Twiddler Syndrome Detected by Patient’s Complaint of ICD Rotation in the Pectoral Pocket

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Background: Twiddler syndrome is a rare cause of pacemaker/ICD lead failure. We present a case of Twiddler syndrome detected by patient’s complaint of generator rotations in the pectoral pocket. Case Report: A 79 year-old woman was implanted an ICD with screw-in shock and atrial leads because of hemodynamically unstable sustained ventricular tachycardia in October, 2010. Proper lead impedance and capture/sensing threshold had been maintained. Five months later, the patient reported that the generator sometimes rotated when she turned over in bed. Fluoroscopy showed that the generator turned over and the leads twisted indicating Twiddler syndrome. Device telemetry did not demonstrate lead malfunction and delivering inappropriate shocks excepting slightly high capture threshold of the shock lead. Re-operation was done, and lead function was still normal after repairing the twisting of both leads. Therefore, lead replacement was not required and the generator was sutured on the pectoral muscle. Twiddler syndrome has not reoccurred so far. Conclusion: It is common that Twiddler syndrome is found by sudden device malfunction, however, patient’s complaint of generator rotations was helpful to find it before device malfunction occurred in the presented case. Lead dislodgement might be avoided by using screw-in leads in this patient.