Cardiac rhythm management devices and ablation procedures in psychiatric patients: A case series and review of the literature

Konstantinos A Gatzoulis; Dimitrios Tsiachris; Georgia Balta; Christos-Konstantinos Antoniou; Petros Arsenos; Polychronis Dilaveris; Dimitrios Tousoulis

doi:10.4103/hm.hm_74_19

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CASE SERIES

Year : 2020 | Volume : 4 | Issue : 1 | Page : 21-25

Cardiac rhythm management devices and ablation procedures in psychiatric patients: A case series and review of the literature

Konstantinos A Gatzoulis¹, Dimitrios Tsiachris¹, Georgia Balta², Christos-Konstantinos Antoniou¹, Petros Arsenos¹, Polychronis Dilaveris¹, Dimitrios Tousoulis¹
¹ First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
² Department of Pharmacology, National and Kapodistrian University of Athens, Athens, Greece

Date of Submission	27-Oct-2019
Date of Acceptance	28-Feb-2020
Date of Web Publication	17-Apr-2020

Correspondence Address:
Dr. Konstantinos A Gatzoulis
181, Dorieon Street, Mail Box: 175, Drafi Attikis 19009, Athens
Greece

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/hm.hm_74_19

Abstract

Psychiatric patients often present with symptoms similar to those indicating the need for a cardiac rhythm management device or even cardiac arrhythmia ablation. However, due to the unreliability of symptom self-reporting, the ability of the underlying neuropsychiatric condition to elicit similar phenomena, and the perceived reduced compliance and increased complication rates among this population, both of the above approaches remain underutilized with often detrimental effects. In the present case series, it is attempted to describe an alternative, electrophysiology study-guided approach to these patients, aiming to both firmly establish the need for invasive intervention (including implantation of pacemakers – three cases, implantable cardioverter-defibrillators – three cases, and electrophysiological ablations – two cases), as well as dispel preconceptions, bordering on stigma, regarding their outcomes.

Keywords: Arrhythmia ablation, case series, device therapy, multidisciplinary approach, psychiatric patients, sudden death prevention

How to cite this article:
Gatzoulis KA, Tsiachris D, Balta G, Antoniou CK, Arsenos P, Dilaveris P, Tousoulis D. Cardiac rhythm management devices and ablation procedures in psychiatric patients: A case series and review of the literature. Heart Mind 2020;4:21-5

How to cite this URL:
Gatzoulis KA, Tsiachris D, Balta G, Antoniou CK, Arsenos P, Dilaveris P, Tousoulis D. Cardiac rhythm management devices and ablation procedures in psychiatric patients: A case series and review of the literature. Heart Mind [serial online] 2020 [cited 2023 May 31];4:21-5. Available from: http://www.heartmindjournal.org/text.asp?2020/4/1/21/282827

Introduction

Psychiatric patients face an increased risk of sudden cardiac death (SCD) compared to the general population.^[1] Indeed, unhealthy lifestyle habits, poor medical care, and comorbidities frequently characterizing this population have been associated with an increased incidence of cardiovascular diseases.^[2],[3] In addition, concurrent use of psychotropic agents has been associated with malignant ventricular arrhythmias.^[4]

Unfavorable electrophysiological alterations in the form of either depolarization/repolarization abnormalities on the 12-lead and signal-averaged electrocardiogram (ECG)^[5],[6] or reduced heart rate variability/increased average 24-h heart rate on the ambulatory ECG have been documented. Moreover, anxiety has been linked to increased risk of ventricular arrhythmia occurrence,^[7] potentially due to sympathetic overdrive.^[8]

However, there is some degree of reluctance in the utilization of modern electrophysiology (EP) procedures among these patients. Furthermore, it is well-documented that even mentally sound implantable cardioverter-defibrillator (ICD) recipients not infrequently develop and manifest severe depressive symptoms, requiring psychiatric support, especially on frequent activations.^{[7],[9],[10],[11]}

In this context, we present a series of eight psychiatric patients, suffering from a variety of serious arrhythmias, managed with all aspects of modern EP practice. Emphasis is given to the patients' psychological and cardiac EP profile, as well as to any procedure-related complication events and long-term clinical course. All patients, or their legal guardians, gave consent for the use of anonymized data.

