Twiddler syndrome as a rare cause of implantable cardioverter defibrillator malfunction

Abstract

Twiddler syndrome that causes device malfunction is a rare complication in patients with an implantable cardioverter defibrillator. In this case report, we present a patient who was referred to our hospital with palpitation and abdominal pulsation 7 months after implantable cardioverter defibrillator implantation.

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

“…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].…”

“…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].…”

“…Hypoperfusion symptoms, such as fatigue and syncope, are observed in pacing-dependent patients. 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].…”

“…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.…”

Common Pacemaker Problems: Lead and Pocket Complications

“…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 rotation of pulse generator on its long axis with subsequent coiling of pacemaker leads (Bhatia et al, 2007).…”