Electroconvulsive Therapy in Patients with Cardiac Pacemakers and Implantable Cardioverter Debrillators

TAMARA J. DOLENC,* ROXANN D. BARNES, DAVID L. HAYES, and KEITH G. RASMUSSEN*

From the *Department of Psychiatry and Psychology, the Department of Anesthesiology, Division of Cardiovascular/Thoracic Anesthesia, the Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota

DOLENC, T.J., ET AL.: Electroconvulsive Therapy in Patients with Cardiac Pacemakers and Implantable Cardioverter Debrillators. Electroconvulsive therapy (ECT) is used to treat major depressive illness, especially in elderly and medically frail patients. Not uncommonly, these patients have cardiac pacemakers or implantable cardioverter debrillators (ICDs). Only a few case reports in the literature describe the use of ECT in such patients. Herein we review our ECT experience treating 26 pacemaker patients and 3 ICD patients. All patients obtained signicant antidepressant benets with ETC. Only one serious cardiac event occurred, a case of supraventricular tachycardia (SVT) requiring a stay on the cardiac intensive care unit. The SVT resolved and the patient went on to receive further uncomplicated ECT treatments. We conclude from this experience that with proper pre-ECT cardiac and pacemaker/debrillator assessment, ECT can be safely and effectively administered to patients with an implanted cardiac device. (PACE 2004; 27:12571263) electroconvulsive therapy; cardiac pacemaker; implantable cardioverter debrillator Introduction Electroconvulsive therapy (ECT) is commonly used to treat depression in patients with a variety of cardiac conditions. ECT is generally quite safe in this population, though risk reduction strategies can minimize complications.1 It is not uncommon in ECT practice to encounter a patient with either a cardiac pacemaker or an implantable cardioverter debrillator (ICD). In the relatively few case reports of the use of ECT in patients with an implanted cardiac device, ECT appears to be safe.213 In reviewing the database of our tertiary care referral center, we found records for 29 cardiac device patients who had undergone ECT, 26 of whom had a cardiac pacemaker and 3 of whom had an ICD. One of the ICD patients has been described previously9 and will be presented again here for completeness. In this report we review our experience in treating these patients, outline some of the safety concerns, and offer recommendations for ECT therapy in this subset of patients. Methods Patients We conducted a chart review of 26 patients with a cardiac pacemaker and three with an ICD who received ECT at the Mayo Clinic between the late 1980s and 2004. We were looking specifically for any complications that occurred during
Address for reprints: Keith G. Rasmussen, M.D., Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Mayo West 11, 200 First St. SW, Rochester, MN 55905. Fax: 507-284-4158; e-mail: rasmussen.keith@mayo.edu Received December 1, 2003; revised April 12, 2004; accepted April 22, 2004.

the treatments, such as emergent worsening of the cardiac conditions or evidence of pacemaker/ICD malfunction. The clinical course of the antidepressant response to ECT was assessed by chart review. All patients were examined by an internist for a preanesthesia medical exam. Further cardiological testing (i.e., echocardiogram, stress testing, adenosine Sestamibi scan, or coronary angiography) was performed as recommended by the internist or cardiology consult service. Presence of pacemakers or ICDs alone has not been a contraindication for ECT in our institution. The standard protocol required device interrogation prior to the rst treatment and after the completion of the ECT course. A magnet to convert the pacemaker from demand mode to xed mode was not routinely used but was present in the treatment suite. In the patients with ICDs the device was programmed to monitor only, i.e., therapies were turned off and the patient was continuously monitored electrocardiographically with cardiac resuscitative equipment immediately available. ICD therapies were turned on immediately after the ECT treatment was completed. Pacemaker/ICD interrogation and programming was performed by the cardiac pacemaker/electrophysiology staff. ECT Technique After placement of a 24 gauge intravenous (IV) catheter all adults received premedication with the anticholinergic agent glycopyrrolate (0.2 mg IV) in the holding area immediately before treatment with ETC. The purpose of this medication is as an antisialogogue and to counteract commonly occurring vagally-mediated bradycardia associated with ETC. 1257

