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Reversible Myocardial Dysfunction and Clinical Outcome in Scuba Divers With Immersion Pulmonary Edema

https://doi.org/10.1016/j.amjcard.2013.01.339Get rights and content

Immersion pulmonary edema in scuba divers is a rare disorder that tends to recur and can be potentially fatal, even in the absence of underlying cardiac disease. Anecdotal cases of reversible myocardial dysfunction have been described in this setting, but little is known of its pathogenesis. The purpose of the present study was to determine the clinical outcomes and the determinants associated with this condition. The data from 54 consecutive divers admitted for acute immersion pulmonary edema during a 5.5-year period were retrospectively studied. A diagnosis of myocardial dysfunction was established by the presence of elevated cardiac troponin T levels, coupled with electrocardiographic changes and/or wall motion abnormalities on the echocardiogram. The demographic, clinical, biologic, and diving characteristics were tested as potential predictors of this disorder. All the patients had complete resolution of symptoms within 72 hours, but 3 required intensive ventilation or hemodynamic support at admission. Reversible myocardial dysfunction was observed in 28% and was associated more with age >50 years (odds ratio [OR] 5.5, 95% confidence interval [CI] 1.5 to 21, p = 0.013), hypertension (OR 8.2, 95% CI 2.1 to 32, p = 0.002), diabetes (OR 22.1, 95% CI 1.1 to 458; p = 0.002), and release of natriuretic peptides (OR 9.1, 95% CI 2.4 to 35, p = 0.001). Follow-up investigations at 1 month were obtained for 49 patients and revealed a significant number of patients with occult hypertension. In conclusion, reversible myocardial dysfunction is not uncommon in divers with immersion pulmonary edema. The short-term overall prognosis is not adversely altered, but severe heart failure with a fatal outcome is unpredictable. Close monitoring of older divers with latent cardiovascular risk factors is warranted.

Section snippets

Methods

We retrospectively reviewed the medical records and diving parameters of scuba divers treated in 2 French hyperbaric facilities (Toulon near the Mediterranean Sea and Brest near the Atlantic Ocean) from January 2007 to June 2012, who met the clinical criteria for IPE (i.e., onset of dyspnea during diving, cough, frothy sputum, bilateral rales) documented by chest computed tomography in the 6 hours after their admission. We excluded the patients with historical and clinical evidence of water

Results

The mean age of the study population was 46 ± 13 years; 18 (33%) were women. Of the 54 patients, 43 (80%) originated from Toulon and 11 (20%) from the area of Brest. The divers with IPE treated in Toulon during the study period represented 12% of all patients referred for a diving injury to this facility, if we included those with incomplete data.

All the patients were admitted to the emergency unit or the intensive care unit for a minimum of 12 hours with usual treatment consisting of

Discussion

The present series is the largest series of IPE in scuba divers in the published data. Our results have tended to demonstrate that RMD accompanying IPE is common, with 28% of patients having cardiac injury, documented by cTnT release and echocardiographic and/or electrocardiographic abnormalities. This phenomenon has rarely been depicted, making a direct comparison with other studies difficult. In a series of 19 scuba divers with documented IPE, Henckes et al5 identified only 2 patients who

Acknowledgment

We gratefully acknowledge the medical team of the cardiology department of Sainte Anne's military hospital (Toulon, France) for conducting the laboratory investigations and performing the echocardiography. We thank P. Constantin, MD, for his participation in our study.

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