Evaluation of Cardiac Adverse Effects After Transition From Bitemporal to Bifrontal ECT

Electroconvulsive therapy (ECT) is an effective and safe treatment for severe or treatment-resistant psychiatric disorders, but transient asystole and arrhythmias can occur during the treatment. Reports have shown that bifrontal electrode placement may reduce these adverse events. Our clinic changed the preferred electrode placement from bitemporal (BT) to bifrontal (BF) in May 2022. We wanted to evaluate whether this transition reduced the duration of asystole and the incidence of arrhythmias, and whether this resulted in similar remission rates.

We retrospectively reviewed the records of 69 patients who had BF ECT between May 2022 and October 2025, and the same number of consecutively treated patients who had received BT ECT before May 2022. We had data on arrhythmias for all patients, on ECG recordings for 69 BF and 42 patients with BT, and ratings for remission on all but 4 patients. Regression analysis controlling for age, sex, and concomitant medications was used to assess differences in the duration of the longest heart interbeat intervals, the rates of arrhythmia, and of clinical remission.

Patients treated with BF ECT had a much shorter duration of interbeat intervals [0.74 s (SD=0.18) vs. 1.32 s (SD=0.57), P=1.5×10-14]. The rates of arrhythmias were reduced, but the difference was not significant (15.9% vs. 27.5%, P=0.082). Remission rates were not significantly different (BF=59.7%, BT=63.6%, P=0.49).

BF ECT had a marked effect on reducing the rate of asystole and possibly the rate of arrhythmias during ECT, without reducing clinical effectiveness. This electrode placement could be preferable for older people and those at increased risk of heart complications.