Cases

Implantable devices

Bradycardia pacemakers

A 59-year-old postinfarction patient with a history of controlled schizophrenia presented with presyncope and intermittent complete heart block. There was mild left ventricular systolic dysfunction. An atrioventricular, rate-responsive DDDR system was implanted. The patient has remained hemodynamically and psychologically stable, with >99% ventricular pacing over the next 7 years.

A 56-year-old severely depressed patient with a history of excessive loss of weight after bariatric surgery for morbid obesity presented with recurrent syncope along with episodes of supraventricular tachycardia. There was no underlying organic heart disease. A first-degree atrioventricular block with borderline sinus bradycardia (SB) and the intermittent second-degree atrioventricular block was present. A baseline EP study revealed atrioventricular node conduction disease (AVNCD) [Figure 1], and a DDDR was implanted with an eventful postoperative period characterized by exacerbation of depressive symptoms, partially due to the development of pneumococcal endocarditis. Following the explantation, a new device was reimplanted contralaterally to the right side. After 2 uneventful years, the patient returned with recurrent presyncope, associated with narrow QRS complex tachycardia. This occurred in the presence of a satisfactory pacemaker function and in a well-controlled mood condition. Despite the presence of AVNCD, repeat EP study induced atrioventricular node reentrant tachycardia (AVNRT). AVNRT was not further inducible after a short single radiofrequency energy application [Figure 2]. The patient remains symptom-free, in good mood condition 18 months later, without any atrial high-rate episodes.

Figure 1: (a) Early Wenckebach phenomenon appearance during atrial pacing (cycle length 550 ms – normal appearance at ~450 ms). (b) Prolonged atrioventricular node effective refractory period. I-V₂surface electrocardiogram leads right ventricular apex distal pacing quadripolar catheter in the right atrium

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Figure 2: Junctional rhythm during radiofrequency application suggesting stimulation and eventual cauterization of the slow pathway. Note that during junctional rhythm, the previously discernible A- and V-waves on the His bundle catheter (arrow) merge denoting synchronous atrial – ventricular activation, as during atrioventricular node reentrant tachycardia. Pacemaker was set to VVI mode at a rate of 30 bpm (backup mode). I-V₆surface electrocardiogram leads MapD-MapP mapping and ablation catheter – Artifact due to energy application, His bundle electrogram distal-His bundle electrogram proximal, right ventricular apex distal-right ventricular apical pacing catheter at the right ventricular apex

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An 81-year-old patient with a 10-year history of permanent atrial fibrillation was suffering from recurrent syncope, dyspnea, and fatigue over the past 6 months attributed to severe bradycardia. Ambulatory monitoring revealed a slow mean heart rate (40 bpm) with multiple symptomatic pauses up to 5.5 s. The patient had a history of schizoidoform disorder and intellectual disability and denied a conventional pacemaker after repeated syncope-related admissions. The next of kin was granted full custody and consented to leadless pacemaker implantation. The patient was sedated by an anesthesiologist in the outpatient clinic and immediately transferred to the EP laboratory where a leadless pacemaker was implanted. The patient was uneventfully discharged with remarkable symptom improvement over the next 18 months.

Implantable-cardioverter defibrillators

A 44-year-old male with a history of familial dilated cardiomyopathy presented with recurrent presyncope attacks. He was in the New York Heart Association functional Class II–III with a left ventricular ejection fraction (LVEF) of 30%, an end-diastolic diameter of 68 mm, and frequent premature ventricular complexes (PVCs), couplets, and 7 runs of nonsustained ventricular tachycardia (nsVT) on a 24-h Holter recording. A complete left bundle branch block and sustained ventricular tachyarrhythmia were induced on EP study while significant AVNCD was also detected. The patient received a cardiac resynchronization therapy – defibrillator (CRTD) system. Although there was a short 1-year period of clinical response, further deterioration of functional stage ensued over the following 2 years, with multiple appropriate ICD activations; including five episodes of electrical storm, putting the patient into severe, poorly responsive, depression. Following supportive psychiatric care, he eventually underwent a successful heart transplantation. The patient remains in excellent clinical and psychological condition 6 years later.

