ECT in a Patient with a Heart Transplant-1991 LTE from the NEJM
Electroconvulsive therapy in a patient with a heart transplant
- PMID: 1861707
- The Pdf is here.
- The full text is copied below:
- To the Editor:
- As heart transplantation becomes more common, physicians will be faced with the prospect of treating serious psychiatric illness in heart-transplant recipients. A recent study reported on the use of nortriptyline for the treatment of depression in nine such patients.* When treatment with antidepressant agents is unsatisfactory, electroconvulsive therapy remains an important option. We report here the safe and successful use of electroconvulsive therapy in a patient with a heart transplant.
A 35-year-old man had experienced episodes of severe depression since his cardiac transplantation 13 months previously. Both of his parents had histories of depression, and his father had been successfully treated with electroconvulsive therapy. Over the preceding 10-month period, the patient had failed to respond to adequate trials of nortriptyline and fluoxetine. Before electroconvulsive therapy his Hamilton Depression Rating score was 25 (a score of more than 20 is usually interpreted as indicative of moderately severe depression). He received eight sessions of bilateral electroconvulsive therapy with a brief-pulse square wave stimulus. He received his routine cardiac medications — 120 mg of diltiazem, 5 mg of enalapril, and 40 mg of propranolol — with a sip of water at 6 a.m. before each treatment; 0.2 mg of glycopyrrolate was given intramuscularly 30 minutes before each treatment to decrease oral secretions. Anesthesia was induced with 80 mg of intravenous methohexital followed by 120 mg of intravenous succinylcholine. The patient tolerated the treatments very well. There were no complications. Heart rate and blood pressure increased only slightly (from 75 to 85 beats per minute, and from 120/80 to 135/90 mm Hg) during the seizures. The cognitive side effects were minimal. The Hamilton Depression Rating score was 12 on completion of the treatments.
Transient arrhythmias that occur during electroconvulsive therapy include vagally induced bradyarrhythmias following the electrical stimulus and tachyarrhythmias during and after the seizure, which are thought to be mediated by the release of circulating catecholamines. In a heart-transplant patient, the lack of vagal innervation would eliminate the risk of bradyarrhythmias. The hyperdynamic effects of released catecholamines are commonly attenuated during electroconvulsive therapy by pretreatment with beta-blockers or other antihypertensive agents, as they were in our patient.
We conclude that electroconvulsive therapy can be safely given to heart-transplant recipients, a patient population that may be particularly vulnerable to serious depression. In fact, the risk of arrhythmias may be decreased because of denervation of the heart.
Charles H. Kellner, M.D.
Russell R. Monroe, M.D.
Carol Burns, R.N.C.
Hilary J. Bernstein, L.M.S.W.
A. Jackson Crumbley, M.D.
Medical University of South Carolina, Medical Center, Charleston, SC 29425–0742Okay, maybe only a semi-classic, but letters-to-the-editor about ECT in the NEJM are as rare as hen's teeth. The fact that the denervated heart obviates the risk of bradyarrhythmias is quite interesting.
In 2006, Fusar-Poli et al. published a comprehensive review in The Journal of Heart and Lung Transplantation, entitled, Antidepressive Therapies after Heart Transplantation. In a table, they report a total of 5 heart transplant patients receiving ECT, including our 1991 patient. They inaccurately noted a 1981 report from Jones and Knight (Anesthesia, (36), 1981, p. 799) as the first. The patient in that report had hypertension, but no heart transplant-the report was about catecholamine release with ECT. I found no additional case reports since 2006, but it is likely that more such patients have been treated.
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