Twiddler's Syndrome with 180 Degree Extreme Rotation of a Permanent Pacemaker Generator

Abstract

patient's manipulation of the pulse generator(1). Obese and elderly patients appear to be at increased risk because the presence of loose subcutaneous tissue allows for rotation of the pulse generator in its pace pocket(2). A 57 year-old obese woman re- ceived a single chamber pacemaker (VVIR) following a diagnosis of high grade atrio- ventricular block after mitral valve replacement. A pre-discharge chest X-ray revealed the pacemaker generator well positioned in the right infraclavicular area of the chest wall (Figure 1). During follow-up, an electrocardiography revealed loss of capture. The device was mobile in the pocket and there was evidence of traction of the lead (Figure 2). There was an extreme rotation of the pulse generator along the sagittal axis (180 degree). She underwent pocket revision and new lead implantation