to-left shunt is not currently justifiable, but certain high risk sub-groups can be identified. Individuals with a history of cerebral, spinal, vestibulocochlear, cardiovascular or cutaneous DCS, migraine with aura or cryptogenic stroke; a family history of PFO or ASD and individuals with other forms of congenital heart disease have a higher prevalence, and for those individuals screening should be considered. If screening is undertaken, it should be by bubble contrast transthoracic echocardiography with provocative manoeuvres (including Valsalva release and sniffing). Appropriate quality control is important. If a shunt is present, advice should be provided by an experienced diving physician taking into account the clinical context and the size of shunt. If shunt-mediated DCS is diagnosed, the safest option is to stop diving. Another is to perform dives with restrictions to reduce the inert gas load, which is facilitated by limiting depth and duration of dives, breathing a gas with a lower percentage of nitrogen and reducing repetitive diving. Divers may consider transcatheter device closure of the PFO or ASD in order to return to normal diving. If transcatheter PFO or ASD closure is undertaken, repeat bubble contrast echocardiography must be performed to confirm adequate reduction or abolition of the right-to-left shunt, and the diver should have stopped taking potent anti-platelet therapy (low dose aspirin is acceptable) before resuming diving.