PACE, Vol. 27

September 2004

1258 Table I. Treatment Characteristics of Patients with Pacemakers or ICDs

Medical Diagnoses DDD DDD DDD 14 AVB None (N) 2 3 AVB AVB PVCs PVCs Device Manufacturer/ Model Pacing Mode Reason for Device ECG during ECT 37 15 6 Years since Device Implantation Number of ECT treatments Years Treated with ECT 1999-2000 1985-198 1984 Medtronic Medtronic Simbios 7006 Unknown Medtronic KSR 701 Unknown VVIR DDD 2 6 AVB SND N N 8 15 2000 1984

Patient number

Gender

Age

1 2

F M

80-81 72-73

CAD, hypertension Hypertension

73

4 5

F F

67 74

DOLENC, ET AL.

September 2004
VVIR VVI 7 13 AVB SND Meditronic Thera SR 8962 Medtronic UUI Medtronic 8830 Medtronic Legend 8416 Unknown Medtronic 8419 Medtronic 8088 Pacesetter 2022L VVIR DDD VVIR DDD VVIR VVIR 6 6 AVB AVB 4 2 3 5 AVB AVB AVB AVB Thera 7950B DDR 0.5 AVB

77

CAD, Ischemic cardiomyopathy, congestive heart failure, status post aortic valve replacement Atrial brillation, hypertension Rheumatic fever, status post mitral valve replacement, status post tricuspid valve annuloplasty Atrial brillation

N N

15 8

1999 1992

82

8 9

F M

63 69

N N

12 10

1991 1989

10 11

M M

77 77

N N N N

12 8 19 9

1997 1994 1997-1998 1992

12 13

F M

89-90 73

PACE, Vol. 27

14

72

Status post myocardial infarction, status post coronary artery bypass grafting, tricuspid valve requrgitation Aortic valve replacement Status post coronary artery bypass grafting, atrial brillation, sick sinus syndrome Atrial brillation Status post coronary artery bypass grafting Hypertension Atrial brillation, hypertension, status post aortic valve replacement CAD, status post two myocardial infarctions, status post percutaneous translumial coronary angioplasty atrial brillation

1995

PACE, Vol. 27
Unknown DDD 2 AVB Brief SVT 53 1999-2002 Unknown Medtronic 7960 Medtronic DDD VVI; ICD 2 1-pacer; 6-ICD SND V Tach N N DDD 0.75 AVB N 5 10 25 1987 1997-1998 2001 DDDR DDD DDD DDDR 9 16 SND AVB 4-6 SND 3-9 SND PVCs N N N 108 48 5 8 1993-1999 1995-1997 1991 1999 Medtronic Elite 7076 Medtronic Legend 8416 Medtronic Symbios 7005 Medtronic Kappa 700 DDD DDD DDDR VVI DDDR ICD ICD 3 4 3 2 3 6 0.25 Syncope SND AVB AVB SND V Tach V Tach N N N N N N N 6 8 10 10 6 3 8 1992 1990 1992 1993 1998 1999 2004 Pacesetter 2016t Medtronic 8416 Telectronics Meta 2016 Unknown Pacesetter Trilogy Medtronic 7223 Guidant H115

15

84-87

16

68

17 18

F F

74-75 67

19

89-95

20

89-91

Paroxismal atrial brillation, congestive heart failure, hypertension Congestive cardiomyopathy, hypertension Hypertension CAD, status post myocardial infarction, ischemic cardiomyopathy, hypertension CAD, recurrent atrial brillation, hypertension CAD, atrial brillation

21

78

22

79

23 24 25

M F F

61 78 73

Paroxysmal supraV Tach, hypertension CAD, status post coronary artery bypass grafting, history of atrial brillation Dilated cardiomyopathy

ECT AND PACEMAKERS/ICDS

September 2004

26

79

27

81

28 29

M F

78 58

Rheumatic heart disease, atrial brillation Congestive heart failure, hypertension CAD, status post two myocardial infarctions Syncope Dilated cardiomyopathy

CAD = coronary artery disease; AVB = trioventricular block; SND = sinus node dysfunction; SVT = supraventricular tachycardia; V Tach = ventricular tachycardia. DDD, DDDR, VVI, and VVIR are NBG codes for pacing nomenclature based on Bernstein AD, Daubert JC, Fletcher RD, et al. PACE 2002; 25:260.

