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 Table of Contents    
CASE REPORT
Year : 2018  |  Volume : 40  |  Issue : 3  |  Page : 288-291  

Electroconvulsive therapy in an elderly patient with severe aortic stenosis: A case report and review of literature


Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication9-May-2018

Correspondence Address:
Dr. Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPSYM.IJPSYM_152_17

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   Abstract 


Electroconvulsive therapy (ECT) is one of the safest treatment options for psychiatric illnesses with no absolute contraindications. However, certain medical conditions including cardiac ailments such as aortic stenosis are associated with increased risk with ECT. We present the case of a 74-year-old female who was suffering from severe depression with psychotic symptoms (which had not responded to two adequate trials of antidepressants), along with severe aortic stenosis, who was managed with modified bilateral ECT and review the available literature.

Keywords: Aortic stenosis, elderly, electroconvulsive therapy


How to cite this article:
Singla H, Grover S. Electroconvulsive therapy in an elderly patient with severe aortic stenosis: A case report and review of literature. Indian J Psychol Med 2018;40:288-91

How to cite this URL:
Singla H, Grover S. Electroconvulsive therapy in an elderly patient with severe aortic stenosis: A case report and review of literature. Indian J Psychol Med [serial online] 2018 [cited 2020 Jan 23];40:288-91. Available from: http://www.ijpm.info/text.asp?2018/40/3/288/232130




   Introduction Top


Electroconvulsive therapy (ECT) is a well-established treatment for various psychiatric conditions.[1] Remission rates with ECT range from 70% to 90% in patients with major depression with older age conferring the greater likelihood of remission.[2] As such, there are no absolute contraindications for the use of ECT. The American Psychiatric Association Task Force report [3] on ECT recommends careful assessment of patients before ECT when the patient has certain medical conditions which can pose substantial risk to use of ECT. These include unstable/severe cardiovascular disease, space-occupying intracranial lesion, recent cerebral hemorrhage or stroke, bleeding or otherwise unstable vascular aneurysm, severe pulmonary condition, or high risk with anesthesia rated as the American Society of Anesthesiologists Class 4 or 5.[3]

Severe aortic stenosis has been reported to increase the risk of noncardiac operation, but this group of patients can undergo noncardiac procedures at a reasonably low risk with careful monitoring of anesthesia.[4] In these patients, acute hypotension can be potentially hazardous [5] since coronary perfusion pressure may be compromised because of the combination of low aortic diastolic pressure [6] and elevated left ventricular end-diastolic pressure.

There is limited literature on the use of ECT in patients with severe aortic stenosis.[7],[8],[9],[10],[11] We present a case of 74-year-old female, having severe aortic stenosis, who received modified bilateral ECT for treatment-resistant depression and discuss the practical considerations involved in the case.


   Case Report Top


A 74-year-old female who had been diagnosed with hypertension 15 years prior to presentation, hypothyroidism 8 years before presentation, and aortic stenosis 2 years before presentation, presented with the first episode depression of insidious onset for the past 9 months, precipitated by a life stressor. Exploration of history revealed that initially she developed sadness of mood, anhedonia, tiredness, bleak and pessimistic views of future, disturbed sleep, and poor appetite. Over the next 2–3 months, the symptoms progressed further, and she additionally developed suicidal ideations, poor attention and concentration, low self-esteem, and delusion of poverty. She had received adequate trials of tablet escitalopram (10–20 mg/day for 3 months) and sertraline (up to 150 mg/day) along with quetiapine (50–100 mg) for 6 weeks without much improvement in psychopathology. While receiving the combination of sertraline and quetiapine, she developed side effects in the form of bradykinesia, rigidity, and tremors.

When evaluated for the first time at the inpatient setting at our center, she was found to have sadness of mood, marked psychomotor retardation, delusion of poverty, suicidal ideations, marked sleep disturbances, and poor oral intake. A diagnosis of severe depression with psychotic symptoms was considered.

She was receiving tablet torsemide 20 mg/d and tablet amlodipine 5 mg/d for hypertension, and tablet thyroxine 50 μg/day for the hypothyroidism. On investigation, she was found to have features suggestive of raised serum urea (55 mg/dl) and creatinine levels (1.6 mg/dl), which were considered to be suggestive of prerenal acute renal failure most likely due to reduced oral intake. All other investigations in the form of hemogram, serum electrolytes, liver function tests, and X-ray chest were found to be within normal limits. Initially, she was treated with tablet mirtazapine up to 22.5 mg/day for 3 weeks, but there was no improvement. However, during this period, her renal status improved over 1 week with oral rehydration and renal diet. Following this, ECT was considered. On further investigation, her echocardiography revealed severe aortic stenosis (aortic value area 0.8 cm 2 [normal values - 2.5–4.5 cm 2]) with the normal left ventricular function. The aortic stenosis velocity was 4.3 m/s and left ventricular ejection fraction was 60%–65%. Her electrocardiogram revealed T wave inversion in leads I, II, aVL, V4–V6. History was again reviewed and patient had no history suggestive of dyspnea, angina, syncope, and congestive heart failure.