A 53-year-old male with a long history of schizophrenia presented with two syncopal episodes with associated cranial injury, in the presence of a history of remote myocarditis. Mild left ventricular impairment, marked SB, frequent PVCs, nsVT, and presence of three out of three conventional LP criteria were noted [Figure 3]. On the EP, inducible sustained monomorphic ventricular tachycardia with evidence of sinus node dysfunction was noted. A DR-ICD was implanted with no further neurological symptoms over the next 3 years. Device interrogation revealed a high percentage of atrial pacing, without any life-threatening arrhythmias.

Figure 3: Late potential detection by means of signal-averaged electrocardiogram. Note the presence of delayed activation of part of ventricular myocardium (between arrows). All three conventional criteria present: QRS duration 125 ms (cutoff >114 ms), low-amplitude signal duration in the last 40 ms of QRS 47 ms (cutoff >37 ms), root mean square at the last 40 ms of QRS 19 μV (cutoff <20 μV)

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A 49-year-old male with a history of the schizoid disorder and recent anterior wall myocardial infarction with relatively preserved LVEF (40%), presented with a short nsVT run and mild QTc prolongation. Ventricular flutter was readily induced on EP study and uncomplicated ICD-DR implantation followed. Over the past 15 months, the patient remains asymptomatic and well-controlled under a stable medication regimen.

Endocardial ablations

A 47-year-old female with a long-standing history of schizoidoform disorder also had a history of paroxysmal episodes of phantom (undocumented) tachycardias. Tachycardia episodes were poorly tolerated, causing anxiety, in addition to numerous fruitless visits to emergency departments. During the last visit, narrow QRS complex tachycardia was documented and terminated with electrical cardioversion. An ablation-based approach was agreed upon. Indeed, in the ensuing EP study, typical AVNRT was induced. The slow pathway was successfully ablated with two brief radiofrequency pulses. The patient remains free of tachycardia events while continuing her psychiatric support 5-year postablation.

An institutionalized 74-year-old male with a long history of cognitive disability was referred for dyspnea and peripheral edemas. He had a 3-year history of typical atrial flutter, treated with anticoagulation and rate control agents. Rate control was unsatisfactory, leading to tachycardiomyopathy and accordingly, an ablation was offered. Typical isthmus-dependent atrial flutter was documented, and tachycardia was terminated after a 2-min radiofrequency lesion. Remarkable clinical and echocardiographic improvement was observed following the immediate postoperative period, with the patient on sinus rhythm 12 months later.

Discussion

Psychiatric patients face the risk of SCD due to a variety of life-threatening bradycardia and/or tachyarrhythmic problems arising from both the use of psychotropic agents and the possible coexistence of organic heart disease.^[4],[6],[7] Contemporary registries have shown that patients with schizophrenia receiving guideline-based pharmacotherapy postmyocardial infarction exhibit similar mortality with the general postinfarction population, whereas withholding it leads to significantly increased risk of death^[12] – and the same is true for postinfarction depression.^[13] Unfortunately, even more so than with medical therapy, the application of lifesaving modern EP-guided treatment modalities among these patients is often delayed if sought at all. The main reasons include an unwillingness to consider nonneurological (cardiac) underlying causes for symptoms and refer patients in the first place, as well as reluctance to offer appropriate therapy, due to perceived increased complication rates, decreased compliance, and unfavorable effects on mental stability.

