Reverse Ratchet Syndrome With Intracardiac Looping

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Reverse Ratchet syndrome (intracardiac lead looping) post-ICD implantation (n=1). Intervention: Surgical revision with secure fixation of the generator and lead sleeves. Primary outcome: Recurrence of atrial fibrillation or lead migration.

Q: What does this research mean for the field?

Reverse Ratchet syndrome can lead to delayed intracardiac lead advancement and looping despite normal device electrical parameters and an absence of symptoms. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Gen Matsuura; Hidehira Fukaya; Tomoharu Yoshizawa; Atsuhiko Sugimoto; Junya Ako

doi:10.1002/joa3.70489

October 1, 2026Journal of ArrhythmiaOpen Access

Reverse Ratchet Syndrome With Intracardiac Looping

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Graphical abstract published by Journal of Arrhythmia — Graphical abstract · Published by Journal of Arrhythmia · CC BY

Why the study?

Delayed intracardiac lead malposition due to reverse Ratchet syndrome and its clinical implications were not well characterized.

Key Points

To describe a rare presentation of reverse Ratchet syndrome resulting in extensive intracardiac lead looping seven years after implantable cardioverter-defibrillator placement.
Clinical, radiographic, and surgical evaluation of a 59-year-old man with dilated cardiomyopathy presenting with atrial fibrillation 7 years after primary prevention ICD implantation.
Surgical pocket re-exploration, atrial lead loop reduction, and dual-anchor fixation of the ICD generator and lead sleeves to the pectoral fascia.
Serial radiography and computed tomography angiography revealed a 180° generator rotation and large intracardiac loops in both atrial and ventricular leads, despite stable electrical parameters and stationary lead tips.
Surgical revision revealed disrupted generator sutures and loose lead sleeves; refixation resolved lead looping without recurrence during 6 months of follow-up.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

P

Population

1 59-year-old man with dilated cardiomyopathy and a primary prevention ICD who developed asymptomatic reverse Ratchet syndrome 7 years post-implantation.

I

Intervention

Surgical revision with secure fixation of the ICD generator and lead sleeves to the pectoral fascia, alongside catheter ablation for atrial fibrillation.

Reverse Ratchet syndrome can manifest as severe intracardiac lead looping years after CIED implantation while remaining completely asymptomatic, emphasizing the critical need for secure device fixation and routine long-term radiographic follow-up.

Implication

Secure fixation may avert recurrent lead issues in reverse Ratchet syndrome; leaves open optimal long-term surveillance protocols.

Abstract

Intracardiac lead looping developed 7 years after ICD implantation due to reverse Ratchet syndrome. Despite marked radiographic abnormalities, device parameters remained stable and the patient was asymptomatic. Inadequate fixation of the generator and lead sleeves likely contributed to lead advancement. Surgical revision with secure fixation prevented recurrence, highlighting the importance of proper device fixation and long-term imaging follow-up to detect delayed lead malposition.

Discussion

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Cite This Study

Matsuura et al. (2026) conducted a case report in Reverse Ratchet syndrome (intracardiac lead looping) post-ICD implantation (n=1). Surgical revision with secure fixation of the generator and lead sleeves was evaluated on Recurrence of atrial fibrillation or lead migration.

synapsesocial.com/papers/6ac74632947fe0d7c564332c https://doi.org/10.1002/joa3.70489

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Reverse Ratchet Syndrome With Intracardiac Looping

Figures

Key Points

Study Design

Structured PICO

Implication

Abstract

Discussion

Cite This Study

Reverse Ratchet Syndrome With Intracardiac Looping

Figures

Key Points

Study Design

Structured PICO

Implication

Abstract

Discussion

Cite This Study

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