Background

• Patients requiring electroconvulsive therapy (ECT) oftentimes have upregulated HPA axis secondary to psychiatric illness
• Elevated cortisol -> permissive effect on catecholamines-> predisposition to arrythmias
• Takotsubo Cardiomyopathy (TTC) can cause QT prolongation

Case

• 67-year-old female underwent right unilateral ECT for major depressive disorder
• 2^nd consecutive day of ECT induction medications: etomidate 8 mg and succinylcholine 30 mg
• Required esmolol 80mg and metoprolol 4mg for sympathetic surge
• During PACU recovery, stable monomorphic VT
• Received 4 mg metoprolol and 100 mg lidocaine -> VT terminated
• Two more episodes of non-sustained VT -> transported to ED for further evaluation

Labs & imaging

• Labs: normal electrolytes, mildly elevated and unchanging troponin, BNP 6000 pg/mL (ref<640 pg/mL)
• EKG: TWIs laterally and QTc 515ms
• CT Angiogram: unremarkable
• TTE: reduced EF from 64% -> 35% and findings suggestive of Takotsubo Cardiomyopathy – mid and apical hypokinesis with preserved basal contractility

Discussion

• Possibilities:
1. Acute psychiatric illness -> TTC -> ECT -> VT
2. Consecutive days of ECT and sympathetic surges in the setting of elevated cortisol -> TTC -> VT
3. ECT -> Coincidental VT -> TTC
• ECT could be cautiously reinitiated based on clinical judgement after full recovery
• Prophylactic beta-blockers should be strongly considered

References

1. Hartnett S, Rex S, Sienaert P. Asystole During Electroconvulsive Therapy: Does Electrode Placement Matter? A Systematic Review. J ECT. Mar 1 2023;39(1):3-9. doi:10.1097/YCT.0000000000000863
2. Mayur PM, Gangadhar BN, Girish K, Prasad KM, Subbakrishna DK, Janakiramiah N. Acute post-ECT cardiovascular response: a comparison of threshold right unilateral and bilateral ECT. J ECT. Jun 1998;14(2):94-8. 
3. Kinoshita M, Kinoshita M, Takahashi R, Mutoh S, Kakuta N, Tanaka K. The Safety and Strategies for Reinitiating Electroconvulsive Therapy After ECT-Induced Takotsubo Cardiomyopathy: A Case Report and Systematic Review. J ECT. Sep 1 2023;39(3):185-192. doi:10.1097/YCT.0000000000000905