(005) Electroconvulsive therapy on patients with Takotsubo cardiomyopathy: Case reports and literature review

Abstract: Background/Significance: Electroconvulsive therapy (ECT) is a safe procedure with infrequent cardiovascular complications. Takotsubo cardiomyopathy (TC) associated with ECT has been rarely reported.

Cases:

JP is a 67-year-old woman with Schizoaffective Disorder, admitted for psychosis and depressive symptoms. ECT was planned given lack of response to multiple antipsychotics, including clozapine, prior to admission. After the first ECT, patient had elevated troponin, EKG with precordial biphasic T-waves and T-wave inversions, prolonged QTc, negative coronary CT angiogram, and apical wall motion abnormality in TTE with preserved LVEF. Cardiac abnormalities were hypothesized to be due to clozapine-related myocarditis, TC, or sarcoidosis, and clozapine was replaced with haloperidol. ECT was resumed and notable for episodes of bradycardia requiring glycopyrrolate, and hypertension requiring labetalol, yet after 12 sessions, most of her psychosis and depressive symptoms remitted.

MT is a 50-year-old woman with MDD with psychotic features, admitted after suicide attempt by hanging. While in NICU, patient was found to have TC with anterior T-wave inversion on EKG and apical hypokinesis in TTE. New EKG 12 days later for ECT clearance showed anteroseptal ST changes suggestive of ischemia, but coronary CTA was normal, and repeat TTE showed no segmental wall motion abnormalities. ECT was started without further cardiac issue but was discontinued after 5 sessions due to marked improvement in depressive symptoms while having intermittent episodes of post-ECT fever and COVID infection with multifocal pneumonia.

NE is a 68-year-old woman with MDD with psychotic features, catatonia, and suspected TC after ECT in 2007, admitted for severe catatonia. During ECT session 3, patient had 4 seconds of asystole on telemetry, immediately following succinylcholine with rapid return of palpable pulse, stable heart rate and blood pressure. Post-procedure EKG and recent TTE were normal, and ECT was continued with rocuronium and sugammadex instead of succinylcholine given its associated risk of asystole. Patient did not have any further episodes of asystole or arrythmia but required multiple medications for high blood pressure during ECT sessions.

Discussion: Regardless of whether TC was diagnosed during the course or prior to initiation of ECT, the decision to perform ECT was based on patient’s symptoms and overall cardiac function. 20 cases of TC associated with ECT have been reported with successful resumption of ECT in 8 cases and varying use of beta-blocker to prevent secondary TC. The reported time between TC and ECT ranges from weeks to months, with our cases being approximately 2 weeks (Medved 2018).

Conclusion/Implications: ECT can be safely performed on patients with recent, including intercurrent, or remote TC with pharmacological management to mitigate cardiovascular risks.

References:

Medved S, et al: Takotsubo cardiomyopathy after the first electroconvulsive therapy regardless of adjuvant beta-blocker use: a case report and literature review. Croat Med J. 2018;59:307-12.

Presenting Author(s)

Hyowon Choi, MD, PhD (she/her/hers)

Resident
Thomas Jefferson University Hospital
Philadelphia, PA, United States

Co-Author(s)

JH

Julia Hannigan, MD

Resident
Thomas Jefferson University Hospital
Philadelphia, Pennsylvania, United States
RM

Rebecca Montana, MD

Resident
Thomas Jefferson University
Philadelphia, Pennsylvania, United States
AB

Andie Belkoff, MD

Resident physician
Thomas Jefferson University Hospital
Philadelphia, Pennsylvania, United States
Emily Sudhakar, MD

Resident Physician
Thomas Jefferson University Hospital
Philadelphia, Pennsylvania, United States
KENNETH M. CERTA, MD DLFAPA

Associate Professor
Thomas Jefferson University Hospital
Philadelphia, Pennsylvania, United States
KC

Keira Chism, MD

Director Consultation Liaison Psychiatry
Jefferson Health
Philadelphia, Pennsylvania, United States