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Ann Thorac Surg 2008;85:1840. doi:10.1016/j.athoracsur.2007.12.015
© 2008 The Society of Thoracic Surgeons
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Correspondence

Cardiac Pacing and Psychologic Disorders

Eloi Marijon, MD, Nicolas Combes, MD, Jean Paul Albenque, MD, Christophe Goutner, MD, Olivier Vahdat, MD, Serge Boveda, MD

Department of Cardiac Pacing, Clinique Pasteur, Departement de Rythmologie, 43-45 ave de Lombez, 31076 Toulouse, BP 27617 Cedex 3, France

(Email: eloi_marijon{at}yahoo.fr).

To the Editor:

Pacemaker failure is a serious condition that may result from lead displacement or fracture. Electrode displacement of permanent pacemakers may in some cases be related to the patient's dislodgement of the electrode.

A 56-year-old woman with symptomatic bradycardia related to sick sinus syndrome was referred to our department for a pacemaker implant. A dual-chamber pacemaker was implanted with one active-fixation lead in the right atrium and the other passive-fixation lead in the right apex ventricle. The leads were inserted without any complications through the subclavian vein and secured with sutures to the pectoral muscle.

The postprocedural chest roentgenogram confirmed appropriate lead placement and excluded any pneumothorax. The electrocardiogram (ECG) revealed atrial pacing with respect to spontaneous AV conduction. After the correct functioning of the device was verified, the patient was discharged 48 hours later.

Two months later, the patient visited the emergency department with a complaint of stimulation of the diaphragm. There was no evidence of active pacing on the ECG, even after the application of a magnet on the pulse generator. A chest roentgenogram showed displacement of both leads, retracted and floating in the superior vena cava, with winding of the leads around the pulse generator (Fig 1). The patient was returned to surgery where the endocardial leads were repositioned, and the generator was fixed to the underlying pectoral muscle. Since then, the patient has been doing well, with no recurrence of lead dislodgment.


Figure 1
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  		Fig 1. (A) Posteroanterior and (B) lateral view chest roentgenograms show coiling of the pacing leads around the pulse generator. Note that the endocardial tips of both atrial and ventricular leads are in the superior vena cava.

 
First described in 1968 [1], twiddler's syndrome results from a spontaneous, subconscious, inadvertent, or deliberate rotation of the pulse generator by the patient resulting in lead dislodgment and pacemaker malfunctioning [2]. Patients most often emphatically deny manipulating their device [2]. Patients at risk of this condition include the elderly and obese, probably because their relaxed subcutaneous tissue facilitates rotation of the pulse generator in its pocket. Other risk factors include female sex, psychiatric illnesses, and the small size of the implanted device relative to its pocket. The mechanical traction dislodges the leads from the endocardium, causing malfunctioning of the device, in some cases diaphragmatic (resulting from ipsilateral phrenic nerve) or pectoral stimulation, or more rarely brachial plexus pacing and dysphonia [3].

Creation of a subpectoral pocket, limitation of the pocket size, or suturing of the device to the fascia may be effective in preventing dislocation episodes. Moreover, although the psychologic profile of these patients has not yet been well addressed and defined, education and psychologic assistance must be attempted and may be effective or helpful in some cases where local factors are not responsible.


   References
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 References
 

  1. Bayliss CE, Beanlands DS, Baird RJ. The pacemaker-twiddler's syndrome: a new complication of implantable transvenous pacemakers Can Med Assoc J 1968;99:371-373.[Medline]
  2. Nicholson WJ, Tuohy KA, Tilkemeier P. Twiddler's syndrome N Engl J Med 2003;348:1726-1727.[Free Full Text]
  3. Gasparini M, Regoli F, Ceriotti C, Gardini E. Images in cardiovascular medicine. Hiccups and dysphonic metallic voice: a unique presentation of Twiddler syndrome. Circulation 2006;114:e534-e535.[Free Full Text]



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Ann. Thorac. Surg., May 1, 2008; 85(5): 1841 - 1842.
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This Article
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