Associazione Nazionale Medici Cardiologi Ospedalieri



Twiddler’s syndrome in a 96-year-old patient treated by repositioning the ventricular lead

Massacesi Cristiano Giulianova (Teramo) – Ospedale “Maria Ss Dello Splendore”, Giulianova | Core Alessandro Giulianova (Teramo) – Ospedale “Maria Ss Dello Splendore”, Giulianova | Di Eusanio Mauro Giulianova (Teramo) – Ospedale “Maria Ss Dello Splendore”, Giulianova | Di Francesco Giuseppe Giulianova (Teramo) – Ospedale “Maria Ss Dello Splendore”, Giulianova | Di Saverio Maria Cristina Giulianova (Teramo) – Ospedale “Maria Ss Dello Splendore”, Giulianova | Marini Lucia Giulianova (Teramo) – Ospedale “Maria Ss Dello Splendore”, Giulianova | Rolando Marco Giulianova (Teramo) – Ospedale “Maria Ss Dello Splendore”, Giulianova | Gregori Gianserafino Giulianova, Teramo (Te) – Ospedale “Maria Ss Dello Splendore”

A 96-years-old woman was admitted to our cardiological intensive care unit in December 2022 with atrioventricular dissociation, with a junctional ventricular escape rhythm at a rate of 38 beats per minute, and an atrial rhythm dissociated from the ventricular rhythm, at a rate of 80 beats per minute (Figure 1).

The patient had a history of third-degree atrioventricular block, effectively treated with single-chamber pacemaker implantation (Assurity MRI SR, Abbott), operation performed approximately 10 months before access, in February 2022.

The patient underwent a chest X-ray, which showed "coiling" of the ventricular catheter in the pacemaker pocket area (left subclavicular), with macroscopic dislocation of the ventricular electrode, which had its distal tip in the right atrium (Figure 2).

Therefore, the clinical case was typical of Twiddler's syndrome.

The patient would therefore have undergone revision surgery. An attempt was made to reposition the original lead, with passive fixation (Isoflex 1948/58, Abbott), by inserting a "straight" stylet, a procedure which was done effectively.

The ventricular lead was repositioned in the right ventricular apex. The detected parameters were optimal (sensing 7 mV, ventricular barrier threshold 0.5 mV/0.4 ms, impedance 797 Ohm).

The result was considered acceptable.

The remainder of the hospital stay was without complications.

The patient was discharged on the fifth day in good general condition.

Twiddler syndrome is defined as a dislocation of one or more catheters, resulting in the catheters "coiling" in the pocket of the device. It is usually related to the manipulation of the generator by the patient itself. It usually occurs within a year of implantation and is usually more common in females, the elderly, the obese, pediatric patients, or patients with psychiatric disorders.

The identification of patients at risk for this pathology, the adequate education of the patient and family regarding the management of the device, the use of catheters with active fixation, as well as the fixation of the generator device to the pectoral muscle, through non-absorbable sutures.

In the case described, the patient denied manipulation of the device, which however could not be excluded, given the age of the patient.