Hemodynamic Responses to ECT in a Patient with Critical Aortic Stenosis

Abstract

We present a case study of a 46-year-old woman with a psychotic depressive illness of 2 months' duration with the coexisting medical diagnoses of critical aortic stenosis, severe labile hypertension, renal failure necessitating hemodialysis of 7-years' duration, and systemic lupus. Because of unresponsiveness to an antidepressant drug regimen, severe motor retardation, mutism, and refusal of food and fluids by mouth, an urgent indication for electroconvulsive therapy (ECT) was established. However, the patient refused ECT, and to allow its initiation, a court order was obtained. In view of the coexisting diagnoses of critical aortic stenosis, labile hypertension, and renal failure, ECT represented a substantially increased risk in this patient because of severe arterial hypertension and tachycardia. The patient was successfully managed during each ECT, using a combination of metoprolol by mouth, which was supplemented by i.v. esmolol immediately prior to the application of the ECT stimulus, and sodium nitroprusside, which was infused for several minutes prior to the seizure and thereafter to attenuate arterial hypertension. Nevertheless, sudden death, a well-known complication of critical aortic stenosis, occurred 96 hours after the fourth ECT.

Anesthetic Considerations for Electroconvulsive Therapy-Especially Hemodynamic and Respiratory Management

“…The hyperdynamic state induced by sympathetic activation can be prevented by ganglion-blockers [46], betablockers [47][48][49][50][51][52][53][54][55][56][57][58][59]67,77], alpha-1 and alpha2-agonists [60][61][62][63][64][65][66], Ca2+-channel antagonists [68][69][70], nitrates [71][72][73][74][75][76] or local anesthetics [78]. Rapid, short-acting opioid [79][80][81] analgesics also possess sympatholytic effects and have recently been investigated as adjuvants during ECT.…”

“…Some case reports demonstrated that sodium nitroprusside, another peripheral-acting vasodilator, induced preventive effects on hyperdynamic changes [73][74][75]. In addition, Sudha et al [76] demonstrated the efficacy of 0.5 mg/kg of sodium nitroprusside administered intraperitoneally in increasing seizure duration in rats.…”

Uncommon but serious complications associated with electroconvulsive therapy: Recognition and management for the clinician

“…These result in transient but quite significant hemodynamic changes, including an initial period of bradycardia [14], followed by a catecholamine surge with increases in blood pressure and heart rate that ordinarily resolve over several minutes after the seizure has ended [15]. Studies have shown the rate of ECT-associated cardiovascular complications to be 7.5% in patients without preexisting cardiovascular conditions, generally in the form of benign poststimulation transitory arrhythmias that resolved within minutes [16].…”

“…Studies have reported a much higher rate (55%) of ECT-associated cardiovascular complications in patients with preexisting cardiovascular conditions [16]. Fortunately, most of these events also correspond to transitory arrhythmias that are self-correcting or controlled using β blockers such as esmolol (a short-acting selective β1 blocker) and labetalol (a nonselective β blocker and α1 blocker), which appear to attenuate effectively these acute hemodynamic responses, even in the setting of preexisting cardiovascular conditions [15,16]. In addition, according to one review, as many as 91% of these patients were able to safely complete their ECT courses [16].…”

Electroconvulsive Therapy for Severe Neuropsychiatric Lupus With Psychosis

“…There has been 1 report of death in an SLE patient given ECT for severe psychotic depressive illness, however the death was resulting from a known complication of a pre-existing critical aortic stenosis in the patient. 18 ECT has also been reported to be of use in SLE patients with catatonia, 8,19Y21 including hyperkinetic and akinetic mutism. 22 More recently in 2010, Fam et al 10 reported the treatment of a case of NPSLE with catatonia with ECT in conjunction with cyclophosphamide.…”