Successful use of electroconvulsive therapy in a patient with atrial septal defect

To the Editor

Electroconvulsive therapy (ECT) has been used with caution in patients with cardiovascular disease (Rayburn, 1997) and is known to have cardiac effects in patients without a known cardiac history (Wells, 2011). Recently the first case of successful ECT in an individual with atrial septal defect (ASD) was reported (Grover et al., 2012). We report a case with significant cardiac complications of a long standing ASD that has been treated successfully with ECT on two separate occasions.

A 65 year old woman was admitted with a one month history of persecutory and nihilistic delusions, auditory hallucinations, agitation and depressed mood with suicidal ideas with no prior psychiatric or substance use history. She was managed by the community Crisis Assessment and Treatment Team (CATT) and was admitted involuntarily to the psychiatry unit as she failed to improve on mirtazapine and quetiapine for almost three weeks. Her oral intake was minimal and she attempted suicide by trying to strangulate herself in the ward. ECT was considered after discussion with the patient and her family. On chest X-ray (antero-posterior view) pulmonary hypertension was identified and on discussion with the medical team, a transthoracic echocardiography was done that revealed a mass in left atrium with dilated right heart. A subsequent transesophageal echocardiogram revealed a large ostium secundum ASD with left to right shunt and severely dilated right ventricle with mild right ventricular systolic dysfunction and severely dilated pulmonary artery. Considering her deteriorating mental state and following cardiology and anaesthetic consultation, it was decided to proceed with ECT and she received 6 bi-temporal ECT treatments over two weeks. Her physical health was monitored and reviewed by the cardiology team periodically in the ward. The treatments were uncomplicated by cardiac or other problems and her psychotic and affective symptoms improved quickly with the treatment. She was started on haloperidol and imipramine and discharged with follow-up from the community mental health clinic on the same treatment. An outpatient cardiac magnetic resonance imaging confirmed a secundum ASD with significant left to right shunt.

She was readmitted with a relapse of her condition four months later with similar symptoms and received 8 bi-temporal ECT treatments with very good response. Her cardiac condition remained unchanged and she received cardiology follow up to manage her ASD.

In this patient ASD was incidentally diagnosed during routine evaluation for ECT. ECT is associated with various cardiac changes which may lead to ischemia and arrhythmias (Grover at al., 2012). Two separate courses of ECT were successfully given and did not have cardiac adverse events including arrhythmias. This case highlights that ECT can be safely administered in patients with significant cardiac complications of ASD in conjunction with cardiology and anaesthetic consultation.