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Patent foramen ovale influences the presentation of decompression illness in SCUBA divers. BACKGROUND: Few have examined the influence of patent foramen ovale (PFO) on the phenotype of decompression illness (DCI) in affected divers. METHODOLOGY: A retrospective review of our database was performed for 75 SCUBA divers over a 10-year period. RESULTS: Overall 4,945 bubble studies were performed at our institution during the study period. Divers with DCI were more likely to have positive bubble studies than other indications (p<0.001). Major DCI was observed significantly more commonly in divers with PFO than those without (18/1,000 v.s. 3/1,000, p=0.02). Divers affected by DCI were also more likely to require a longer course of hyperbaric oxygen therapy (HBOT) if PFO was present (p=0.038). If the patient experienced one or more major DCI symptoms, the odds ratio of PFO being present on a transoesophageal echocardiogram was 3.2 (p=0.02) compared to those who reported no major DCI symptoms. CONCLUSION: PFO is highly prevalent in selected SCUBA divers with DCI, and is associated with a more severe DCI phenotype and longer duration of HBOT. Patients with unexpected DCI with one or more major DCI symptoms should be offered PFO screening if they choose to continue diving, as it may have considerable prognostic and therapeutic implications.