Combining Information on Multiple Detection Techniques to Estimate the Effect of Patent Foramen Ovale on Susceptibility to Decompression Illness

The assembly and the maintenance of the International Space Station is expected to require hundreds of extravehicular excursions (EVA's) in the next 10 years. During an EVA, in order to allow movement and bending of limbs, spacesuit pressures are reduced to about 4.3 psi. as compared with about 14.7 psi. for normal atmospheric pressure at sea level. However, the exposure of astronauts to reduced pressures in spacesuits, is conducive to fonnation and growth of gas bubbles within venous blood or tissues, which could cause decompression illness (DCI), a pathology best known to occur among deep-sea divers when they return to the surface. To reduce the risk of DCI, astronauts adjust to the reduced pressure in stages for a prolonged time known as a "pre-breathe" period prior to their extravehicular activity. Despite the use of pre-breathe protocols, an increased risk of DCI can arise for about 25% of humans who have a small hole, known as a patent foramen ovale (PFO), between two chambers of the heart. The atrial septum's fossa oval is, an embryological remnant of a flap between the septae primum and secundum allows fetal right atrial blood to pass into the left atrium, and usually closes after birth (Hagen, et al,. 1984). If fusion does not occur, a valve-like opening, the foramen ovale persists between the two atria. It has been suggested that astronauts with PFO's might be at greater risk of stroke or other serious neurological DCI because bubbles from a venous site may traverse a PFO, travel to the aorta and then enter the cerebral circulatory system causing a stroke (Figure 1). Astronauts are not now screened for PFO's, however consideration is being given to doing so. Here, we study three main methods abbreviated here as "ITE", "TCD" and "TEE", for detecting PFO's in living subjects. All involve the introduction of bubbles into a vein, immediately after which a sensory probe attempts to detect the bubbles in systemic circulation. Presence of the injected bubbles in the systemic circulation is indicative of a PFO. More detailed descriptions are given after the explanation of PFO's under Figure I. Even if a true PFO affects the risk of DCI, there remains a question of how effective screening would be if the detection method has errors of omission and/or commission. Of the three methods studied here, TEE is the "gold standard", matching autopsy results with near-perfect sensitivity and specificity (Schneider, et al. , 1996). However TEE is also the most difficult method to implement, requiring an internal esophagal probe, and is therefore not widely used. Currently, the easiest to use and most common PFO detection method is TTE, which uses an external chest probe. This method has a specificity of near 100%, but suffers from a low sensitivity rate (about 30%). More recently, TCD has been developed, which uses ultrasound probes to detect the presence of bubbles in cerebral arteries. Studies indicate that TCD is quite effective, having a sensitivity of about 91% and a specificity of about 93% (Droste, et al., 1999) when applied correctly, however implementation is difficult and requires considerable training.