Patent Foramen Ovale (PFO)

[Kemosabe]

Hey guys,

I was hoping a Flight Doc could help me with a few questions as far as waiver possibilities.

I apologize beforehand for the long post, but I figured it was best to wrap as much as I could of it into one. I am a 23 y/o male interested in attaining an SNA slot via Navy OCS hopefully within the next year if all goes well. However there are a few issues that need to be resolved before I go forward.

I was diagnosed in 2002 with Patent Foramen Ovale (PFO), which as I understand is essentially a hole in between the left and the right atria of the heart. Apparently this is an extremely common condition, the hole normally closes up within a year after birth but not always, and is labeled a PFO. In the letter, from my cardiologist to my pediatrician, the MD wrote that the PFO "was trivial and requires no special precautions." According to the NAMI waiver guide:

3.10 Atrial Septal Defect (ASD)/Patent Foramen Ovale

AEROMEDICAL CONCERNS: Physiologically, it is difficult to differentiate between patent foramen ovale (no murmur, no change in S2) and atrial septal defects (murmur, fixed split in S2). For the purposes of this discussion, the two conditions will be both considered "atrial septal defects". Atrial septal defects predispose individuals to several conditions. The known frequency of the condition in our age group and the relative lack of demonstrated pathology however argue against any significant effect. It has been postulated that ASD predisposes to decompression sickness (DCS). Valvular dysfunction can occur and pulmonary hypertension may develop.

WAIVER: Personnel found to have a Patent Foramen Ovale or hemodynamically stable ASD are PQ for aviation duty. Hemodynamically stable is defined as: (1) asymptomatic, (2) no right ventricular enlargement on echocardiogram, (3) no fixed splitting of S2, (4) normal EKG and (5) normal CXR. Designated aviators with surgically corrected ASD may be considered for waiver. Waivers are not recommended for candidates

So the condition is DQ for candidates. Understood. However, in 2010 I went to see a cardiologist to check out the PFO and had what is known as a bubble study done. Essentially they shake a saline solution up until it bubbles and inject it into your veins so it can be seen on an EKG once the solution enters the heart. If there's no hole between the left atrium and right atrium, the bubbles will simply be filtered out in the lungs. If you have a patent foramen ovale, some bubbles will appear on the left side of the heart. So when I had this study done, there were no bubbles that occurred on the left side of my heart.

Basically, if my PFO has found to be closed, using the bubble study method and/or other methods, would the history of the PFO be found disqualifying? Thanks in advance.

 

[wlawr005]

Hey guys,

I was hoping a Flight Doc could help me with a few questions as far as waiver possibilities.

I apologize beforehand for the long post, but I figured it was best to wrap as much as I could of it into one. I am a 23 y/o male interested in attaining an SNA slot via Navy OCS hopefully within the next year if all goes well. However there are a few issues that need to be resolved before I go forward.

I was diagnosed in 2002 with Patent Foramen Ovale (PFO), which as I understand is essentially a hole in between the left and the right atria of the heart. Apparently this is an extremely common condition, the hole normally closes up within a year after birth but not always, and is labeled a PFO. In the letter, from my cardiologist to my pediatrician, the MD wrote that the PFO "was trivial and requires no special precautions." According to the NAMI waiver guide:

3.10 Atrial Septal Defect (ASD)/Patent Foramen Ovale

AEROMEDICAL CONCERNS: Physiologically, it is difficult to differentiate between patent foramen ovale (no murmur, no change in S2) and atrial septal defects (murmur, fixed split in S2). For the purposes of this discussion, the two conditions will be both considered "atrial septal defects". Atrial septal defects predispose individuals to several conditions. The known frequency of the condition in our age group and the relative lack of demonstrated pathology however argue against any significant effect. It has been postulated that ASD predisposes to decompression sickness (DCS). Valvular dysfunction can occur and pulmonary hypertension may develop.

