Cardiac Patients and Diving
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1 Cardiac Patients and Diving Vincent LAFAY Club des Cardiologues du Sport Hôpital Saint Joseph, CHU Salvator, MARSEILLE
2 Conflict of Interest
3 Subaquatic cardiac resuscitation
4 Pathophysiology Immersion: redistribution of blood volume Increasing pre load Increasing cardiac output (15-20%)
5 Pathophysiology Immersion: redistribution of blood volume Increasing pre load Increasing cardiac output (15-20%) Cold and Hyperoxia: Peripheral vaso constriction Increasing post load Bradycardia, Arrhythmias
6 Pathophysiology Immersion: redistribution of blood volume Increasing pre load Increasing cardiac output (15-20%) Cold and Hyperoxia: Peripheral vaso constriction Increasing post load Bradycardia, arrhythmias Pressure: Loaded ventilation Impaired diastolic function
7 Pathophysiology Immersion: redistribution of blood volume Increasing pre load Increasing cardiac output (15-20%) Cold and Hyperoxia: Peripheral vaso constriction Increasing post load Bradycardia, arrhythmias Pressure: Loaded ventilation Impaired diastolic function Décompression: Gas embolism Impaired diastolic function Left- Right Shunt
8 Cardiac patient can adapt but less than healthy
9 Cardio-Vasc Contraindications 01/2012 Permanent contraindications Congenital Heart Disease Symptomatic Heart Failure Obstructive Cardiomyopathy
10 1/ Heart failure patient Limited adaptation Beware asymtomatic heart failure Echocardiography : insufficient
11 2/ Arrhythmias / Conduction Immersion: redistribution of blood volume idem Cold and Hyperoxia: Peripheral vaso constriction Bradycardia Conduction disturbances Arrhythmias Pressure: loaded ventilation Idem Decompression : Gas embolism Idem
12 Cardio-Vasc Contraindications 01/2012 Permanent contraindications Congenital Heart Disease Symptomatic Heart Failure Obstructive Cardiomyopathy Risk of syncope Paroxysmal tachycardia Non pacing 2 or 3 AV block Temporary contraindications Antiarrhythmic treatment: evaluation (*) Beta Blockers : evaluation (*)
13 Arrhythmias
14 2/ Arrhythmias Will dive : Asymptomatic patients + Normal heart Non sustained arrhythmias Ablated arrhythmias Isolated bundle branch block Won't dive : Sustained arrhythmias WPW, junctional tachycardia AV block Atrial fibrillation!?
15 Bêta-Blockers
16 3/ Valvular Heart Disease Immersion: redistribution of blood volume Idem Cold and Hyperoxia: Peripheral vaso constriction Idem Pressure: loaded ventilation Idem Decompression : Gas embolism Cavitation : beware stenosis
17 Cardio-Vasc Contraindications 01/2012 Permanent contraindications Congenital Heart Disease Symptomatic Heart Failure Obstructive Cardiomyopathy Risk of syncope Paroxysmal tachycardia Non pacing 2 or 3 AV block Valvular heart disease (*) Temporary contraindications Antiarrhythmic treatment: evaluation (*) Beta Blockers : evaluation (*)
18 Valvular heart disease
19 3/ Valvular heart disease Will dive : Asymptomatic patients Mild valvulopathy Won't dive : Symptomatic patients Severe valvulopathy Moderate valvulopathy? Stress test / No EF alteration / No LV dilatation Particular diving conditions
20 4/ Ischemic Heart Disease Immersion: redistribution of blood volume Increasing cardiac output Cold and Hyperoxia: Peripheral vaso constriction Coronary vasoconstriction Coronary steal? No Nitrox? Pressure: loaded ventilation Idem Decompression : Gas embolism Idem
21 Cardio-Vasc Contraindications 01/2012 Permanent contraindications Congenital Heart Disease Symptomatic Heart Failure Obstructive Cardiomyopathy Risk of syncope Paroxysmal tachycardia Non pacing 2 or 3 AV block Valvular heart disease (*) Temporary contraindications Ischemic Heart Disease : evaluation (*) Antiarrhythmic treatment: evaluation (*) Beta Blockers : evaluation (*)
22 Coronary artery disease
23 4/ Ischemic Heart Disease Will dive : Asymptomatic patients / 6 months delay LVEF > 50% No ischemia (stress test) Regular cardio. follow up (+ 1 stress test / year) Won't dive : Symptomatic patients Diffuse trivessel / Left main coronary Coronary spasm Smokers
24 5/ Hypertension Immersion: redistribution of blood volume Idem Cold and Hyperoxia: Peripheral vaso constriction Acute hypertension Acute Heart failure No Nitrox? Pressure: loaded ventilation Impaired diastolic function Decompression : Gas embolism Impaired diastolic function
25 Cardio-Vasc Contraindications 01/2012 Permanent contraindications Congenital Heart Disease Symptomatic Heart Failure Obstructive Cardiomyopathy Risk of syncope Paroxysmal tachycardia Non pacing 2 or 3 AV block Valvular heart disease (*) Temporary contraindications Ischemic Heart Disease : evaluation (*) Uncontrolled systemic blood pressure Antiarrhythmic treatment: evaluation (*) Beta Blockers : evaluation (*)
26 5/ Hypertension BEWARE!!!! Echocardiogaphy: Hypertrophy, diastolic function Stress test..
27 6/ Heart Diseases with shunt
28 Cardio-Vasc Contraindications 01/2012 Permanent contraindications Congenital Heart Disease Symptomatic Heart Failure Obstructive Cardiomyopathy Risk of syncope Paroxysmal tachycardia Non pacing 2 or 3 AV block Valvular heart disease (*) Temporary contraindications Ischemic Heart Disease : evaluation (*) Uncontrolled systemic blood pressure Antiarrhythmic treatment: evaluation (*) Beta Blockers : evaluation (*) Right-left shunt evidenced after decompression illness (*)
29 Cardio-Vasc Contraindications 01/2012 Permanent contraindications Congenital Heart Disease Symptomatic Heart Failure Obstructive Cardiomyopathy Risk of syncope Paroxysmal tachycardia Non pacing 2 or 3 AV block Valvular heart disease (*) Rendu-Osler disease Temporary contraindications Ischemic Heart Disease : evaluation (*) Uncontrolled systemic blood pressure Antiarrhythmic treatment: evaluation (*) Beta Blockers : evaluation (*) Right-left shunt evidenced after decompression illness (*) Pericarditis
30 Scuba / Apnea SCUBA : Cf. FFESSM Apnea :. Not for cardiac patients!
31 Conclusions For all divers: Medical screening Blood pressure evaluation +++ ECG No trained : Stress test (> 40 years old) Echocardiography (HTA) No hasty decision...
32 The FFESSM Heart Group Benoît BROUANT MD, cardiologist, Rémy KRAFFT MD, cardiologist, Gérald PHAN MD, cardiologist, Gérard FINET MD, PhD, cardiologist, Vincent LAFAY MD, PhD, cardiologist, Frédéric ROCHE MD, PhD, physiologist, Bruno LEMMENS MD, pneumologist, Bruno GRANDJEAN MD, hyperbarist Websites :
33 Environmental constraints All divers concerned including cardiac patients Start from the very beginning of the dive Way back more «expensive» 5 constraints Immersion Cold Hyperoxia High pressure? Decompression
34 For meditation ARNOLD RW, Undersea Biomed Res, 1985
35
36 Heart-lungs interactions
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