An unusual cause of oversensing leading to inappropriate ICD discharges

Spencker, Sebastian; Poppelbaum, Andreas; Müller, D.

doi:10.1016/j.ijcard.2007.06.088

Cited by 17 publications

(19 citation statements)

References 5 publications

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“…Twiddler's syndrome has been known to be an uncommon cause of malfunction in pacemakers, ICDs, and cardiac resynchronization therapy devices [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15]. The prevalence of this syndrome was reported to be 0.07% in cases with a pacemaker [2,7].…”

Section: Discussionmentioning

confidence: 99%

“…This syndrome occurs if the patient consciously or unconsciously twiddles the implanted generator in the subcutaneous pocket [4]. Twiddling of the pulse generator can result in twisting of the leads within the pocket; this usually results in dislocation or fracture of the leads, which causes loss of capture and abnormal sensing [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15]. In these cases, the electrocardiogram shows a failure to capture and the chest radiography reveals the dislodged and twisted leads.…”

Section: Discussionmentioning

confidence: 99%

“…In a few reports, the dislodged lead caused ipsilateral phrenic nerve stimulation leading to the sensation of diaphragmatic and abdominal pulsations [6,11,14]. Twiddler's syndrome is more serious and potentially life threatening in cases with a defibrillator because treatment of ventricular arrhythmias would be disabled and inappropriate shocks could be delivered due to over sensing [10,12,13].…”

Section: Discussionmentioning

confidence: 99%

“…According to most published reports, patients with Twiddler's syndrome are usually diagnosed due to some type of sudden device malfunction [1][2][3][4][6][7][8][9][10][11][12][13][14][15]. Early detection of this condition can also be achieved with a home monitoring system [8].…”

Section: Discussionmentioning

confidence: 99%

“…If several risk factors for Twiddler's syndrome, such as obesity, excessive movements of the upper limbs, active manipulation of the generator, large size pocket, or dementia, are observed, preventive maneuvers like anchoring the generator to the bottom of the pocket or sub-pectoral implants should be considered during implantation. Furthermore, Twiddler's syndrome usually occurs one year or less after implantation of the device [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15]. In the case presented, the condition was diagnosed 5 months after the implantation.…”

Section: Discussionmentioning

confidence: 99%

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Twiddler's syndrome detected by patient's complaint of implantable cardioverter‐defibrillator rotation in the subcutaneous pocket

Konishi

Tokano

Nakazato

et al. 2012

Journal of Arrhythmia

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a b s t r a c tTwiddler's syndrome presents as a rare implantable-cardioverter defibrillator (ICD) malfunction that is potentially fatal. The following case is that of a 79-year-old woman, who was implanted with an ICD and experienced Twiddler's syndrome. Five months after the implantation, the patient complained that the generator sometimes rotated in the subcutaneous pocket. Fluoroscopy showed that the generator had rotated and the leads were twisted, which is compatible with Twiddler's syndrome. Although all the leads were functioning normally, a procedure to repair the twisted leads was performed. Twiddler's syndrome is usually detected due to a serious device malfunction; however, this case study suggests that it can be detected prior to ICD malfunction by the patient's complaint.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 3 more Smart Citations

Twiddler's syndrome detected by patient's complaint of implantable cardioverter‐defibrillator rotation in the subcutaneous pocket

Konishi

Tokano

Nakazato

et al. 2012

Journal of Arrhythmia

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Triple atrial sensing during cardiac resynchronization

Barold

Kucher

Halfenberg

2020

Journal of Arrhythmia

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cardiac resynchronization, implantable cardioverter-defibrillator, pacemaker, Twiddler syndrome, ventricular tachycardia A 77-year-old man received a transvenous cardiac resynchronization device with cardioverter-defibrillation capability (Lumax 640 HF-T; BIOTRONIK). Ten months later, he presented with a shock. Figure 1 shows the data retrieved by interrogating the device.What is the interpretation of the recording and the mechanism of the shock? Why is atrial sensing present in all three channels?The device parameters and marker annotations were as follows: VT1 = programmed ventricular tachycardia interval for antitachycardia pacing (first therapy) 350 ms (170 bpm) and VF = ventricular fibrillation 270 ms (220 bpm). Therapy for VT1 was initiated with antitachycardia pacing (ATP); four bursts first followed by four ATP ramps and then a 40 J shock if ATP was unsuccessful.In Figure 1, the marker channels are on top and the electrograms are below. A = atrium, RV = right ventricle, and LV = left ventricle.There is sinus rhythm at about 115 beats per minute and the third atrial beat is unsensed. There is also atrial undersensing before the shock on the right side of the tracing. Intermittent atrial undersensing is because of the atrial lead displacement. The right ventricular lead shows a double waveform consisting of the atrial and ventricular electrograms. On the right, there is a single episode of Mobitz type II AV block demonstrated by the loss of a ventricular electrogram. The right ventricular lead was displaced to the right atrium where the near-field atrial electrograms and the far-field ventricular electrograms are recorded. The right ventricular channel senses both the atrial and ventricular electrograms resulting in short ventricular intervals alternating with long ones. The short intervals (173-188 ms), depicted by VF markers, correspond to the PR interval. The long intervals, depicted by VT1 markers, measure less than 350 ms (the VT1 interval) except for a longer interval after the non-conducted atrial beat. The device delivers a shock at the end of the tracing as shown by the large baseline deflection. Note that all three leads demonstrate atrial sensing. | LEF T VENTRICUL AR S EN S INGSome implantable devices for cardiac resynchronization therapy (CRT) with cardioverter-defibrillator capability, as the one in this report, can sense LV activity. 1 LV sensing functionality was designed primarily to prevent pacing into the vulnerable period of the LV myocardium. Displacement of an LV lead toward the coronary sinus places it where left atrial activity may be sensed. There are no reports of far-field atrial oversensing during sinus rhythm by a correctly positioned LV lead for CRT. 2 Consequently, far-field atrial sensing by an LV lead strongly suggests lead displacement toward the AV groove. Although far-field atrial sensing did not involve the delivery of therapy it contributes to the description of triple atrial sensing. | T WIDDLER SYNDROMEFar-field atrial oversensing in the right and left ventricular lea...

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Unusual “ratchet syndrome”: spontaneous lead retraction after a generator exchange

et al. 2013

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A 72-year-old female with idiopathic dilated cardiomyopathy underwent a generator exchange for a cardiac resynchronization therapy defibrillator with a full-pocket capsulectomy. The lead position after the operation was identical to that before the operation on the chest X-ray. After 4 months, a subacute exacerbation of her heart failure was caused by cardiac resynchronization therapy failure due to a dislodgement of the left ventricular lead. An aggressive adhesiotomy of the connective tissue around the leads made it possible for the lead to retract by a ratchet-like movement through the suture sleeve, so-called "ratchet syndrome", after the generator exchange.

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An unusual cause of oversensing leading to inappropriate ICD discharges

Cited by 17 publications

References 5 publications

Twiddler's syndrome detected by patient's complaint of implantable cardioverter‐defibrillator rotation in the subcutaneous pocket

Twiddler's syndrome detected by patient's complaint of implantable cardioverter‐defibrillator rotation in the subcutaneous pocket

Triple atrial sensing during cardiac resynchronization

Unusual “ratchet syndrome”: spontaneous lead retraction after a generator exchange

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