Electroconvulsive Therapy for Depression in Patient With Implanted Spinal Cord Stimulator

Abstract

to increased parasympathetic discharge. This can be particularly concerning in Fontan physiology. In our patient, there were no remarkable hemodynamic changes, her vital signs were within 20% of baseline throughout. If she developed signs of hemodynamic instability or vital signs exceeding 20% of baseline, we would primarily be concerned for pulmonary hypertension due to increased pulmonary vascular resistance and or decreased ejection fraction. Therefore, we were prepared to place an arterial line to assist in monitoring and assessment, defibrillation, as well as intubation. If she needed intubation, our ventilation plan was developed to minimize pulmonary vascular resistance by using spontaneous ventilation and low PEEP. In addition, hyperventilation after induction is standard to allow for a favorable seizure. In our patient, significant hyperventilation can drop cardiac output by increasing alveolar distension or increasing intrathoracic pressure, therefore, we used a mild hyperventilation strategy to minimize risk. Hand bag ventilation was used at a rate mildly increased from her baseline respiratory rate.It is known that ECT causes parasympathetic discharge resulting in bradycardia. The bradycardia might be longer in duration, as Fontan patients have frequent issues with the sinoatrial node dysfunction. Fontan patients are at a higher risk for atrial dysrhythmias. Electroconvulsive therapy has a compensatory tachycardiac phase after the parasympathetic discharge, which poses a risk for Fontan patients. Sustained tachycardia is not well tolerated in single ventricles and can lead to severe hemodynamic effects. The safest treatment is immediate cardioversion. Antiarrhythmic drugs can be detrimental to ventricular contractility and vascular resistance.She tolerated the procedure and underwent subsequent treatments. Her mood improved, and she was stable for discharge. We demonstrated ECT can be done safely in a compensated patient with a history of a Fontan procedure and discuss risks and potential complications.