She was cleared for ECT under high-risk consent and it was decided to administer ECT in a setting where all the equipments for cardiopulmonary resuscitation were available in case of any cardiac emergency. ECT was administered without the use of anticholinergics and injection esmolol was given before ECT. She was properly oxygenated during the ECT procedure. Throughout the procedure and 2 h after the procedure, her electrocardiogram, blood pressure, heart rate, and oxygen saturation were closely monitored. She received nine effective bilateral modified ECTs, all of which were uneventful and by the end of ECT course, and she achieved clinical remission and was discharged on tablet mirtazapine 30 mg/day. She has been maintaining well thereafter for the past 2 years.


   Discussion Top


The present case adds to the limited literature on the use of ECT in patients with severe aortic stenosis. A review of existing literature [Table 1] shows that there are only 5 cases reports and a small study in which ECT was used in 10 patients with aortic stenosis.[7],[8],[9],[10],[11],[12] In all these reports, all the patients except one [8] were elderly and ECT was used successfully without much complications in all the cases except one report,[10] in which a patient developed bradycardia in the 1st session and ECT was withheld after that.
Table 1: Available data on the use of electroconvulsive therapy among patients with severe aortic stenosis

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As recommended by Mueller et al., 2007[9] index case was adequately investigated including carrying out echocardiography before starting of ECT. In accordance with the recommendations, patient was also evaluated for blood cell count, electrolytes, and creatinine before start ECT.[9]

Three main hemodynamic goals have been suggested while giving ECT in patients with aortic stenosis, these include maintenance of optimal values for stroke volume, heart rate, peripheral vascular tone, and venous return.[13] Other authors suggest that it is important to avoid hypotension, decrease in preload, systemic vascular resistance, and contractility as well as excessive tachycardia.[9] In many of the existing case reports, these issues were taken care off. In the index case, short-acting beta blocker, injection esmolol, was given to the patient to take care of the anticipated hemodynamic changes as was done in some of the previous case reports.[7],[8],[9],[11],[12] In addition, anticholinergic was avoided and post-ECT recovery was monitored extensively for any delayed event, as suggested in some of the previous case reports.[8],[9],[12]


   Conclusion Top


The index case suggests that ECT can be given safely in patients with medical illnesses like severe aortic stenosis and there are no absolute contraindications for ECT. However, special care should be taken when administering ECT in patients with severe aortic stenosis. Careful evaluation by the cardiology and anesthesiology services is mandated to assess risk and to minimize risk, and high index of suspicion is required for timely intervention to minimize the mortality in these patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Accornero F. An eyewitness account of the discovery of electroshock. Convuls Ther 1988;4:40-49.  Back to cited text no. 1
[PUBMED]    
2.
O'Connor MK, Knapp R, Husain M, Rummans TA, Petrides G, Smith G, et al. The influence of age on the response of major depression to electroconvulsive therapy: A C.O.R.E. Report. Am J Geriatr Psychiatry 2001;9:382-90.  Back to cited text no. 2
    
3.
American Psychiatric Association. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training and Privileging. Washington, DC: APA Press; 2001.  Back to cited text no. 3
    
4.
O'Keefe JH Jr., Shub C, Rettke SR. Risk of noncardiac surgical procedures in patients with aortic stenosis. Mayo Clin Proc 1989;64:400-5.  Back to cited text no. 4
    
5.
Sethna DH, Starr NJ, Estafanous FG. Cardiovascular effects of non-depolarizing neuromuscular blockers in patients with aortic valve disease. Can J Anaesth 1987;34:582-8.  Back to cited text no. 5
[PUBMED]    
6.
Marcus ML, Doty DB, Hiratzka LF, Wright CB, Eastham CL. Decreased coronary reserve: A mechanism for angina pectoris in patients with aortic stenosis and normal coronary arteries. N Engl J Med 1982;307:1362-6.  Back to cited text no. 6
[PUBMED]    
7.
Rasmussen KG. Electroconvulsive therapy in patients with aortic stenosis. Convuls Ther 1997;13:196-9.  Back to cited text no. 7
[PUBMED]    
8.
Levin L, Wambold D, Viguera A, Welch CA, Drop LJ. Hemodynamic responses to ECT in a patient with critical aortic stenosis. J ECT 2000;16:52-61.  Back to cited text no. 8
[PUBMED]    
9.
Mueller PS, Barnes RD, Varghese R, Nishimura RA, Rasmussen KG. The safety of electroconvulsive therapy in patients with severe aortic stenosis. Mayo Clin Proc 2007;82:1360-3.  Back to cited text no. 9
[PUBMED]    
10.
Sutor B, Mueller PS, Rasmussen KG. Bradycardia and hypotension in a patient with severe aortic stenosis receiving electroconvulsive therapy dose titration for treatment of depression. J ECT 2008;24:281-2.  Back to cited text no. 10
[PUBMED]    
11.
O'Reardon JP, Cristancho MA, Cristancho P, Fontecha JF, Weiss D. Electroconvulsive therapy in a 96-year-old patient with severe aortic stenosis: A case report and review of the literature. J ECT 2008;24:96-8.  Back to cited text no. 11
    
12.
O'Reardon JP, Cristancho MA, Ryley B, Patel KR, Haber HL. Electroconvulsive therapy for treatment of major depression in a 100-year-old patient with severe aortic stenosis: A 5-year follow-up report. J ECT 2011;27:227-30.  Back to cited text no. 12
    
13.
Stoelting RK, Dierdorf SF. Anesthesia and Co-existing Disease. 3rd ed. New York: Churchill Livingstone; 1993. p. 32-5.  Back to cited text no. 13
    



 
 
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