Pacemaker twiddler's syndrome: a note on its mechanism.

Area of Science:

• Cardiology
• Medical Devices
• Electrophysiology

Background:

• Implantable pacemakers are crucial for managing bradyarrhythmias.
• Endocardial pacing systems, particularly bipolar configurations, are widely used.
• Complications associated with pacemaker implantation require careful monitoring and analysis.

Observation:

• Two elderly female patients developed a loss of pacing capture weeks after implantation of a bipolar endocardial ventricular inhibited demand pacing system.
• Radiographic imaging revealed that the endocardial catheter had been pulled out.
• The catheter displacement was attributed to the formation of a multi-twined loop within the subcutaneous pulse generator pocket.

Findings:

• The primary finding is an unusual mechanism of pacemaker lead dislodgement.
• The formation of a looped lead within a "loose and laxed" subcutaneous pocket is identified as the cause of catheter pull-out.
• This mechanical complication resulted in total loss of capture, rendering the pacemaker ineffective.

Implications:

• This case highlights a rare but significant complication of pacemaker implantation.
• Understanding lead looping mechanisms is essential for preventing lead dislodgement.
• Recommendations for surgical technique and pocket management are crucial for improving long-term pacemaker function and patient safety.