Erosive Twiddler’s Syndrome: A Severe Case with Externalization of the Pacemaker

Abstract

Implantable pacemakers have been the mainstay of therapy for patients with severely decreased left ventricular ejection fractions and recurrent arrhythmias, among other cardiac pathology. Twiddler's syndrome (TS) is an uncommon but potentially life-threatening complication of pacemaker therapy, defined as pacemaker malfunction in the setting of device lead dislodgment due to physical manipulation. Traditionally, there are three distinct TS variants (reeling, ratchet and coiling). This case offers evidence of a unique and new variant of TS, severe recurrent erosive subtype with pacemaker externalization.

Neuropathophysiology of coronavirus disease 2019: neuroinflammation and blood brain barrier disruption are critical pathophysiological processes that contribute to the clinical symptoms of SARS-CoV-2 infection

“…The viral RNA is then translated into several structural proteins required for viral assembly, non-structural proteins (produced from the cleavage of two large polyproteins) required for viral RNA synthesis, and accessory proteins required to overcome the immunity of the host (Fig. 1 ) (Bartlam et al 2005 ; Perlman and Netland 2009 ; Liu et al 2014 ; Valencia 2020 ). Thereafter, the virus starts to replicate, and subsequently assembled to form similar viruses, which may be slightly different from the original viral RNA genome.…”

“…However, the viral RNA genome may be transcribed to the corresponding mRNA, which is then translated in the cytoplasm to form envelope glycoproteins (Fig. 1 ) (Bartlam et al 2005 ; Perlman and Netland 2009 ; Liu et al 2014 ; Valencia 2020 ). These glycoproteins are inserted into the membrane of the endoplasmic reticulum or Golgi network, and together with the nucleocapsid protein, germinate in the endoplasmic reticulum-Golgi intermediate compartment.…”

“…The products are assembled; bud off to form new viral replicates (Fig. 1 ) (Bartlam et al 2005 ; Perlman and Netland 2009 ; McBride et al 2014 ; De Wit et al 2016 ; Valencia 2020 ). The viral vesicles then fuse with the plasma membrane, releasing the virus to infect other cells (Fig.…”

Troubleshooting During Temporary Epicardial Lead Implantation in a Child with an Erosive Twiddler’s Syndrome and Multiple Sternotomies

“…[2][3][4][5] An erosive subtype of the Twiddler's syndrome with pacemaker externalisation without lead dislodgement and pacemaker failure was previously reported in an adult patient. 6 In the current patient, the pacemaker was eroded with loss of capture of the heart rate. However, the heart rhythm could be captured with a higher voltage indicating that the permanent epicardial leads were functional but needed a higher voltage for rhythm capture.…”