Hemodynamic responses to ECT in a patient with critical aortic stenosis

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.