Electroconvulsive Therapy in Patients with Cardiac Pacemakers and Implantable Cardioverter Defibrillators

Electroconvulsive Therapy in Patients With Cardiac Implantable Electronic Devices: A Case Report and Systematic Review of Published Cases

OBJECTIVE

The aims of the study were to report the case of a 54-year-old man with recurrent depressive disorder with multiple medical comorbidities having a dual-chamber pacemaker, treated successfully with 11 sessions of electroconvulsive therapy, and to conduct a systematic review of published cases documenting the use of electroconvulsive therapy (ECT) in patients with cardiac implantable electronic devices (CIEDs) for treating major psychiatric disorders.

METHODS

We searched electronic databases (MEDLINE, PubMed, Google Scholar, Embase, Cochrane Library, PsycINFO, and Crossref) and included studies reporting on the use of electroconvulsive therapy in patients with CIEDs.

RESULTS

Thirty-five publications across 53 years (1967-2021) reported on 76 patients (including current report) who received a pooled total of 979 modified ECT sessions. The most common adverse events were premature ventricular contraction and hypertension. There have been no reports of serious adverse effects that necessitated the cessation of ECT.

CONCLUSIONS

Electroconvulsive therapy is a safe and efficacious treatment for major psychiatric disorders, and the presence of CIEDs should not delay or deter the use of ECT in these patients.

Mortality and acute somatic events following electroconvulsive therapy in patients with pre-existing somatic comorbidity - A register-based nationwide Danish cohort study

OBJECTIVE

To examine whether electroconvulsive therapy (ECT) is associated with risk of mortality and acute somatic events in patients with or without somatic comorbidity.

METHODS

A total of 174,495 patients with an affective disorder, of whom 41% had somatic comorbidity, were followed from 2005 through 2018 for ECT, mortality, and acute somatic outcomes using Danish registers. The association of ECT with outcomes was estimated using Cox proportional hazard regression.

RESULTS

Patients, of whom 6943 (4.0%) had ECT, were followed for a median of 6.7 years. Compared to non-ECT treated patients, ECT was associated with a lower risk of death from natural causes, which was independent of somatic comorbidity. ECT was not associated with the risk of acute somatic events neither in patients with somatic comorbidity nor in patients without somatic comorbidity, except for cardiac events within 0-30 days of follow-up after the first ECT, for which there was a 3.7-fold higher risk in patients with no somatic comorbidity. This analysis, however, was based on few events.

CONCLUSION

In modern clinical practice, in patients with affective disorders and somatic comorbidity, ECT is not associated with a higher risk of death from natural causes or acute somatic events.

[Anesthesia for electroconvulsive therapy]

Electroconvulsive therapy (ECT) is an important component in the treatment of depression and schizophrenia in Germany. For this intervention patients undergo short-term general anesthesia and muscle relaxation. Before anesthesia can be carried out patients are subject to a comprehensive examination. For general anesthesia all established hypnotics can be used, but differences with respect to the success of the ECT have been described. Short-acting or reversible relaxants should be preferentially used. The risks of general anesthesia during ECT are estimated to be low but a transient hemodynamic instability of patients can occur. Treatment can be performed as an inpatient but also as an outpatient procedure.

Neurostimulation Therapies

Depression is one of the most disabling conditions in the world. In many cases patients continue to suffer with depressive disorders despite a series of adequate trials of medication and psychotherapy. Neuromodulation treatments offer a qualitatively different modality of treatment that can frequently prove efficacious in these treatment-refractory patients. The field of neuromodulation focuses on the use of electrical/electromagnetic energy, both invasively and noninvasively, to interface with and ultimately alter activity within the human brain for therapeutic purposes. These treatments provide another set of options to offer patients when clinically indicated, and knowledge of their safety, risks and benefits, and appropriate clinical application is essential for modern psychiatrists and other mental health professionals. Although neuromodulation techniques hold tremendous promise, only three such treatments are currently approved by the United States Food and Drug Administration (FDA) for the treatment of major depressive disorder: electroconvulsive therapy (ECT), vagus nerve stimulation (VNS), and repetitive transcranial magnetic stimulation (rTMS). Additionally, numerous other neurostimulation modalities (deep brain stimulation [DBS], magnetic seizure therapy [MST], transcranial electric stimulation [tES], and trigeminal nerve stimulation [TNS]), though currently experimental, show considerable therapeutic promise. Researchers are actively looking for ways to optimize outcomes and clinical benefits by making neuromodulation treatments safer, more efficacious, and more durable.