1259

DOLENC, ET AL.

American Society of Anesthesiology (ASA) standard monitors (ECG, pulse oximetry, and noninvasive blood pressure monitoring) are used continuously throughout the procedure. General anesthesia is induced with thiopental sodium (dose 3-4 mg/kg IV) until loss of lid reex occurs. Neuromuscular blockade is achieved with succinylcholine chloride (dose 0.6-1.0 mg/kg IV). Oxygen is administered via bag-and-valve apparatus and disposable anesthesia face mask during the procedure and respiration is assisted for the brief apneic period. In particular, ECG monitoring was begun before any device manipulations (e.g., turning off of an ICD) took place. After anesthesia and muscular paralysis were achieved, electrical current was applied to the head using either the Thymatron DGX or Thymatron System IV ECT apparatus (Somatics, Inc., Lake Bluff, IL, USA), which produce a constant current, brief pulse electrical stimulus. The amount of applied electrical charge in millicoulombs can be precisely quantied with this device. Stimulus electrode placement was either bilateral (i.e., one electrode on each temporal region) or unilateral (i.e., one electrode on the right temporal region and the other just to the right of the vertex of the skull) as chosen by the treating psychiatrist. Seizure threshold, which is the minimum amount of electrical charge required to induce a generalized tonic clonic seizure, was determined at the rst session using a titration procedure previously described.14 For subsequent treatments, a 1.5-times threshold dose was applied when bilateral stimulus electrode placement was used. For unilateral stimulus electrode placement, a 6-times seizure threshold electrical dose was used. These anesthetic and technical parameters are consistent with standard ECT practice.15 Seizure termination was conrmed by cessation of convulsive movements of a limb cuffed before succinylcholine administration and by termination of spike and wave activity on the EEG. Occasional doses of beta blocking agents (typically labetalol or esmolol) were administered to dampen the hemodynamic response to ETC. Vital signs, ECG, and pulse oximetry monitoring were continued after the end of the seizure until the patient was fully stable, typically for 30-45 minutes. Results Table I includes age, gender, cardiac diagnoses, characteristics of the ECT course (including number of treatments and any untoward events), pacemaker type, the reason for pacemaker placement and length of time since device implantation. There were 14 men and 15 women in the group. Average age was approximately 75 years. The most common reasons for pacemaker place1260

ment were third degree atrioventricular block, atrioventricular node ablation for atrial brillation, and sick sinus syndrome. The pacemaker had been implanted on average 5 years prior to ECT initiation. All 3 of the patients with an ICD received the ICD for symptomatic ventricular tachycardia with ICD implant occurring approximately 2, 3, and 6 years prior to ECT treatment. All patients received ECT for severe depression. The 29 patients received a total of 493 treatments. The number of ECT treatments per patient ranged from 3 to 108. Some patients received only an acute series of treatments, typically 5-10 total treatments being given 2 to 3 times per week, for the episode of depression, and some went on to receive maintenance treatments as a relapse prevention strategy. Maintenance treatments were most commonly done at monthly intervals, occasionally for long periods of time in patients with chronic relapsing depressive illness,16 thus explaining the large number of treatments in some patients. Pacemaker Patients Of the 26 pacemaker patients in our series, three displayed occasional ventricular ectopic beats during therapy with no hemodynamic sequelae. An 87-year-old pacemaker patient (patient #15 in Table I) developed supraventricular tachycardia with aberrant conduction after ECT treatment number.29 This occurred after the seizure was over and was not triggered by the electrical stimulus of the ETC. There was also no evidence of ventricular pacing during the tachycardia, i.e., nothing to suggest that the tachycardias was in any way pacemaker-mediated. The patient had no history of similar arrhythmias. He was treated acutely with amiodarone and esmolol intravenously. After the supraventricular tachycardia was resolved, the pacemaker function was normal. Though he was hemodynamically stable during this episode, he was unresponsive for 90 minutes during which time he had some spontaneous movements of all four extremities. He was subsequently monitored in the coronary care unit for 24 hours without additional dysrhythmias and serial electrocardiograms and serum troponin levels showed no evidence of myocardial infarction. There was no evidence of acute cerebral event or new cognitive impairment. However, as his depression was quite severe and he had been refractory to medications, he went on to receive another 24 ECT treatments with no untoward cardiac events noted. All patients had device interrogation before and most after their ECT courses; there was no evidence of device dysfunction. The device specic programmer was available during ECT in all patients.
PACE, Vol. 27

