Table 2. Summary of clinical considerations for ECT in patients with CIED.

1. Before ECT Multidisciplinary team liaison involving psychiatrist, anaesthesiologist, cardiologist, cardiac electrophysiologist. Device interrogation ✠ Type of CIED, model, and manufacturer details ✠ Indication ✠ Battery longevity and condition of the leads. ✠ Programming details and pacemaker dependency. ✠ Magnet rate and rhythm if planning to use a magnet, ✠ History of malfunctions or cardiac events. Assess patient’s underlying rhythm and rate - assess the need for back up pacing. Anticholinergic if indicated - Preferably glycopyrrolate. Pacemaker - Asynchronous mode in pacemaker dependent patient/ turn off rate adaptation if excessive chest wall movement with breathing support is a concern. ICD - Deactivation of anti-tachycardia function. Ensure the availability of competent authority to handle CIED during ECT if necessary.

2. During ECT Proper grounding of all monitoring devices. Adequate electrical insulation of patient. Ensure that electronic devices are placed in safe distance away from the CIED. Monitor cardiac rhythm and peripheral pulse oximetry and disable artefact filter in ECG monitor if available. Ensure proper muscle relaxation to avoid myopotentials and use non-depolarizing muscle relaxants if succinylcholine-induced fasciculation is of concern. Avoid subthreshold stimulus. If EEG monitoring is not available to record the seizure, place the cuff in the lower limb to observe the seizure movement.

3. After ECT Monitor vitals and prompt detection and treatment of tachyarrhythmia and hypertension if indicated. Interrogation of CIED by competent authority. Turn on the rate adaptation and adjusting the pacing mode of pacemaker if modified before ECT. Re-enable the anti-tachycardia function ICD if modified before ECT.