We present a case study of a 46-year-old woman with a psychotic depressive
illness of 2 months' duration with the coexisting medical diagnoses of crit
ical aortic stenosis, severe labile hypertension, renal failure necessitati
ng hemodialysis of 7-years' duration, and systemic lupus. Because of unresp
onsiveness to an antidepressant drug regimen, severe motor retardation, mut
ism, and refusal of food and fluids by mouth. an urgent indication for elec
troconvulsive therapy (ECT) was established. However, the patient refused E
CT, and to allow its initiation, a court order was obtained. In view of the
coexisting diagnoses of critical aortic stenosis, labile hypertension, and
renal failure, ECT represented a substantially increased risk: in this pat
ient because of severe arterial hypertension and tachycardia. The patient w
as successfully managed during each ECT, using a combination of metoprolol
by mouth, which was supplemented by i.v. esmolol immediately prior to the a
pplication of the ECT stimulus, and sodium nitroprusside, which was infused
for several minutes prior to the seizure and thereafter to attenuate arter
ial hypertension. Nevertheless, sudden death, a well-known complication of
critical aortic stenosis, occurred 96 hours after the fourth ECT.