WAIVER: Personnel found to have a Patent Foramen Ovale or hemodynamically stable ASD are PQ for aviation duty. Hemodynamically stable is defined as: (1) asymptomatic, (2) no right ventricular enlargement on echocardiogram, (3) no fixed splitting of S2, (4) normal EKG and (5) normal CXR. Designated aviators with surgically corrected ASD may be considered for waiver. Waivers are not recommended for candidates

So the condition is DQ for candidates. Understood. However, in 2010 I went to see a cardiologist to check out the PFO and had what is known as a bubble study done. Essentially they shake a saline solution up until it bubbles and inject it into your veins so it can be seen on an EKG once the solution enters the heart. If there's no hole between the left atrium and right atrium, the bubbles will simply be filtered out in the lungs. If you have a patent foramen ovale, some bubbles will appear on the left side of the heart. So when I had this study done, there were no bubbles that occurred on the left side of my heart.

Basically, if my PFO has found to be closed, using the bubble study method and/or other methods, would the history of the PFO be found disqualifying? Thanks in advance.

Nevermind, I went back and read it again and now I understand.

Best of luck, keep trying until you get the answer you want.

 

[BusyBee604]

Hey guys,
I was hoping a Flight Doc could help me with a few questions as far as waiver possibilities.

Thanks in advance.

Welcoms Kemosabe, interesting situation. You came to the right place, and the fees aren't bad either. We have several fully qualified, outstanding Flight Surgeons here, but they stay busy "making the rounds", so be patient, it could take several days for them to pop in to answer your questions, It'll be worth the wait.

In the meantime, take the time to fill in your member profile... it will help us & the Docs help you. Say Hi to "Da Ranger" for us when you join up with the Dude!

BzB

 

[TimeBomb]

Kemosabe,
A couple questions first: what prompted you to have an echocardiogram done in 2002 that diagnosed the ASD? Secondly, did the echo tech have you do a Valsalva maneuver on the echo in 2010? A Valsalva changes the pressures in the heart, and can force bubbles across an ASD/PFO.

ASD/PFO are also associated with embolic stroke in young people, thought to be related to a similar mechanism as the increased risk for decompression sickness, namely that microscopic blood clots or air bubbles (in the case of DCS) bypass the lungs and enter the left heart, where they are distributed to the body.
R/

 

[Kemosabe]

Thanks for the quick replies.

vlawr005, Thanks. I saw your post before you edited it and asked about it below.

BusyBee604, I'll definitely do that for ya!

TimeBomb,
I had an echocardiogram done in 2002 because my pediatrician heard a murmur. The cardiologist wrote a letter to my pediatrician after looking at the murmur and discovered the PFO, and here is what he wrote:

"Lungs are clear, chest is symmetrical with a regular rhythm, a quiet precordium, normal first and second heart sounds and a II/VI low pitched systolic ejection murmur heard best at the left middle sternal border, loudest in the supine position. There were no diastolic murmurs, no clicks, rubs, or thrills. Liver and spleen are not enlarged. Four extremity pulses are normal.

EKG showed sinus rhythm at 65 beats per minute and normal axis of +48 degrees in the frontal plane and prominent LV forces for age. PR of .14, QRS of .09, and a normal QT of .38 seconds.

The 2 dimensional echocardiogram showed normal intracardiac anatomy, normal Dopplers, and a trivial PFO.

This murmur is an innocent flow murmur which requires no special precautions or cardiac follow up. The PFO is trival and does not need any special precautions."

As to the second question, I don't specifically remember the valsalva maneuver but there were some other things I was asked to do when they were performing the test, such as clenching. I'm seriously considering going back to the cardiologist to have it looked at it again and to ask specific questions.

As far as the waiver guide goes, when it refers to personnel, is that already winged aviators, or does it include both applicants and aviators? The guide states PFO found to be stable is PQ for personnel, but later states it is not a waiverable condition for applicants so I am a little confused.

Thanks for all the help!

 

[wlawr005]

Yeah, that's what I was confused about as well. It basically says that it's okay as long as you are already winged, but a waiver is not recommended for applicants.

