Case Report: Electroconvulsive Therapy for Treatment Resistant Depression in a 68 year old male with a Cardiac Resynchronization Therapy Device with Defibrillator

Frank Copeli, MD

VA Boston Healthcare System
Case Report: Electroconvulsive Therapy for Treatment Resistant Depression in a 68 year old male with a Cardiac Resynchronization Therapy Device with Defibrillator

Scientific Abstract

Background: Electroconvulsive therapy has been applied safely in patients with cardiac pacemakers and implantable cardiac devices. Cardiac Resynchronization Therapy Devices (CRT), available with and without defibrillation (CRT-P and CRT-D), benefit patients with Heart Failure with reduced ejection fraction (HFREF). There are currently no case reports on the use of ECT in patients with cardiac resynchronization therapy devices.

Methods: Patient is a 68-year-old male with a history of major depressive disorder, PTSD, cluster B personality traits who presented in December 2019 for suicidal ideation in the context of a major depressive episode. He has His medical history is notable for atrial fibrillation on warfarin, DM2 on insulin, non-ischemic cardiomyopathy with HFREF. In 2015, patient’s ICD was replaced with CRT-D.

Patient’s initial MADRS was 30 on admission scoring highly for suicidal ideation. Prior to ECT, Anesthesia, Cardiology, and Electrophysiology (EP) services were consulted. Patient’s CRT-D device was interrogated and determined to be functioning and medically optimized for ECT. His ejection fraction was 30% approximately 6 months earlier.

Results: Prior to first session, Electrophysiology reprogrammed device and patient had defibrillator pads placed. A brief seizure was achieved. EP recommended placement of magnet on CRT-D for subsequent sessions. For the following 3 sessions, adequate seizures were obtained. During ECT therapy, patient underwent echocardiogram which indicated ejection fraction of 20-25%. Cardiology recommended patient could continue with ECT if euvolemic and asymptomatic. After 4th session, a collaborative decision was made with patient to forego further ECT given patient’s improvement in mood. Prior to discontinuation, MADRS score was 0.

Conclusion: This case indicates ECT can be provided safely to patients with a CRT-D device; placing device in electrocautery mode with defibrillator pads as well as disabling defibrillator function with a magnet both proved effective methods to provide ECT safely. Further study of ECT in patients with CRT devices is warranted to observe patients who complete a course of 6- 12 sessions.

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research Areas

Authors

Frank Copeli, MD Anderson Chen, MD Demin Ma, Ph.D., MD Fe Festin, MD