An elderly 91-year-old female patient was admitted for paroxysmal atrial fibrillation in September 2011. During this admission, she was evaluated for and received a permanent pacemaker. Later that night, the patient became very agitated and dislodged her atrial lead. The patient was taken back to the cardiac cath lab for a lead revision the following morning. This procedure went well, and the patient was sent home the next day.
Six weeks after the lead revision, the patient experienced an episode of significant twitching and discomfort on the left side of her chest. Re-interrogation of the pacemaker revealed it was not working, and examination of the chest x-ray showed complete dislodgement of both the atrial and ventricular pacemaker leads. The atrial lead was significantly coiled and appeared to be pulled entirely out of the atrium. The x-ray demonstrated a significant problem. The possibility of Twiddler’s syndrome was discussed.
Pacemaker Twiddler’s syndrome is a phenomenon in which a patient will dislodge a pacing electrode by manipulating the permanently implanted pacemaker generator, causing the pacing system to fail. This occurs due to the patient’s deliberate or subconscious spinning or twiddling of the pulse generator. It is not a common finding, occuring in only 0.07%–1.7% of implants.
Symptoms of Twiddler’s syndrome may include decreased heart rate, device malfunction, twitching of the arm, chest, abdomen, and stomach area. Patients with psychotic disorders or patients with large pacemaker pockets are more prone to experience Twiddler’s syndrome. Preventive measures can include adequate fixation of the generator to the fascia, use of a Dacron patch over the generator, small pocket formation, and close patient follow-up.
The patient was taken to the cardiac cath lab and the permanent pacemaker was explanted. The atrial lead was found to be extremely coiled and pulled entirely back to the generator. The ventricle lead was pulled back as well, but not as severely. After arrival to the cath lab procedure room, the pacemaker pocket was re-opened and the generator was removed. The atrial lead was coiled and knotted, and came completely out of the pocket with the generator. Both leads were removed from the generator and completely extracted. The generator was not impacted by the event. New atrial and ventricular leads were implanted. Longer pacer leads (a 53 cm for the atrial lead and a 58 cm for the ventricle lead) were used for extra slack to reduce the risk of dislodgement; these were connected to the original generator. A Bard® Parsonnet™ pouch was placed over the pacemaker and secured to the chest wall. A shoulder immobilizer was also put in place on the patient. The patient was discharged without further complications.