“Ratchet” syndrome, another etiology for pacemaker lead dislodgement: A case report

EHRA expert consensus statement and practical guide on optimal implantation technique for conventional pacemakers and implantable cardioverter-defibrillators: endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), and the Latin-American Heart Rhythm Society (LAHRS)

With the global increase in device implantations, there is a growing need to train physicians to implant pacemakers and implantable cardioverter-defibrillators. Although there are international recommendations for device indications and programming, there is no consensus to date regarding implantation technique. This document is founded on a systematic literature search and review, and on consensus from an international task force. It aims to fill the gap by setting standards for device implantation.

An Unusual Cause of Pacemaker Lead Displacement: ‘Reverse Ratchet’ Syndrome

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Ratchet mechanism selectively causing idiopathic macrodislodgement of an active-fixation coronary sinus lead: a case report

BACKGROUND

'Idiopathic' lead macrodislodgement may be due to Twiddler's syndrome depending on active twisting of pulse generator within subcutaneous pocket. All leads are involved, at any time from implantation, and frequently damaged. In the past few years, a reel syndrome was also observed: retraction of pacemaker leads into pocket without patient manipulation, owing to lead circling the generator. In other cases, a 'ratchet' mechanism has been postulated. Reel and ratchet mechanisms require loose anchoring, occur generally briefly after implantation, with non-damaged leads. We report the first case of an active-fixation coronary sinus lead selective macrodislodgement involving such ratchet mechanism.

CASE SUMMARY

A 65-year-old man underwent biventricular defibrillator device implantation, with active-fixation coronary sinus lead. Eight months later, he complained of muscle contractions over device pocket. At fluoroscopy, coronary sinus lead was found near to pocket, outside of thoracic inlet. Atrial and ventricular leads were in normal position. After opening pocket, a short tract of coronary sinus lead appeared anteriorly dislocated to generator, while greater length of lead body twisted a reel behind. The distal part of lead was found outside venous entry at careful dissection. Atrial and ventricular leads were firmly anchored.

DISCUSSION

Our case is a selective 'Idiopathic' lead macrodislodgement, possibly due to a ratchet mechanism between the lead and the suture sleeve, induced by normal arm motion; such mechanism incredibly, and for first time in literature involves a coronary sinus active-fixation lead.

CONCLUSION

Careful attention should always be paid to secure anchoring even of active-fixation coronary sinus leads.

A Presentation of Twiddler's Syndrome with Underlying Ratchet Mechanism

Twiddler's syndrome, reel syndrome, and ratchet phenomenon are rare causes of pacemaker lead displacement. The presentation of Twiddler's syndrome with underlying ratchet mechanism is quite rarely reported in literature. In this case report we present a 63-year-old male with a history of non-ischemic cardiomyopathy who had his biventricular implantable cardioverter defibrillator leads dislodged and presented as sub-acute exacerbation of heart failure. This case highlights the underlying mechanism of twiddler's syndrome, its clinical presentation, management, and prevention.

Late Ratchet syndrome involving isolated left ventricular lead dislodgement post‐cardiac resynchronization therapy defibrillator generator change

Lead dislodgement following cardiac implantable electronic device (CIED) generator change is rare. We report a case including the postulate mechanism of an isolated left ventricular lead dislodgement 3 months after cardiac resynchronization therapy defibrillator pulse generator change.

Twiddler's Syndrome: A Rare Hardware Complication in Spinal Cord Stimulation

Twiddler's syndrome is an uncommon hardware complication involving the lead and pulse generators in cardiac pacemakers and defibrillators, deep brain stimulators, and vagal nerve stimulators. However, until very recently, it had not been reported in spinal cord stimulation (SCS). Considering the incidence of hardware complications of spinal cord stimulation, there may be an underreporting of Twiddler's syndrome due to lack of awareness. Two cases of Twiddler's syndrome as a hardware complication of SCS were identified between 2005 and 2015. One patient with hardware failure due to Twiddler's syndrome refused to have a revision surgery. The other patient who had a lead migration associated with coiling of the lead and twisting of pulse generator needed a revision surgery. Twiddler's syndrome in patients treated with SCS is an uncommon but important adverse event. Awareness of characteristic presentation and radiologic finding is essential in the identification of Twiddler's syndrome in SCS.

Idiopathic Lead Migration: Concept and Variants of an Uncommon Cause of Cardiac Implantable Electronic Device Dysfunction

OBJECTIVES

This cumulative case study was performed to properly address the possible mechanisms, forms, and consequences of "twiddler's," "reel," and "ratchet" syndromes.