September 2004

ECT AND PACEMAKERS/ICDS

ICD Patients ECT in the 3 patients with the ICD was generally uneventful, with each patient enjoying a substantial antidepressant effect of the treatments. A pacemaker/ICD nurse specialist was present at each treatment to interrogate and program therapies with the patient on continuous monitoring. One patient (#29 in Table I) developed tachycardia (up to approximately 180 beats/min) with a rate dependent left bundle branch block and hypotension in the recovery room after the treatment, which responded promptly to esmolol administration (i.e., the rate and blood pressure quickly normalized). She did not receive glycopyrrolate prior to any of the subsequent treatments and did not experience a similar event. Discussion This is the largest series of patients with implanted pacemakers treated with ETC. We have also described three patients with an ICD. Results of our series support the view that ECT can be safely used in patients with pacemakers and ICDs. Review of the literature revealed a relatively small number of cases of ECT in patients with implanted cardiac devices (Table II). Specic concerns in these patients include: electrical interference from the ECT stimulus, device sensing of myopotentials originating from succinylcholine induced fasciculations or muscle contractions resulting from incomplete muscular paralysis and sensing by the device of relatively common but benign dysrhythmias during the seizure. Recommendations for pacemaker and

Table II. Reported Cases of ECT in Patients with Pacemakers or ICDs # of Patients 1 1 1 1 1 1 1 2 2 1 1

Author YoumansGibson Ballenger Gibson Blitt Abiuso Janhar Alexopoulos Alexopoulos Goldberg Pornnoppadol Lapid

Device PM PM PM PM PM PM PM PM ICD ICD ICD

Complication None None None None None None None None Death in 1 patient due to CHF None* None

*ICD therapies left on after initial treatment.

PACE, Vol. 27

ICD patients are listed in Table III. Caregivers should also follow any recommendations specic to the device manufacturer as outlined in the device technical manual. General clinical guidelines for monitoring patients with pacemakers and ICDs include using multilead ECG monitoring and having equipment available to rapidly obtain central access in the event that vasoactive medications or transvenous pacing are needed. Assessing the plethysmography tracing of a pulse oximeter is a useful surrogate for an arterial line tracing in the event of dysrhythmias. An external debrillator must be readily available for patients who have had their ICD temporarily disabled. We discuss some the clinical considerations separately for the two types of devices. There are 8 reports of 9 pacemaker patients receiving ECT (Table II).26,8,12,17 No one had apparent complications. During ECT only a minimum amount of electricity reaches the heart due to high tissue resistance. The pacemaker should not be affected by the ECT stimulus because it is protected by high voltage circuitry.18 Safety precautions should include proper grounding of all monitoring devices, insulating the patients stretcher, and ensuring that the patient is not touched during presentation of the electrical stimulus by somebody who is in contact with ground.18 Skeletal muscle potentials that occur during ECT may fall within the range of the pacemakers sensing circuit and inhibit demand pacemakers2 or may trigger the activity of a pacemaker.19 Signicant electrical myopotentials can be generated by skeletal muscle, and these skeletal muscle myopotentials are well within the sensing capabilities of most newer pulse generators. Inhibition of pacemaker output by myopotentials is especially common with unipolar pacing systems, and therefore if the fasciculations caused by succinylcholine are causing a problem with the pacemaker, it may be prudent to switch to a nondepolarizing muscle relaxant for future ECT treatments. Alternatively, the sensitivity of the pacemaker could be reprogrammed to be less sensitive. It is possible to convert a demand pacemaker to an asynchronous mode if inhibition from noncardiac electrical signals resulted in bradycardia or asystole.2,3,10,19 This can be achieved by placing a magnet over the pulse generator of the pacemaker for most pacemaker models. The magnet could be used prophylactically in patients who have manifested pacemaker inhibition during previous treatments.2 Careful pre-ECT evaluation of pacemakers and ICDs is mandatory, including thorough history, physical exam, screening laboratory tests and ECG, 1261

