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Paper text:
twiddler 's syndrome , first described by bayliss in 1968 , is a rare but potentially lethal complication of pacemaker treatment . in this syndrome
there is painless dislodgment of device leads resulting from the patient 's manipulation of the implanted device .
the majority of patients with this condition are diagnosed within the first year of implant . in this report
we present a patient who was diagnosed with twiddler 's syndrome within 48 hours of implantation of the permanent pacemaker .
a 66-year - old post - cabg ( coronary artery bypass grafting ) , nondiabetic , nonhypertensive , male patient with good left ventricular systolic function ( ejection fraction 60% ) was admitted with symptomatic intermittent complete heart block .
baseline electrocardiogram ( ecg ) revealed complete rbbb ( right bundle branch block ) with left axis deviation .
a dddr ( dual chamber rate adaptive pacemaker ) system was implanted in the right prepectoral area with a bipolar passive fixation ventricular lead and an active fixation bipolar screwing atrial lead at right atrial appendage .
measured ventricular lead r wave , threshold and lead impedance were 14 mv , 0.5 v , and 640 ohm , respectively .
atrial lead p wave , threshold , and lead impedance were 3.5 mv , 0.5 v , and 590 ohm , respectively .
an ecg also corroborated proper functioning of the dddr system . during the postoperative hospital stay , a routine chest skyagram on 2 day revealed dislodgment of ventricular lead .
pacemaker interrogation showed complete loss of pacing and sensing in ventricular lead with intact atrial lead function .
the patient was immediately rushed to the pacing laboratory where a prophylactic temporary pacemaker was inserted .
fluoroscopy clearly showed the pulse - generator with twisted ventricular lead around it [ figure 1 ] .
the atrial lead was seen to be in position but the initial loop was drastically reduced [ figure 2 ] .
the atrial lead can also be traced the atrial lead is shown to be in position , although the loop originally kept was reduced significantly .
the temporary pacemaker lead can also be identified lower down the pacemaker pocket was immediately reopened .
postoperative hospital stay was uneventful and the patient was doing well in subsequent follow - ups .
risk factors for this condition include elderly age group , obesity , female gender , psychiatric illness , and the small size of the implanted device relative to its pocket .
pacemaker lead displacement according to its position may produce failure to pace , diaphragmatic contraction by phrenic nerve stimulation , vagus nerve , pectoral muscle , or brachial plexus stimulation resulting in rhythmic arm twitching and finally may wrap around the pulse - generator as in our case .
older literature suggests a subgroup of partial twiddler 's syndrome where capturing function is maintained .
although originally described with pacemakers , the condition has also been reported with implantable cardioverter - defibrillators .
although the majority of cases occur during the first year of implantation , a " late twiddler 's syndrome " has also been reported .
so far the earliest reported case is at 17 h. our patient was detected to have twiddler 's syndrome within 48 h of implantation . the majority , like our patient , deny any history of manipulation of the device .
the presence of heavy dressing also probably precluded him from any manipulation , so other factors such as movement of the body may have some role in this peculiar syndrome . minimizing the pocket size and suturing
some authorities have advocated the use of a dacron patch , which stabilizes the pulse - generator by promoting tissue in - growth , in all cases of device implantation .
, there was no dislodgement of atrial screwing lead initially , and after active fixation of ventricular lead the situation did not recur in the subsequent follow - ups .
. active fixation of device leads should always be performed to prevent this situation along with other preventive measures .
twiddler 's syndrome , a rare but potentially lethal complication of cardiac pacemaker treatment , is generally diagnosed within the first year of implantation . 
 it is characterized by device malfunction due to dislodgement of cardiac leads resulting from some form of manipulation by the patient . in this report 
 we present a patient who was diagnosed twiddler 's syndrome within the initial 48 h of implantation of permanent pacemaker . in our case , 
 passive fixation of ventricular lead perpetuated this situation and subsequent active fixation prevented any recurrence . 
 active fixations fixations of device leads are very much essential to prevent this catastrophic complication .