Displacement of pacemaker leads due to twisting of the box on part of the patient is called
Twiddler’s syndrome, first described in 1968 (Nicholson et al., 2003).Twiddler syndrome
that causes device malfunction is a rare complication in patients with an implantable cardioverter defibrillators (ICD) (Fahraeus & Höijer, 2003). Twisting of the pulse generator
within the device pocket may cause the dislocation of the lead, diaphragmatic stimulation,
and loss of capture (Figure 7). The prevelance of this syndrome is 0.07% (Gungor et al.,
2009). Classically, Twiddler syndrome occurs in obese women with loose, fatty
subcutaneous tissue and is characterized by rotate on of pulse generator on its long axis with subsequent coiling of pacemaker leads (Bhatia et al., 2007). Other risk factors are mental disorders, female sex, and the small size of the implanted generator with a large pocket (Cardall et al., 1999). This disorder may induce lead dislodgement or lead fracture and cause life-threatening symptoms in case of pacemaker dependency. When the pulse generator is rotated along the transverse axis it is referred by us as the Reel syndrome, a variant of Twiddler syndrome (Camero-Varo et al., 1990).
In Twiddler syndrome, electrocardiography shows failure of capture and the chest
radiography reveals the dislodged and twisted leads (Pereira et al., 1999). Hypoperfusion symptoms such as fatigue, tiredness, confusion, presyncope, and syncope may be obse
rved (Cardall et al., 1999). If the problem has occured because of pacemaker migration or poorly fashioned pacemaker pocket, the pocket should be revised. As an inappropriate ICD
therapy may be proarrhythmic and may lead to sudden cardiac death, Twiddler syndrome
should be considered in patients with ICD who had resistant ventricular arrhythmias and
abdominal pulsation. To avoid this life-threatening complication of ICD implantation, we
should take care to limit the pocket size, suture the device to the fascia, and instruct the
patients not to manipulate their device pockets.
Pacemaker Twiddler syndrome. Postero-anterior and lateral chest X-ray showing
displacement of both leads, especially the ventricle one, retracted and floating in the right
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