Twiddler's syndrome: An unusual cause of repeated shocks by implantable cardioverter-defibrillator in an asymptomatic patient

Abstract

Twiddler's syndrome refers to malfunction of pacemaker or implantable cardioverter-defibrillator (ICD) resulting from deliberate or unintentional twisting of pulse generator in device pocket, resulting in lead dislodgment. We report a case of a 65-year-old woman with multiple ICD shocks and antitachycardia pacing events on device interrogation, while she was unaware of the ICD discharges. Twiddler's syndrome is rare and mostly occurs in obese or elderly because of loose subcutaneous tissue allowing pulse generator to rotate in its pocket. It can be prevented by patient education against hand manipulating the generator. Smaller device pocket or suturing generator to fascia can also prevent future episodes.

New Technologies and Applications in Sacral Neuromodulation: An Update

“…Moreover, the correct implantation of a small rechargeable device with the necessity for frequent recharges may be more challenging in obese patients, since the angle and distance between the superficially implanted IPG and recharger may change significantly between recharging sessions, thus making the recharge more cumbersome for obese patients. Furthermore, the stability of the IPG inside the fat tissue could be compromised and/or the patient might be more likely exposed to twiddler's syndrome [10]. The latter occurs when patients manipulate or rotate their device leading to a dislodgment of the leads with subsequent malfunction of the modulation system.…”

Twiddler’s syndrome after implantation of baroreflex activation therapy: a case report

“… 16 Consecutive device dysfunction may result in life-threatening conditions due to insufficient pacing or inappropriate shock delivery in PM or ICD patients. 5–8 , 16 Although this was not an issue in our case of BAT, suboptimal device positioning at the time of generator and lead relocation might have contributed to early Twiddler’s syndrome only a few weeks afterwards. The generator was placed in a more subcutaneous position despite the fact that the initial position was sub-pectoral due to the patient body constitution.…”

“…4 in 1968 after implantation of a transvenous pacemaker (PM), and was, in addition, observed after implantation of transvenous implantable cardioverter-defibrillators (ICD), 5 or even subcutaneous ICD systems, 6 which commonly leads to insufficient pacing or inappropriate ICD therapy delivery. 5–8 Furthermore, this rare complication may occur in neurological 9 or anaesthesiologic devices 10 and was described following implantation of BAT by Galand et al . 11 for the first time.…”

Aşırı Aktif Mesane Yönetiminde Sakral Nöromodülasyon Uygulamaları

“…Özellikle obez hastalarda yüzeysel olarak implante edilmiş IPG ile şarj cihazı arasındaki açı ve mesafe önemli ölçüde değişebileceğinden bu hastalarda cihazın doğru implantasyonu küçük cihazlarda zor olabilir ve sık şarj etme gerekliliğine neden olabilir. IPG'nin yağ dokusu içindeki stabilitesi tehlike yaratabilir ve hastayı Twiddler sendromuna sokabilir (22) (20). AAM tedavisinde SNM uygulama güvenliğine bakıldığında en çok bildirilen advers olay ve cerrahi revizyon nedenleri implant bölgesinde ağrı (%3-33) ve stimülasyonda istenmeyen değişiklikler (%15-42) olarak saptanmıştır.…”