To refute the above concerns, we have presented a series of eight cases to emphasize the need for a thorough diagnostic and therapeutic approach among such patients. Although our hospital is a tertiary center for cardiac EP, it lacks a neurology-psychiatry department, necessitating external consultation when deemed appropriate. Thus, cases included in the present series represent a selected, rather than an all-comer cohort. Consequently, on presentation to our department, patients, or their guardians when deemed legally necessary, had already consented to the possibility of invasive procedures being performed. We did not encounter patients in acute psychiatric crises, an absolute contraindication to any nonurgent invasive procedure. As a result, the main function of the treatment team was, following diagnosis, to assess which option was best suited for a given patient and treat potential complications of any kind.

Implantation of lifesaving devices could be used in this patient population, without significant complications, in the expectation of significant clinical benefit, affecting not only the arrhythmic but also the psychiatric disorder. Although ICDs have been associated with increased prevalence of depression (up to 30% in some cohorts),^{[7],[10],[11]} with electrical storm being the strongest trigger, these effects do appear to decrease over time,^[11] and the “post ICD shock stress reaction” is amenable to appropriate therapy.^[10] Moreover, methodological disparities between studies assessing the psychological effects of ICD shocks^[14],[15] may account for discrepant findings.^[16] Indeed, sometimes, ICD implantation significantly contributes to the reduction of depressive symptoms.^[17]

Patients with cognitive impairment or dementia and standard device indications are not at increased risk for device complications.^[18] Conversely, it is well documented that a significant proportion of heart failure and/or postmyocardial infarction patients develop depression, associated with decreased heart rate variability and increased mortality if left untreated.^{[13],[19],[20]} The psychiatric support of these patients is an essential and integral part of an effective team-based therapeutic approach. Our patient series findings suggest that the degree of left ventricular involvement is not a necessary prerequisite for the estimated associated risk. Two of three ICD and all three of pacemaker recipients had either well-maintained or completely normal LVEF. Thus, further risk stratification approaches are required in this patient population as well.^[21] A multifactorial tiered stage EP-inclusive approach is both safe and effective.^[22] Indeed, the decision to implant a device among our patients was partially based on noninvasive imaging and electrocardiographic criteria from the 12-lead, signal-averaged and ambulatory electrocardiography recordings with the results of EP study, when warranted, being decisive. This is because additional risk factors cluster in this patient group^[2],[3],[4] with effects potentially accentuated on treatment with a variety of antipsychotic agents.^[23] As shown by our case series, a symptom that cannot be ignored in such patients is the occurrence of pre- and/or syncope. The presence of such neurological symptoms may be related to drug-induced polymorphic ventricular tachycardia or significant pauses, even in the absence of detectable underlying structural heart disease.

Not infrequently, the resolution of heart failure and/or neurological symptomatology by the institution of appropriate device therapy, whether antibradycardia pacemaker, ICD, or CRT-D, contributes to significant psychological improvement, a feature observed in the majority of our patients. This is explainable on the basis of correcting a potent hemodynamic stressor in a particularly sensitive patient population. Accordingly, the disappearance of the recurrent tachycardia episodes in patients after successful ablation following an EP-guided approach had a remarkable quality of life effect, as observed in the previous studies.^[24],[25] Moreover, marked improvement in patients' cognitive status has been observed in our practice following the initiation of bradycardia pacing resulting in improved cerebral perfusion when symptoms were due to bradycardia that was often unrecognized for a prolonged time.

Conclusions

EP-guided procedures can safely and effectively be applied among psychiatric patients, provided that a team approach, consisting of the primary care physician, the psychiatrist, and the interventional electrophysiologist, is pursued. The role of the former is crucial since prompt symptom recognition and referral depend on him. Survival benefits are expected to be enhanced in this patient population with an increased risk of SCD despite the associated stigma of reduced compliance, a presumed incidence of an increased complication rates, and the fear of mental destabilization. Such obstacles lead to the inadequate implementation of modern electrophysiological tools in their treatment. A strict requirement for intervention success is the recognition of the high-risk patient in a timely fashion by applying a multifactorial tiered stage EP-inclusive approach.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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Figures

[Figure 1], [Figure 2], [Figure 3]

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