Electroconvulsive Therapy in Patients with Cardiac Pacemakers

There are few contraindications to electroconvulsive therapy and it is generally well tolerated. However, electroconvulsive therapy in elderly patients with cardiac pacemakers in situ theoretically presents an increased risk of complications. We undertook a retrospective audit of all patients who received anaesthesia for electroconvulsive therapy between January 1999 and September 2005. There were ten patients who had cardiac pacemakers in situ. They underwent a total of 147 electroconvulsive therapy treatments. In 146 out of the 147 treatments, the anaesthesia proceeded uneventfully. The findings suggest that provision of anaesthesia and electroconvulsive therapy in patients with cardiac pacemakers, including rate-responsive pacemakers, is a safe undertaking, with no extra precautions being needed except for routine ECG monitoring.

Neurostimulation for depression in epilepsy

Epilepsy is often associated with comorbid psychiatric illnesses that can significantly impact its long-term course. The most frequent of these psychiatric comorbidities is major depressive disorder, which affects an estimated 40% of patients with epilepsy. Many patients are underdiagnosed or undertreated, yet managing their mood symptoms is critical to improving their outcomes. When conventional psychiatric treatments fail in the management of depression, neuromodulation techniques may offer promise, including electroconvulsive therapy (ECT), vagus nerve stimulation (VNS), and repetitive transcranial magnetic stimulation (rTMS), as discussed in this review. "This article is part of the Supplement issue Neurostimulation for Epilepsy."

Anaesthesia in electroconvulsive therapy. Special conditions

OBJECTIVES

Electroconvulsive therapy (ECT) is one of the main techniques available for the treatment of such serious mental illnesses as schizophrenia and drug-resistant depression. The pre-anaesthetic assessment appropriate for patients with various mental disorders or pathologies does not differ substantially from that of any patient prior to undergoing anaesthesia for a surgical procedure. The present review aims to propose guidelines to achieve a higher level of safety and effectiveness during ECT in the most frequent situations, in accordance with the current literature.

METHODS

We conducted a search on the role of anaesthesia in ECT in the Ovid MEDLINE, PubMed, and SciELO (Scientific Electronic Library Online) databases, with special attention to the populations undergoing this type of therapy. The search was carried out between 1978 and December 2016.

RESULTS

We included the 96 articles that contained the most important recommendations for the preparation of this guide.

CONCLUSIONS

We propose these guidelines in order to achieve a higher level of safety and effectiveness during ECT in special conditions. We also summarize the most important attitude to be taken into account by the anaesthesiologist in these cases.

Electroconvulsive therapy for depression in a patient with an Inspire hypoglossal nerve stimulator device for obstructive sleep apnea: A case report

OUTCOME OBJECTIVES

METHODS: This is a case report of a patient who underwent placement and initiation of a hypoglossal nerve stimulator device in the context of receiving electroconvulsive therapy for bipolar depression between February and September 2016. To our knowledge, this has not yet been reported in the literature. Outcome measurements included successful device activation and successful device use throughout electroconvulsive therapy.

RESULTS

The patient underwent successful device implantation, activation, and use without disruption throughout electroconvulsive therapy sessions. No special device deactivation was required during electroconvulsive therapy sessions.

CONCLUSION

Obstructive sleep apnea is a common disorder that causes significant reduction in quality of life and is an independent risk factor for multiple comorbidities. Electroconvulsive therapy is an established treatment for medication-refractory depression with minimal risk in most patient populations. This is the first report in the literature of a patient undergoing ECT for bipolar depression with recent activation of Inspire hypoglossal nerve stimulator who had no disruption in the function of his implanted device.

