“…On the other hand, Reel syndrome is due to rotation of the device on its transverse axis leading to the coiling of the leads around the generator without any damage to the leads. Ratchet syndrome involves upward and downward shoulder motion causing progressive retraction of the leads without twisting or coiling around the device [ 3 , 4 ]. Fig.…”
“…On the other hand, Reel syndrome is due to rotation of the device on its transverse axis leading to the coiling of the leads around the generator without any damage to the leads. Ratchet syndrome involves upward and downward shoulder motion causing progressive retraction of the leads without twisting or coiling around the device [ 3 , 4 ]. Fig.…”
“…Ratchet syndrome is caused by ‘sliding’ of the generator back and forth, laterally along the frontal plane resulting in lead displacement with ratcheting. 6 One proposed mechanism for lead dislodgement in Ratchet syndrome is the ‘unidirectional brake’ effect of a suture sleeve, resulting in a one-way mobilization of PPM leads after device manipulation. 7 The different radiological manifestation of device manipulations are described in Figure 3 .…”
Background
Pacemaker lead dislodgement and failure, related to device manipulation, is a rare complication of permanent pacemaker (PPM) insertion. Reel’s, Twiddler’s, and Ratchet syndrome are rare causes of pacemaker failure with varying mechanisms, defined by their classical lead and generator findings on chest X-ray imaging. Misleading patient presentations may be attributed to lead stimulation of surrounding structures.
Case summary
A 77-year-old female was admitted with abdominal wall pulsations, abdominal pain, and lower limb jerking 3 months following PPM insertion. Following exclusion of a ruptured abdominal aortic aneurysm, the presence of Reel syndrome was noted on the patient’s chest X-ray and the electrocardiogram showed inappropriate pacing. Deactivation of the pacemaker resulted in immediate symptom cessation and urgent repositioning of pacemaker leads was undertaken.
Discussion
This case highlights the importance of considering pacemaker complications causing non-cardiac symptomatology. Pacemaker lead stimulation of surrounding structures can present in an unconventional fashion, veiling the diagnosis. However, a structured approach to undifferentiated neuromuscular presentations in patients with PPMs should consider lead dislodgement as a differential diagnosis. Rapid recognition of lead dislodgement, device deactivation, and re-implantation or repositioning of the leads are critical in preventing potentially life-threatening complications.
“…Owing to this rotational movement, the electrode winds as a braid, which defines the characteristic appearance of this finding. Ratchet syndrome is caused by retraction and electrode dislocation with ratcheting but without coiling of the generator due to progressive displacement of the electrodes from their fixing protections 2. Twiddler's and Reel syndromes have similar aetiologies; female gender, large pocket, obesity, children, older people and dementia can be listed as contributing factors and their prevalence is unknown.…”
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