Pacemaker Twiddler's Syndrome: Report of four cases

Pacemaker twiddler's syndrome deseribes an infrequent cause of pacemaker fail ure as a result of spontaneous, subconscious or purposeful twisting of pulse generator in its pocket leading to the endocardial electrode rotation areund the pulse generator and retraction into the superior vena cava or subelavian vein. In this report we deseribe four patients with pacemaker twiddler's syndrome encountered during the last ten years. All four patients mentioned frequ~nt oval massage on the pacemaker pocket. The first patient was very obese and the second; third and fourth patients were very thin. The obese patient had abundant subcutaneous fat tissue, and in the very slim patients the subcutaneous tissue was loose. Three of four patients were elderly. These predisposing factors might be important in the development of this condition. All four patients were symptomatic. The diagnosis of twiddler's syndrome was made on symptoms, ECG and fluoroscopic or chest X-ray findings. In the first and third patients, a new lead was implanted and in the second and fourth patients the same lead was repositioned and reimplanted .. In conclusion, twiddler's syndrome must be considered in patients with pacemaker dysfunction especially in the elderly, thin or abese patients. It may be prevented by an appropriately sized pocket and fixing the electrodes at the site of the implanted device and placing and fixing the pacemaker under the pectoralis muscle fascia.