Twiddler's syndrome: a rare cause of pacemaker failure.

160 Twiddler's syndrome was first described by Bayliss et al. in 1968 [1]. This condition is a rare cause of pacemaker failure, resulting from the dislodging of pacing electrodes by manipulation, often unconsciously, of the implanted pacemaker [2]. This report describes a rare condition of pacemaker failure in a patient with twiddler's syndrome resulting from unintentional rotation of the pacemaker causing atrial lead dislodgement from the endocardium and malfunction of the device. A 69 year old diabetic and hypertensive woman was hospitalized for weakness. Complete atrioventricular block was diagnosed on electrocardiogram and a permanent AV sequential pacemaker (DDDR, Biotronik, Germany) was implanted with a screw in Selox ST 60 electrode in the right atrium and a passive-tined electrode in the right ventricular apex. Pre-discharge chest X-ray revealed well-positioned electrodes [Figure A] and ECG showed appropriate function of the pacemaker. Four days later a heart rate of 60 beats per minute was measured, associated with abdominal tingling, namely, a phrenic nerve stimulation (the patient described this feeling as a sensation of fetal movements during pregnancy). The patient mentioned that the external monitor electrode located above the pacemaker generator caused irritation. The patient was referred to hospital where an ECG showed paciemaker under-sensing and non-capture of the atrial electrode and normal ventricular pacing at 60 beats per minute – the lower rate of the pacemaker programming. A chest AV = atrioventricular X-ray revealed a dual-chamber pacemaker with displaced electrodes of right ventricular and atrium, with coiling around the pacemaker [Figure B]. Re-implantation of the electrode was performed successfully using the same electrodes. The patient was discharged 2 days later after evaluation of the pacemaker function and appropriate placement of the electrode on X-ray. Comment Twiddler's syndrome is a rare cause of pacemaker failure, resulting from the dislodging of pacing electrodes by manipulation , often unconsciously, of the implanted pacemaker [2]. Sometimes, when the leads are displaced and loop around the pacemaker body, ipsilateral phrenic nerve or brachial plexus stimulation may occur with resultant cycling contractions of the abdomen [3] or arm muscles [4]. Risk factors associated with twiddler's syndrome are female gender, obesity, older age and dementia [1,2,4], although it appears that dementia is by far the greatest risk factor [5]. Chest X-ray is the most important and simplest diagnostic tool. The majority of patients with twiddler syndrome are diagnosed within the first year of implant. Twiddler syndrome may lead to a …