September 2004

DOLENC, ET AL.

Table III. Recommendations For Pacemaker and ICD Patients Undergoing ECT Pre-ECT PACEMAKER PATIENT 1) Internal medicine or cardiology consultation* During ECT Post-ECT

2) Device interrogation to document programmed parameters ICD PATIENT 1) Internal medicine or cardiology consultation*

2) Device interrogation to document programmed parameters

1) Magnet should be available 1) Device interrogation after acute series of treatments in unlikely event of pacemaker inhibition and symptomatic bradycardia 2) Proper attention to 2) Device interrogation can be grounding done in maintenance ECT patients as per routine cardiac care 1) Tachyarrhythmia therapies 1) Device interrogation as part of post-treatment activation turned off while patient on continuous ECG monitoring 2) Tachyarrhythmia therapies turned off after seizure is over 3) Proper attention to grounding

*The consultation is not required because of the presence of a device but to assure medical suitability for undergoing ECT and the associated anesthesia.

as well as cardiology consultation if necessary to determine the severity of cardiac disease. Pacemaker interrogation is encouraged to document programmed parameters prior to the rst treatment and again at the completion of the entire ECT course. Given the need to turn off ICD therapies per our current protocol, it is necessary that the ICD patient be seen before and after each ECT treatment. This would require the presence of someone from the pacemaker/electrophysiology staff to be present for each treatment. As with all patients receiving ECT, cardiac monitoring should be continuously performed during and immediately after the procedure. Literature review revealed 4 patients with ICDs who received ECT.7,9,11 In 3 patients, ICD therapies were programmed off. All 3 patients received ECT uneventfully although one of the patients died of progressive heart failure, but the death was felt to be unrelated to the ICD. In the fourth case reported11 the ICD was deactivated during the rst treatment. He did not develop any dysrhythmias or electrical oversensing that could have resulted in appropriate or inappropriate ICD function. Therefore, during subsequent ECT treatments, the ICD therapies were left on and no untoward ICD related events were noted. The authors recommended, based on this single patient experience, that ICDs be left activated during ECT to treat potentially lethal ventricular dysrhythmias during

treatments which in their opinion outweighed the risks of inappropriate ICD discharge. Given the smaller number of ICD patients that have undergone ECT therapy there is some controversy regarding management. The risk of programming the ICD therapies off would be the occurrence of ventricular tachyarrhythmias that would not be treated. However, if the patient is continuously monitored for the period of time during which the ICD therapies are programmed off and resuscitative equipment and trained personnel are present to administer external debrillation, then the patient should be protected at all times. Careful attention must be paid to turning therapies back on and documentation of the reprogramming. The risks of not turning ICD therapies off include inappropriate discharge of the ICD. The ICD could theoretically sense electromagnetic interference (EMI) created by the ECT therapy. If sufcient EMI was sensed to satisfy debrillation criteria, the ICD would discharge. Two concerns exist with an inappropriate ICD discharge. One concern would be the discomfort of the discharge but in an anesthetized patient this would not be a problem. The second concern would be that the unnecessary discharge during a normal rhythm could initiate a true ventricular dysrhythmia requiring the ICD to again detect and discharge. If there was simultaneous detection of EMI from the ECT, this

