Reel syndrome, a diagnostic conundrum: a case report

Figures

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  Figure 1. Presenting and post-procedure chest X-ray. Chest X-ray showing dislodged electrodes (green arrow) and leads coiled around the generator (red arrow) (A, left). This chest X-ray reveals characteristic findings of reel syndrome with pacing leads migration and coiling around the pacemaker generator. A repeat chest X-ray (B, right) is performed after permanent pacemaker lead repositioning and reveals adequately placed electrodes (green arrows) and a generator absent of significant coiling (red arrow).

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  Figure 2. Electrocardiogram at the time of presentation. This electrocardiogram taken in the emergency department reveals intermittent atrial pacing, under sensing of the ventricular lead and ventricular pacing spikes occurring after the QRS complex. The homogenous QRS morphology in the presence of variable ventricular pacing suggests a complete absence of ventricular capture.

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  Figure 3. Manifestations of device manipulation-related pacemaker lead dislodgement. This figure depicts the classical radiological and anatomical effects of device manipulated-related permanent pacemaker lead displacement. The normal permanent pacemaker insertion is depicted in panel A. In panel B, the pacemaker generator has been rotated along the frontal plane, resulting in a Reel syndrome and associated lead displacement. Panel C depicts the lead shortening associated with Ratchet syndrome, where the generator is translated back and forth laterally along the frontal plane, resulting in lead displacement. Panel D depicts a classical Twiddler syndrome, where the generator is rotated along the axial plane, resulting in lead dislodgement and braiding. This can often damage the lead integrity and may require permanent pacemaker lead replacement.

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  Figure 4. Potential neuronal stimulation mechanisms in permanent pacemaker lead dislodgement. This figure describes the potential mechanisms of neuromuscular pacing and their presentation, in device manipulation-related lead dislodgements. Pacing of the brachial plexus (arrow A) may result in rhythmic arm,10 or pectoral muscle (arrow B) contractions.11,12 Pacing of the Vagus or recurrent laryngeal nerve (arrow C) may result in vagal symptoms or voice changes, respectively.13 Finally, pacing of the phrenic nerve (arrow D) which can result in thoraco-abdominal pulsations is a more common manifestation of permanent pacemaker lead dislodgement.14–16 The posterior panel reveals the spinal nerves and anteriorly positioned (dashed) sympathetic trunk. Arrow E depicts the thoracic nerves originating from the spinal column, with somewhat close proximity to the superior vena cava and permanent pacemaker leads. Pacing of the thoraco-abdominal nerves (arrow E), the sympathetic trunk (arrow F), or the thoraco-lumbar spinal nerves (arrow G), may result in abdominal, pelvis, or lower limb pulsations.

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  Figure 5. Diagnostic work-up of patients with a history of permanent pacemaker insertion who present with unexplained neuromuscular symptoms. The figure describes a stepwise approach to diagnosing pacemaker lead dislodgement in patients presenting with a history of permanent pacemaker insertion and unexplained neurological symptoms, which may be attributed to permanent pacemaker lead dislodgement. An important first step is to rule out acute neurological causes that may require urgent treatment. All patients should receive an electrocardiogram, chest X-ray, and cardiac monitoring. Then, guided by the presentation and baseline investigations, urgency of pacemaker interrogation can be determined.

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