Perioperative management of cardiac rhythm assist devices in ambulatory surgery and nonoperating room anesthesia

PURPOSE OF REVIEW

Patients with cardiac implantable electronic devices (CIEDs) frequently undergo various surgical procedures and in the past perioperative management involved only placing magnet over the device. New programming features, development of implantable cardiac defibrillator (ICD), cardiac resynchronization therapy, and increasing complexity of the operating room equipment have led to new sources of electromagnetic interference (EMI). A comprehensive understanding of the CIED is necessary to provide a timely and optimal care to the patients.

RECENT FINDINGS

Technological advancements and direct implantation of the transvenous implantable cardiac defibrillators into the heart have led to less clear lines between the pacemakers and the ICD. Subcutaneous ICD as well as the leadless transcatheter deployed intracardiac pacemaker development has complicated the issue further.

SUMMARY

Rapidly developing technologies and increasing number of patients with these devices coming for noncardiac surgeries necessitate continuous education of the anesthesia team regarding perioperative management of such devices.

Electroconvulsive therapy in 77-year-old patient with pacemaker: a case report

The treatment of a 77-year-old patient suffering from severe psychotic depression with a cardiac pacemaker is described. Because of treatment-resistant depression, electroconvulsive therapy (ECT) was introduced. In the course of ECT, there was a great improvement in his mental state without any cardiac complications. This case may be evidence for the safety and effectiveness of ECT in the elderly, even with cardiac comorbidities. Some recommendations for ECT in patients with pacemakers are discussed.

The role of electroconvulsive and neuromodulation therapies in the treatment of geriatric depression

Geriatric depression is associated with increased mortality because of suicide and decreases in functional and physical health. Many elders' depression is resistant to psychotherapy and medication and can become chronic. Electroconvulsive therapy (ECT) is increasingly used in the treatment of medication-resistant or life-threatening geriatric depression. Neuromodulation therapies (subconvulsive, focal, or subconvulsive and focal) are alternatives for the management of treatment-resistant depression in the elderly. Therapies that combine both strategies could be safer but may not be as effective as ECT. This review covers the evidence on the safety and efficacy of ECT and the neuromodulation therapies in geriatric depression.

A rare case of propofol-induced liver injury during modified electroconvulsive therapy in an elderly woman

A 75-year-old woman developed depression in 2010 and was treated with oral medications at our Department of Psychiatry. Since she showed no tendency toward improvement, she underwent modified electroconvulsive therapy (mECT). Later, she developed severe liver injury that was presumably induced by the propofol used for mECT. Propofol is an intravenous anesthetic agent that reportedly can be used relatively safely in the presence of liver dysfunction. We herein report the first case of propofol-induced liver injury definitively diagnosed based on positive drug lympocyte stimulation testing (DLST).

Cardiac rhythm management devices and electroconvulsive therapy: a critical review apropos of a depressed patient with a pacemaker

Electroconvulsive therapy (ECT) is an effective treatment and, with the proper risk-minimizing strategies, is relatively safe even in depressed patients with cardiovascular diseases. Specifically, patients with cardiac rhythm management devices (CRMDs) require particular attention because no controlled trials exist to support current empirical recommendations. We present a depressed patient with a pacemaker successfully treated with ECT, and we critically review the relevant literature. Pooled results from 63 patients and 821 ECT sessions showed that 90% of ECT sessions have been performed on depressed patients with their pacemakers in sensing mode and rate adaptation, where available, activated as well. Only 4% of sessions were performed with those functions disabled, whereas no data was available for 6% of ECT sessions. Pooled results from case series and reports highlight a discrepancy between current clinical practice and many guidelines. Electroconvulsive therapy is probably safe in depressed patients with asynchronous fixed-rate pacemakers, although there is a risk of ventricular tachycardia and fibrillation. A larger body of case series and reports suggests that there might be no need to convert synchronous demand pacemakers to asynchronous fixed-rate pacing. Regarding patients with implantable cardioverter defibrillators, antitachycardia treatment was deactivated during most ECT sessions. In depressed patients with CRMDs anticholinergics might be best avoided. In all cases, proper ECT procedures, namely, patient and pacemaker electrical isolation, strict grounding and adequate muscle relaxation along with interrogation and monitoring of CRMDs before and after each session should ensure uncomplicated electroconvulsive treatments.

