Electroconvulsive therapy has potent cardiovascular effects, which may pose a challenge in treating patients with preexisting cardiac disease. Although it is well studied in the treatment of refractory depression, there are still pitfalls to overcome when treating those with comorbid cardiovascular disease. The synergistic effects of depression and cardiovascular disease in affecting the morbidity and mortality of patients make treatment a significant issue. The authors discuss 3 elderly patients treated for major depression, all of whom previously had implantable cardioverter-defibrillators placed. All 3 patients were effectively treated, with no major adverse effects. The cases illustrate how taking the appropriate preventative measures allow even the most medically challenging patient to undergo effective treatment and highlight the debate surrounding the intraoperative management of implantable cardioverter-defibrillator devices.