Interdisciplinary safety precautions protocol for electroconvulsive therapy (ECT) in a patient with treatment-resistant major depression and Brugada ECG

Abstract Introduction Brugada syndrome (BrS) is a rare cause of sudden cardiac death in young, otherwise healthy individuals with a structurally normal heart. The diagnosis of BrS is made by typical ECG changes (so-called “coved” type 1-ECG) that may be transient and can be unmasked by sodium-channel-blocking medications. Once the pathognomonic ECG pattern is identified, potentially aggravating drugs have to be discontinued. Since many drugs in psychiatric indications have the potential to induce Brugada-like ECG changes, therapy in such patients is challenging and a rapid worsening of depressive or psychotic symptoms can be the consequence. The limited remaining psychopharmacological treatment options may lead to the consideration of electroconvulsive therapy (ECT). Methods In a patient with treatment-resistant major depression and high risk of suicide, a Brugada type 1-ECG has been recorded during routine control under antidepressant pharmacotherapy. We report on the successful treatment using ECT after establishing an interdisciplinary safety precautions protocol for patients with suspected BrS, involving cardiologists, anesthesiologists and psychiatrists. Results Specific considerations of the safety precautions protocol include choice of anesthetic agents, advanced cardiac monitoring, specific emergency prearrangements and the ECT procedure itself. The type of muscle relaxant chosen and the autonomic response on the seizure stimulation were considered most important to avoid ECT-related adverse events. Conclusion ECT might be a promising option in the treatment of severe depressive episodes in patients presenting with a Brugada ECG, if an interdisciplinary risk assessment and safety precautions are carefully considered.