BACKGROUND

Twiddler's, reel, and ratchet syndromes are rare entities responsible for lead displacement of cardiac implantable electronic devices (CIED).

METHODS

From 2007 to 2012, 1,472 CIED were implanted at our center. Eighty-nine cases were reviewed for failure of pacing circuit integrity. Only 9 met the inclusion criteria for idiopathic lead migration (ILM) and were grouped as ILM (twiddler) or ILM (reel). For a pooled analysis of cases, a review of the literature from 1990 to 2012 was performed, and the authors identified 78 cases from 64 publications.

RESULTS

The study population consisted of 87 cases (45 women; median age, 66 years; 46 with ILM [twiddler] and 41 with ILM [reel]). Migration affected only 1 lead in 65% of 46 devices with more than 1 lead. None of the previously reported risk factors-manual manipulation of the device, elderly age, obesity, oversized pocket, and psychiatric history-correlated with the risk of ILM.

CONCLUSIONS

Neither manual manipulation of the device nor the other traditional risk factors reported in the literature for ILM syndrome correlated with the risk of ILM.

Double twiddle trouble, a new variant of twiddler syndrome

The twiddler syndrome results in retraction and coiling of the lead in the pacemaker pocket with subsequent pacemaker malfunction. If the lead׳s parameters are not affected, then the problem can be corrected by lead repositioning. We describe the first reported case of a dramatic pacemaker lead coiling with a double level of lead compromise, with one of them being intra-cardiac. This condition affected our treatment strategy, as the repositioning of the lead was unfeasible.

Reel syndrome in an ICD with DF4 connector

This is the first case report about a patient implanted with a DF4 lead suffering from reel syndrome. The reel syndrome may occur due to a ratchet mechanism where the device generator creates torque on a lead fixed at the fixation sleeve. Theoretically, this is less likely to occur in DF4 connectors due to their higher stiffness.

Ratchet-traction effect: an underdiagnosed mechanism of pacing lead dislodgement

Pacing lead dislodgement contributes substantially, to the list of causes of early pacemaker failure. Reel's syndrome is a rare cause of pacemaker failure, resulting from the dislodging of pacing electrodes by manipulation of the pulse generator by the patient. We describe here an intriguing case of pacemaker lead dislodgement by a novel and frequently underdiagnosed mechanism that mimicked the fluoroscopic diagnosis of reel's syndrome.

Twiddler syndrome with a twist: a cause of vagal nerve stimulator lead fracture

Twiddler syndrome is uncommon in children and most commonly described as causing lead retraction with implanted cardiac pacemakers and defibrillators. We report an uncommon case of a child repeatedly "twiddling" a vagal nerve stimulator to the point of lead fracture. The findings of Twiddler syndrome illustrated here apply to all implanted devices and show the complication of lead fracture in addition to the more commonly reported complication of lead retraction. This case highlights the need to be aware of the radiographic findings of this phenomenon in children with implanted vagal nerve stimulators due to the perceived increased risk of "twiddling" in pediatric and developmentally delayed patients.

Unusual "ratchet syndrome": spontaneous lead retraction after a generator exchange

A 72-year-old female with idiopathic dilated cardiomyopathy underwent a generator exchange for a cardiac resynchronization therapy defibrillator with a full-pocket capsulectomy. The lead position after the operation was identical to that before the operation on the chest X-ray. After 4 months, a subacute exacerbation of her heart failure was caused by cardiac resynchronization therapy failure due to a dislodgement of the left ventricular lead. An aggressive adhesiotomy of the connective tissue around the leads made it possible for the lead to retract by a ratchet-like movement through the suture sleeve, so-called "ratchet syndrome", after the generator exchange.

An unusual case of combined classic and reverse twiddler's syndrome

In recent years the phenomenon of reverse twiddler's syndrome has been described, characterized by pulse generator manipulation resulting in lead advancement rather than retraction. We describe what we believe to be the first reported case of both classic and reverse twiddler's syndrome occurring simultaneously in a patient with a biventricular implantable cardioverter-defibrillator.

Reel syndrome-not a twiddler variant

We report three cases of an unusual form of "reel syndrome" characterized by isolated, reeling dislodgement of a single lead in patients with dual-chamber or biventricular devices. One of these patients presented with worsening heart failure due to loss of left ventricular pacing and the others were detected incidentally during scheduled device checks. We suspect that a ratchet mechanism was probably responsible for this and that this type of dislodgement is not a twiddler variant. We propose a simple solution for prevention.