1262

September 2004

PACE, Vol. 27

ECT AND PACEMAKERS/ICDS

could theoretically interfere with device detection and treatment of a ventricular tachyarrhythmia. Until additional data are presented it seems reaReferences
1. Rasmussen KG, Rummans TA, Richardson JR. Electroconvulsive therapy in the medically ill. Psychiatr Clin North Am 2002; 25:177 193. 2. Abiuso PR, Dunkelman R, Proper M. Electroconvulsive therapy in patients with pacemakers. JAMA 1978; 240:24592460. 3. Alexopoulos GS, Frances RJ. ECT and cardiac patients with pacemakers. Am J Psychiatry 1980; 137:11111112. 4. Ballenger JC. Electroconvulsive therapy and cardiac pacemakers. Psychosomatics 1973; 14:233234. 5. Blitt CD, Kirschvink LJ. Electroconvulsive therapy with a cardiac pacemaker. Anesthesiology 1976; 45:580. 6. Gibson TC, Leaman DM, Devors J, et al. Pacemaker function in relation to electroconvulsive therapy. Chest 1973; 63:1025 1027. 7. Goldberg RJ, Badger JM. Major depressive disorder in patients with the implantable cardioverter debrillator. Two cases treated with ECT. Psychosomatics 1993; 34:273277. 8. Jauhar PM, Weller M, Hirsch SR. Electroconvulsive therapy for patient with cardiac pacemaker. Br Med J 1979; 1:9091. 9. Lapid MI, Rummans TA, Hofmann VE, et al. ECT and automatic internal cardioverter-debrillator. J ECT 2001; 17:146 148. 10. Pearlman CA Electroconvulsive therapy for patient with cardiac pacemaker. JAMA 1986; 255:1501. 11. Pornnoppadol C, Isenberg K. ECT with implantable cardioverter debrillator. J ECT 1998; 14:124126. 12. Youmans CR Jr, Bourianoff G, Allensworth DC, et al. Cardiovas-

sonable to continue to turn ICD therapies off during ECT with careful external monitoring and external debrillation available.

13. 14. 15.

16. 17. 18. 19. 20. 21.

cular alterations during electroconvulsive therapy in patients with cardiac pacemakers. South Med J 1972; 65:361365. Youmans CR Jr, Bourianoff G, Allensworth DC, et al. Electroshock therapy and cardiac pacemakers. Am J Surg 1969; 118:931937. Petrides G, Fink M, Husain MM, et al. ECT remission rates in psychotic versus nonpsychotic depressed patients: a report from CORE. J ECT 2001; 17(4):244253. American Psychiatric Association Committee on ECT. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging (2nd Ed.): Washington, D.C., American Psychiatric Association, 2001. Russell JC, Rasmussen KG, OConnor MK, et al. Long-term maintenance ECT: A retrospective review of efcacy and cognitive outcome. J ECT 2003; 19:49. Alexopoulos GS, Shamoian CJ, Lucas J, et al. Medical problems of geriatric psychiatric patients and younger controls during electroconvulsive therapy. J Am Geriatr Soc 1984; 32: 651654. Abrams R. Electroconvulsive therapy (4th Ed.): New York, Oxford University Press, 2002. Cohen-Cole SA, Stoudemire A. Major depression and physical illness: Special considerations in diagnosis and biologic treatment. Psychiatr Clin North Am 1987; 10:117. Pinski SL, Trohman RG. Implantable cardioverter-debrillators: Implications for the nonelectrophysiologist. Ann Intern Med 1995; 122:770777. DiMarco JP. Implantable cardioveter-debrillators. NEJM 2003; 349:18361847.

PACE, Vol. 27

September 2004

1263