A Spinning Nightmare of Twiddler's Syndrome?

Twiddler's syndrome is a known complication of CIED implantation. Most published cases of Twiddler's syndrome are described as being secondary to patient manipulation of the pulse generator leading to horizontal rotation and "reeling" of the pacemaker leads around the generator. The authors of this paper present a case of an 81-year-old female who had her anchoring suture across the pulse generator break after implant. This led to rotation of the pulse generator in the vertical axis and subsequently led to RV lead rotation in the longitudinal axis. The patient developed rising thresholds and low impedance on the RV lead, with fluoroscopy confirming an insulation break and lead fracture. Due to the nature of the lead rotation, extraction was impossible, and the lead was capped and buried. The case report highlights a unique mechanism by which a lead can rotate along its longitudinal axis, and is a reminder to implanting physicians regarding the importance of proper anchoring techniques.