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

Subcutaneous Implantable Cardioverter-Defibrillator Lead Dislodgement Masquerading as Left Shoulder Pain

Implantable cardioverter-defibrillators (ICDs) have demonstrated efficacy in the prevention of sudden cardiac death secondary to cardiac arrhythmias in eligible patients. Complications with the subcutaneous ICD (S-ICD) are rarer than with the transvenous ICD but do still exist. Our patient presented four weeks after the insertion of S-ICD with complaints of left shoulder pain radiating to the chest wall and swelling over the S-ICD site. He was initially treated for rotator cuff injury and subacromial impingement syndrome but upon obtaining chest radiography was found to have a lead displacement traversing the splenic flexure of the colon. The patient was managed by a treatment team involving cardiology, surgery, and infectious disease and underwent S-ICD removal, exploratory laparotomy with splenic flexure mobilization, and completion of a four-week antibiotic course ultimately leading to reimplantation of S-ICD.

Diagnosis and treatment of the rare procedural complication of malpositioned pacing leads in the left heart: a single center experience

Objectives. This study assessed the management approach and outcome of the pacemaker or implantable cardioverter-defibrillator (ICD) leads malpositioned in the left heart. Malpositioned leads (MPLs) may have deleterious consequences, and appropriate management remains uncertain. Methods. The study population included all patients referred to a single institution for MPL in the left side of the heart after pacemaker or ICD implantation during the period from 2015 to 2021. The approach and outcome of lead management were retrospectively assessed. Results. During the study period, 6887 patients underwent device implantation. MPL was diagnosed in five patients (0.07%). In four cases, the pacing lead was placed in a coronary sinus (CS) branch, while the pacing lead was inside the left ventricle (LV) in one case. Symptoms suggestive of lead malposition were reported by 2 patients (40%). One of the patients presented with recurrent TIAs. Another presented with inappropriate ICD shocks. In one asymptomatic case, an ICD lead changed position from the right ventricle to the CS, suggesting idiopathic lead migration. In 4/5 patients, the leads were removed or repositioned by percutaneous approach, with no major periprocedural complications. Conclusions. In this series of MPL in the left heart, two patients presented with thromboembolic events or inappropriate ICD shocks. These serious complications highlight the critical need for early correct diagnosis and proper management of MPL.

Reel syndrome, a diagnostic conundrum: a case report

BACKGROUND

Pacemaker lead dislodgement and failure, related to device manipulation, is a rare complication of permanent pacemaker (PPM) insertion. Reel's, Twiddler's, and Ratchet syndrome are rare causes of pacemaker failure with varying mechanisms, defined by their classical lead and generator findings on chest X-ray imaging. Misleading patient presentations may be attributed to lead stimulation of surrounding structures.

CASE SUMMARY

A 77-year-old female was admitted with abdominal wall pulsations, abdominal pain, and lower limb jerking 3 months following PPM insertion. Following exclusion of a ruptured abdominal aortic aneurysm, the presence of Reel syndrome was noted on the patient's chest X-ray and the electrocardiogram showed inappropriate pacing. Deactivation of the pacemaker resulted in immediate symptom cessation and urgent repositioning of pacemaker leads was undertaken.

DISCUSSION

This case highlights the importance of considering pacemaker complications causing non-cardiac symptomatology. Pacemaker lead stimulation of surrounding structures can present in an unconventional fashion, veiling the diagnosis. However, a structured approach to undifferentiated neuromuscular presentations in patients with PPMs should consider lead dislodgement as a differential diagnosis. Rapid recognition of lead dislodgement, device deactivation, and re-implantation or repositioning of the leads are critical in preventing potentially life-threatening complications.

Twiddler’s syndrome after implantation of baroreflex activation therapy: a case report

Background

Twiddler’s syndrome is a rare complication after implantation of cardiac pacemakers or cardioverter-defibrillators that usually occurs within the first year after the procedure. However, it has not yet been described following implantation of baroreflex activation therapy (BAT).

Case summary

A 61-year-old female patient was referred to the cardiology outpatient clinic due to uncontrolled arterial hypertension despite maximal doses of several established drugs. Therefore, right-sided BAT implantation was successfully performed in February 2017 with good clinical response. Because of sustained neck pain at the site of stimulator, surgical revision was performed in November 2019 including a switch of the lead to the contralateral position. Approximately 1 month later, Twiddler’s syndrome was identified on the basis of recurrent pain at the generator site necessitating pocket-revision, however, the lead was only untwisted but not replaced. A few weeks afterwards, unfortunately, lead revision was indispensable due to lead fracture.

Discussion

This case presents the uncommon phenomenon of Twiddler’s syndrome after BAT implantation. In addition, the commonly twisted lead should always be replaced as well during surgical pocket-revision in order to ensure proper long-term function.

Twiddler Syndrome without Lead Dislodgment Discovered by Remote Monitoring

Twiddler syndrome is an uncommon yet dangerous phenomenon usually resulting in lead displacement with loss of capture of cardiac implantable electronic devices. In this case report, we present an interesting case of Twiddler syndrome without lead dislodgment which was detected by an alert triggered by an increase in impedance on remote monitoring.

Twiddler's syndrome with occult lead insulation damage in a child with epicardial pacemaker leads

We present a rare case of incidentally diagnosed Twiddler's syndrome in a child 7 years after implantation of a dual-chamber pacemaker system with epicardial leads. During revision, an insulation defect of the ventricular lead was evident, despite unremarkable prior pacemaker lead testing. The lead was repaired and a new generator was suture-fixated to prevent re-occurrence of generator manipulation.

Twiddler’s syndrome with a subcutaneous implantable cardioverter-defibrillator presenting with an inappropriate shock: a case report

Background

Subcutaneous implantable cardioverter-defibrillators (S-ICDs) are increasingly used in patients at risk of fatal cardiac arrhythmias. Twiddler’s syndrome is a condition in which a device is manipulated by the patient after implantation leading to lead twisting and retraction. Device manipulation has been reported multiple times in transvenous pacing systems and occasionally leads to inappropriate discharges from implanted defibrillators. However, little has been reported about device manipulation in S-ICD devices.

Case summary

We present the case of a 16-year-old who underwent insertion of an S-ICD for idiopathic dilated cardiomyopathy. He represented for a pacing check following a discharge from the device. This showed a significant change in the sensed vectors. Chest radiographs confirmed lead retraction and suggested device manipulation. The device was turned off to prevent further inappropriate shocks. The patient underwent successful reimplantation of a S-ICD device.

Discussion

This case highlights that twiddler’s syndrome can occur in those with an S-ICD and lead to an inappropriate device discharge. The patient in this case had a number of risk factors that have been previously associated with twiddler’s syndrome.