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J Thorac Cardiovasc Surg 1995;110:269-271
© 1995 Mosby, Inc.

BRIEF COMMUNICATIONS

Recurring twiddler's syndrome: Report of a case

Crescencio Camacho, MDa, Javier Ortigosa, MDa, Juan-Francisco Oteo, MDa, Manuel de Artaza, MDa, Santiago Serrano-Fiz, MDb, José-Miguel Molina, MDc


Madrid Spain

Address for reprints: Crescencio Camacho, MD, Cardiology Department, Clínica Puerta de Hierro, 28035 Madrid, Spain.

We report the case of a 78-year-old male patient in whom a dual-chamber endocavitary pulse generator was implanted. After 14 days he came to the emergency department because of frequent annoying contractions of the abdominal muscles, which were openly visible. A chest x-ray film revealed a ventricular lead wound around the pulse generator, with the tip introduced into the superior vena cava (Fig. 1). The atrial lead was in the proper position. The ventricular lead was reimplanted and the atrial lead was repositioned for even greater stability. The pacemaker functioned normally and the patient left the hospital.



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  		Fig. 1. Chest x-ray film. Posteroanterior (A) and lateral (B) projections showing migration of ventricular lead (arrow), which is wound around pulse generator.

 
Ten days later the patient returned to the hospital with the same symptom. A newer chest x-ray film (Fig. 2) disclosed the ventricular lead a second time in the superior vena cava, on this occasion at a higher level. Again the electrode was reimplanted, this time under general anesthesia, by placing the pulse generator beneath the pectoral muscle and securing it to the fascia. The ventricular lead was likewise secured. The patient has remained free of symptoms since he left the hospital a year ago, and the pacemaker is functioning normally.



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  		Fig. 2. Chest x-ray film. Lateral projection showing relocated atrial electrode. Ventricular electrode migrated to higher level into superior vena cava (arrow).

 
The overall prevalence of twiddler's syndrome is up to 1.1%.Go 1 It is uncommon in patients with dual-chamber pacemakers, although there have been cases of dislodgment of the atrial lead alone.Go 2 In this case, on neither of the two occasions was the migration of the atrial lead, although it had changed position within the right atrium after the first reimplantation. Unusually, the ventricular lead migrated alone on the two occasions.

Several surgical techniques and precautions have been proposed to prevent twiddler's syndrome,Go 3 although these have not always proved successful.Go 4 In our patient, the procedure consisted of fastening the pulse generator and the origin of the ventricular lead to the pectoral fascia, and the result has been good.

The recidivant migration of the ventricular lead in a dual-chamber pacemaker is uncommon. We report such a case and propose a surgical technique, used in our case, useful in prevention of the recurrence of twiddler's syndrome.

Footnotes

From the Cardiology Department,a Cardiac Surgery Department,b and Intensive Care Unit,c Clínica Puerta de Hierro, Madrid, Spain. Back

J THORAC CARDIOVASC SURG 1995;110:269-71 Back

References

  1. Hill PE. Complications of permanent transvenous cardiac pacing: a 14-year review of all transvenous pacemakers inserted at one community hospital. PACE Pacing Clin Electrophysiol 1987;10:564-70.[Medline]
  2. Ellis GL. Pacemaker twiddler's syndrome: a case report. Am J Emerg Med 1990;8:48-50.[Medline]
  3. Roberts JS, Wenger NK. Pacemaker twiddler's syndrome. Am J Cardiol 1989;63:1013-6.[Medline]
  4. Lal RB, Avery Rd. Aggressive pacemaker twiddler's syndrome: dislodgement of an active fixation ventricular pacing electrode. Chest 1990;97:756-7.[Abstract/Free Full Text]




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