Images in clinical medicine. The twiddler syndrome

Prevalence and predictors of Twiddler's syndrome

BACKGROUND

Twiddler's syndrome is a poorly understood clinical phenomenon when patients either consciously or subconsciously rotate their cardiac device resulting in lead dislodgement. We aimed to determine the true prevalence and risk factors associated with Twiddler's syndrome in a real-world population.

METHODS

A retrospective chart review was performed on all patients who underwent cardiac device implantation from January 1st 2017 until Jan 1st 2022. We specifically searched for the terms "Twiddler" or "Twiddler's" imbedded within the text of the medical chart. Demographic and clinical variables were collected from the electronic medical record system. We utilized multivariable logistic regression analysis as well as Kaplan-Meier prediction models to determine independent clinical predictors of Twiddler's syndrome as well as associated mortality, respectively.

RESULTS

Twenty one out of 1793 patients (1.2%) were identified as having Twiddler's syndrome after chart review. Independent variables associated with Twiddler's syndrome were female sex (OR 3.76; 95% CI 1.29-10.95), antidepressant medications (OR 3.58; 95% CI 1.07-11.99), and BMI (OR 1.08; 95% CI 1.03-1.31). There was no increased six-month mortality via Kaplan-Meier analysis.

CONCLUSION

Our study shows that 1.2% of patients in our real-world population had evidence of Twiddler's syndrome. Independent predictors of Twiddler's syndrome include female sex, antidepressant medications as well as BMI.

A Potentially Lethal Dysfunction of a Subcutaneous Implantable Cardiac Defibrillator: "The Phantom Menace"?

In this article we describe, to our knowledge, the first case of a potentially lethal dysfunction of a subcutaneous implantable cardioverter-defibrillator (S-ICD). A 70-year-old patient underwent primary S-ICD implantation. Nine months after, communication could not be established with the device. Chest radiography revealed that the lead had moved and wrapped around the generator. After equipment extraction, we observed the lead wound around the sagittal axis of the generator. A burn mark with melted metal was found inside the generator. Our hypothesis is an electric arc occurred between the retracted lead and the generator. This could be the first reported Reel syndrome secondary to S-ICD implantation.

Early detection of twiddler syndrome due a congestion alert by remote monitoring

There are often false‐positive alerts of thoracic impedance monitoring; however, the “false‐positive alerts” might indicate any clinical problem of patient. In the present case, an alert for a drop in intrathoracic impedance, which generally indicates exacerbation of heart failure, enabled early detection of twiddler syndrome.

[An exceptional cause of pacemaker dysfunction]

Twiddler syndrome is a very rare and surprising complication of pacemaker treatment. We report the case of a woman with psychiatric disease who presented two cardiac arrests due to loss of ventricular capture. Finally, pacemaker retropectoral implantation resolves the problem.

"Twiddler syndrome" in two patients with deep brain stimulation

Twiddler syndrome occurs when a patient intentionally or unintentionally manipulates an implantable generator (usually a pacemaker) and dislodges the pacing leads, causing malfunction of the device. Though the syndrome has been described in patients with pacemakers, to our knowledge only one spontaneous case has been described in patients undergoing deep brain stimulation for movement disorders. We report the clinical cases of two patients with Parkinson's disease who had subthalamic bilateral electrodes implanted and presented the twiddler syndrome 2 and 3 years after surgery. We analysed the possible mechanisms of this syndrome and note that twiddler syndrome should be suspected in patients undergoing deep brain stimulation and showing hardware dysfunction.