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Case: An 85 year-old male presented with major depressive disorder refractory to medical therapy. A series of eight electroconvulsive therapy (ECT) was planned. Past medical history includes a small penetrating ulcer in the aortic arch, an ascending aortic aneurysm measuring 4.3 x 4.4 cm, atrial fibrillation on anticoagulation and hypertension. Medications include metoprolol, coumadin, simvastatin, alprazolam and venlafaxine.