An unusual cause of pacemaker malfunction: A case report of an association of twiddler and reel syndrome

Introduction and importance: Lead dislodgement syndromes (Twiddler, Ratchet or Reel syndromes) are rare causes of cardiac stimulation device malfunction that can occur most commonly early after device implantation. Each one of them associated with a unique pattern of lead coiling and dysfunction. Our clinical case reports an unusual association and shed the light on the available diagnostic modalities. Case presentation: A 62-year-old woman who was referred to our hospital for a symptomatic high degree AV block, she underwent dual chamber pacemaker implantation. She experienced 3 weeks following implantation a rhythmic twitching of the right arm without syncope. The device interrogation revealed an increase in both leads pacing impedance and chest X-ray showed leads had pulled out of the heart and were tangling and wrapped repeatedly around the pulse generator. Revision procedure was performed to reposition the leads. Clinical discussion: Recognizing this complication early can prevent life threatening complication and is then of the utmost importance. Twiddler's syndrome is due to rotation of the device along its long axis. Reel syndrome is produced by device rotation along the transverse axis. In most cases, lead replacement or reposition is needed. Preventive measures such as patient education and use of a smaller pocket will reduce the risk of developing the syndrome. Conclusion: Our case highlights the available diagnostic modalities for early detection of twiddler's syndrome. The unique nature of this case increases the importance of considering device lead dislodgement as the cause for patients presenting with extra-cardiac symptoms.