Unusual twiddler syndrome: movement ties the knot.

The ‘twiddler syndrome’ is a rare condition (incidence reported below 0.1%), which occurs when a patient, either consciously or unconsciously, rotates or “twiddles” the implanted pacemaker or ICD in its pocket, resulting in torsion, dislodgement, and often fracture of the pacing lead [1]. The diagnosis is confirmed by a chest radiograph which reveals a twisted, entangled, and dislodged pacing lead. The condition, which was first described by Bayliss et al. in 1968, can occur if the subcutaneous tissues are lax, if the pacemaker is untethered in its pocket, or if the size of the pacemaker pocket exceeds that of the device and occurs especially in obese or old patients [2].