She was treated with diuretics in addition to her anti-ischaemic treatment. Drug history did not include beta blockers. Electrolyte imbalance and hypothyroidism were excluded biochemically. Routine laboratory parameters were within normal limit, except for an elevated serum creatinine of 2.28 mg/dL and urea of 120 mg/dL. Echocardiogram revealed anterior wall hypokinesia with a left ventricular ejection fraction of 50 %. An emergent temporary pace maker (TPM) was set at a rate of 60 beats per minute. She had no cognitive deficit.Īn immediate ECG revealed intermittent complete heart block alternating with junctional rhythm and sinus bradycardia, with a heart rate of approximately 42 beats/minute (Fig. Physical examination revealed a heart rate of 42 beats/minute, blood pressure 140/80 mmHg, bilateral crackles on lung auscultation and auscultation of the praecordium revealed no abnormality. Her medical history was significant for ischaemic heart disease, hypertension, diabetes mellitus and chronic kidney disease. Pacemaker lead re-positioning was done and she was counseled against further twiddling of the generator.Īn 87 year old Bangladeshi lady presented with a 4 month history of recurrent episodes of syncope associated with complete loss of consciousness for several seconds, and shortness of breath. Chest X-ray showed a rotated pulse generator and coiled and dislodged right ventricular (RV) lead. Electrocardiography (ECG) showed complete heart block with pacemaker spikes and failure to capture. She admitted to repeatedly twiddling with the PPM pulse generator. We report the case of an 87 year old Bangladeshi lady who presented with recurrent syncopal attacks seven weeks after PPM implantation. We believe it is under-reported in a South Asian setting, and should be considered as a possible cause of pacemaker failure, particularly in elderly patients presenting with dizziness, syncope and bradyarrhythmias, post Permanent Pacemaker (PPM)-implantation. First described by Bayliss in 1968, it is a rare but potentially fatal complication of pacemaker treatment. This leads to a rotation of the device, coiling of the lead and its dislodgement, leading to pacemaker failure. The pacemaker-twiddler’s syndrome refers to the permanent malfunction of a pacemaker resulting from manipulation of the pulse generator within its skin pocket. Lead repositioning is required, however proper patient education and counselling against further manipulation is paramount to long-term management. Chest X-ray and electrocardiograms are simple and easily-available first line investigations for its diagnosis. Twiddler’s syndrome should be considered as a cause of pacemaker failure in elderly patients presenting with bradyarrythmias following pacemaker implantation. Subsequently, she underwent successful lead repositioning with strong counselling to avoid further twiddling. An emergent temporary pace maker was set at a rate of 60 beats per minute. Chest X-ray showed coiled and retracted right ventricular lead and rotated pulse generator. She had no cognitive deficit.Īn immediate electrocardiogram showed complete heart block with pacemaker spikes and failure to capture. Physical examination revealed a heart rate of 42 beats/minute, blood pressure 140/80 mmHg and bilateral crackles on lung auscultation. She admitted to repeatedly manipulating the pacemaker generator in her left pectoral region. ventricle paced, ventricle sensed, inhibitory mode) implantation with the indication of complete heart block, and presented to us again 7 weeks later, with syncopal attacks. Case presentationĪn 87 year old Bangladeshi lady who underwent a single chamber ventricular pacemaker (VVI mode: i.e. Treatment involves repositioning of the dislodged leads and suture fixation of the lead and pulse generator within its pocket. More commonly reported among elderly females with impaired cognition, the phenomenon usually occurs in the first year following pacemaker implantation. This causes coiling of the lead and its dislodgement, resulting in failure of ventricular pacing. It occurs due to unintentional or deliberate manipulation of the pacemaker pulse generator within its skin pocket by the patient. The pacemaker-twiddler’s syndrome is an uncommon cause of pacemaker malfunction.
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