Cardiac Rhythm Management Devices and Electroconvulsive Therapy

Abstract

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 77-year-old patient with pacemaker: a case report

“…The synchronous mode was preserved to minimize the risk of VT/VF episodes, which are the most serious side effects occurring in the asynchronous mode. 4 …”

“…As such, taking into account other case reports, staying with the synchronous mode might be preferable. 4 Dolenc et al reported that anticholinergic agents used immediately before ECT might be used to prevent the patient from developing bradycardia or asystolia. 3 Atropine should protect the patient from bradycardia connected with activating the parasympathetic nervous system, especially in patients with primary bradyarrhythmia or heart block.…”

“… 2 However, the use of anticholinergics has been criticized. 4 The anesthesiologist should always be prepared for pacemaker-malfunction episodes.…”

“…There have been no large, randomized clinical studies of ECT treatment on patients with implanted pacemakers. Recommendations, which cover additional procedures before, during, and after ECT, were proposed by Kokras et al 4 According to these, before each ECT, the physician is supposed to check the parameters of the pacemaker and ensure that the electrodes are correctly placed. Proper cooperation between the ordering psychiatrist, anesthetist, and cardiologist is required.…”

“… 1 , 2 It is considered a safe method in psychiatric patients with cardiac diseases. 3 , 4 However, there are not sufficient published data on the use of ECT in patients with implanted pacemakers. The proper treatment of these patients seems to be a complex problem, especially for the elderly.…”