Defibrillator twiddler's syndrome causing device failure in a subpectoral transvenous system

Twiddler's syndrome is well described as a complication of cardiac pacing. Defibrillator twiddler's syndrome has been recently reported with abdominal implantations of epicardial and transvenous defibrillator systems. We report a case of a patient with a transvenous defibrillator system implanted with the pulse generator placed in the subpectoral plane. The patient developed twiddler's syndrome, which resulted in retraction of both leads. This caused inappropriate shocks due to sensing both the atrial and ventricular electrograms. While the subpectoral position leaves the generator deeper and more difficult for the patient to access, it may not lessen the chance of twiddler's syndrome. It is possible that the subpectoral position may actually predispose the patient to this malady.