Electroconvulsive therapy in the setting of implantable cardioverter-defibrillators

Electroconvulsive therapy has potent cardiovascular effects, which may pose a challenge in treating patients with preexisting cardiac disease. Although it is well studied in the treatment of refractory depression, there are still pitfalls to overcome when treating those with comorbid cardiovascular disease. The synergistic effects of depression and cardiovascular disease in affecting the morbidity and mortality of patients make treatment a significant issue. The authors discuss 3 elderly patients treated for major depression, all of whom previously had implantable cardioverter-defibrillators placed. All 3 patients were effectively treated, with no major adverse effects. The cases illustrate how taking the appropriate preventative measures allow even the most medically challenging patient to undergo effective treatment and highlight the debate surrounding the intraoperative management of implantable cardioverter-defibrillator devices.

Electroconvulsive therapy in patients with vagus nerve stimulation

Numerous studies have demonstrated the safety and efficacy of electroconvulsive therapy (ECT) for various psychiatric conditions, and it has been approved by the Food and Drug Administration for the treatment of refractory depression. Recently, the Food and Drug Administration also approved vagus nerve stimulation as a treatment for chronic or recurrent depression. Although electrical stimulation is used for both ECT and vagus nerve stimulation, the mechanisms of their action are very different. The American Psychiatric Association task force identifies no absolute contraindications to the use of ECT. The authors present 2 interesting cases of successful ECT in combination with vagus nerve stimulator.

Effects of electromagnetic interference on implanted cardiac devices and their management

Potential interference between implanted cardiac devices such as pacemakers and implantable cardioverter-defibrillators and electromagnetic fields is an important concern for physicians taking care of patients with pacemakers and implantable cardioverter-defibrillators. There are many sources of electromagnetic interference (EMI); however, only a small number of these cause significant problems that need attention. Regardless of its source, EMI is of greater concern for a patient who is dependent on paced rhythm because inhibition of the pacemaker by EMI may produce ventricular standstill. It is important that cardiologists, internists, emergency medicine, critical care physicians, and anesthesiologists be aware of how EMI can affect the function of implanted cardiac devices so that appropriate treatment can be rendered and preventive measures instituted.

Electroconvulsive Therapy: A Review of History, Patient Selection, Technique, and Medication Management

Electroconvulsive therapy (ECT) is a safe and effective treatment for severe and persistent depression, bipolar disorder and schizophrenia. Though ECT is now over 60 years old, it remains an underutilized treatment today. History, patient selection, safety, and characteristics of the treatment stimulus, technique, and medications used in ECT are reviewed. Dosing strategies, as pertaining to seizure threshold, will be considered. Mechanisms of action, especially with regard to serotonin, norepinephrine, and dopamine receptor expression will be discussed.

Concomitant use of vagus nerve stimulation and electroconvulsive therapy for treatment-resistant depression

OBJECTIVE

This study explored the use of electroconvulsive therapy (ECT) in the pivotal study of vagus nerve stimulation (VNS) for treatment-resistant depression.

METHODS

The clinical characteristics and outcomes of study participants who received ECT during the first 12 months of VNS were compared with those who did not receive ECT. Physicians were instructed to turn off VNS during administration of ECT.

RESULTS

Of 205 (evaluable sample) patients who received VNS, 14 also received ECT. Participants who received ECT had a statistically significant greater number of hospital admissions (P = 0.037, Wilcoxon) and number of suicide attempts during their lifetimes (P= 0.022, Fisher exact test). Of 55 responders (> or =50% reduction in Hamilton Rating Scale for Depression-24 questions [HRSD-24] scores) after 12 months of VNS, 3 had received ECT. Of 32 remitters (HRSD-24 score, < or =9), 2 had received ECT. Administration of ECT did not affect the implanted VNS device, and the presence of the implanted VNS device did not affect the administration of ECT.

CONCLUSIONS

Electroconvulsive therapy and VNS are not mutually exclusive. They can be used safely and effectively either sequentially or concurrently. Each can be prescribed as the depressive condition warrants-ECT for emergently worsening depressive symptoms and maintenance therapy and VNS for chronic, long-term therapy.