Cardiac Ultrasound During ECT: Pilot Study From Harvard

Out on PubMed, from investigators at Harvard, is this paper:

Exploring Brain and Heart Interactions during Electroconvulsive Therapy with Point-of-Care Ultrasound.

Chang MG, Barbour TA, Bittner EA.Med Sci (Basel). 2024 Mar 22;12(2):17. doi: 10.3390/medsci12020017.PMID: 38525771

The abstract is copied below:

Background: Electroconvulsive therapy (ECT) is a procedure commonly used to treat a number of severe psychiatric disorders, including pharmacologic refractory depression, mania, and catatonia by purposefully inducing a generalized seizure that results in significant hemodynamic changes as a result of an initial transient parasympathetic response that is followed by a marked sympathetic response from a surge in catecholamine release. While the physiologic response of ECT on classic hemodynamic parameters such as heart rate and blood pressure has been described in the literature, real-time visualization of cardiac function using point-of-care ultrasound (POCUS) during ECT has never been reported. This study utilizes POCUS to examine cardiac function in two patients with different ages and cardiovascular risk profiles undergoing ECT.

Methods: Two patients, a 74-year-old male with significant cardiovascular risks and a 23-year-old female with no significant cardiovascular risks presenting for ECT treatment, were included in this study. A portable ultrasound device was used to obtain apical four-chamber images of the heart before ECT stimulation, after seizure induction, and 2 min after seizure resolution to assess qualitative cardiac function. Two physicians with expertise in echocardiography reviewed the studies. Hemodynamic parameters, ECT settings, and seizure duration were recorded.

Results: Cardiac standstill was observed in both patients during ECT stimulation. The 74-year-old patient with a significant cardiovascular risk profile exhibited a transient decline in cardiac function during ECT, while the 23-year-old patient showed no substantial worsening of cardiac function. These findings suggest that age and pre-existing cardiovascular conditions may influence the cardiac response to ECT. Other potential contributing factors to the cardiac effects of ECT include the parasympathetic and sympathetic responses, medication regimen, and seizure duration with ECT. This study also demonstrates the feasibility of using portable POCUS for real-time cardiac monitoring during ECT.

Conclusion: This study reports for the first time cardiac standstill during ECT stimulation visualized using POCUS imaging. In addition, it reports on the potential differential impact of ECT on cardiac function based on patient-specific factors such as age and cardiovascular risks that may have implications for ECT and perioperative anesthetic management and optimization.

Keywords: ECT; POCUS; PPOCUS; anesthesia; echocardiography; electroconvulsive therapy; neuropsychiatry; point-of-care ultrasound; portable point-of-care ultrasound; portable ultrasound; psychiatry.

The paper is here.

And from the text:

If you ever wondered what happens to the EKG/heart during the fuzzed out artifact of stimulus delivery, here is your answer. This is an interesting use of POCUS technology, but the interpretation of the findings will determine if it becomes hokus-POCUS technology. 

Let's not freak out; nothing here changes the safety profile of ECT, and this incremental knowledge about intra-procedural cardiac function may, in fact, be useful.

These are pilot data, only 2 patients, and with lots of uncontrolled ECT-related variables. It does highlight an issue with the now-popular long stimulus duration with lower frequency...

I am surprised that the authors did not comment on whether the older patient had coronary artery disease, arguably the biggest risk factor in ECT, but perhaps such is implied by his other comorbidities, including stroke.

Kudos to these authors for this intriguing investigation; here's hoping they will follow it up with more data.