Here's the deal...there was a guy who got shot in the face and was missing one of the four main arteries leading to his brain. After a lot of FS telling him no, he found one that said yes and is now a semi-famous (notorious?) Naval Aviator. Keep searching around until you get the answer you want...it's doesn't flat out say the condition is disqualifying, just that a waiver isn't recommended

 

[Kemosabe]

Faceshot from Speed and Angels, eh?

Thanks for the support.

 

[TimeBomb]

Kemosabe,
The waiver guide is really confusing me on this one also. ASD/PFO used to be CD, no waiver recommended for candidates. The way I read the guide now, I get the impression that an incidentally noted PFO/ASD is not considered disqualifying (NCD) for either candidates or designated personnel, since it just says "personnel", making no distinction between candidates and designated personnel. The next sentence could be interpreted to apply to a distinct situation regarding the disposition of surgically corrected ASD/PFO. Surgical correction of a symptomatic ASD/PFO can be waived in designated personnel, but not in candidates. Maybe I'm just parsing the waiver guide like Bill Clinton, but it's probably worth having your recruiter call NAMI for a ruling on this one before you go to a lot of additional expense with another cardiology evaluation and echo.
R/

 

[Kemosabe]

That's how I read it as well, but having the "waivers are not recommended for candidates" at the end confuses me. Not sure if it's adding to the previous sentence or wrapping up the whole paragraph by touching on all areas.

I will definitely have to get in touch with my recruiter. I'm still at the very beginning stages of applying so it will probably take some time to get an answer.

Also, when it states "waivers are not recommended for candidates," does that mean they are not given to candidates, or generally not given?

 

[TimeBomb]

Kemosabe,
Across the Navy, medical only recommends a course of action to the line. If the line chooses to agree with medical's recommendation, that's their choice. If they choose not to agree with medical's recommendation, that's also their choice. The line determines what their needs are at the moment, and uses that information to decide if a waiver of standards will or will not be granted. That said, the aperture is generally pretty small for candidates when it comes to waivers.
R/

 

[Kemosabe]

Understood. I'm just going to press forward and hope for the best, the rest is out of my control. I'll look into the issue with my recruiter and will relay my findings here once that happens.

I know this is a Navy website, but interestingly enough, asymptomatic or stable PFO is not considered an issue in the Air Force and a waiver isn't required for it.

 

[BusyBee604]

I know this is a Navy website, but interestingly enough, asymptomatic or stable PFO is not considered an issue in the Air Force and a waiver isn't required for it.

Not surprising, they're not required to takeoff and land on, gasp, SHIPS, day and night!

BzB

 

[exNavyOffRec]

Understood. I'm just going to press forward and hope for the best, the rest is out of my control. I'll look into the issue with my recruiter and will relay my findings here once that happens.

I know this is a Navy website, but interestingly enough, asymptomatic or stable PFO is not considered an issue in the Air Force and a waiver isn't required for it.

Some issues for one service are not for others and vice versa.

A conversation that I had right before I left recruiting with N3M on their view was why waiver when there are many that don't need to be waivered, however the only way to find out is to get the physical done and see what N3M says.

 

[Renegade One]

The 2 dimensional echocardiogram showed normal intracardiac anatomy, normal Dopplers, and a trivial PFO.

Seriously, I hope it's that easy for you...

 

[Kemosabe]

NavyOffRec, I understand. I wasn't trying to say that's the way it should be or anything like that, just think it's odd that it can be totally different between two branches.

RenegadeOne, I wish it would be that easy. We will see.

The only reason I mentioned that was to basically tell myself and anyone who has this same issue that there are other options. I've always wanted to fly, especially for the Navy, and helicopters specifically. So, if it doesn't work out after I've gone through everything, that's life. I'll simply just have to look elsewhere.

The Army's waiver guide doesn't even mention the defect, well only once and that has to do specifically with the PFO being surgically closed. Good news if this doesn't work out for the Navy.

I'm going to see the cardiologist in a week to ask him some specific questions about the issue. I want to know if the tests are all negative, and there is no sign of the PFO, is it considered to be closed and no longer existent and so on. Hoping for good news about it.