Abrams S, Peart I. Twiddler's syndrome in children: an unusual cause of pacemaker failure. Heart. 1995; 73:(2)190-192

Aliyev F, Celiker C, Türkoğlu C, Turhan FN. Early development of pacemaker Reel syndrome in an elderly patient with cognitive impairment. Turk Kardiyol Dern Ars. 2009; 37:(7)488-489

Arias MA, Pachón M, Puchol A, Jiménez-López J, Rodríguez-Picón B, Rodríguez-Padial L. Terminology management for implantable cardiac electronic device lead macro-dislodgement. Rev Esp Cardiol (Engl Ed). 2012; 65:(7)671-673

Armaganijan LV, Toff WD, Nielsen JC Are elderly patients at increased risk of complications following pacemaker implantation? A meta-analysis of randomized trials. Pacing Clin Electrophysiol. 2012; 35:(2)131-134

Case study: pacemaker twiddler's syndrome. 2012. (accessed 24 February 2020)

Bali HK, Chattree KK, Bali SK, Chauhan HKC, Shukla CP. A tale of early Reel syndrome caused by an over-enthusiastic masseuse. Indian Heart J. 2013; 65:(6)703-704

Barold S, Stroobandt R. Twiddlers syndrome. Türk Aritmi. Pacemaker ve Elektrofizyoloji Dergisi. 2009; 7:(1)51-53

Bayliss CE, Beanlands DS, Baird RJ. The pacemaker-twiddler's syndrome: a new complication of implantable transvenous pacemakers. Can Med Assoc J. 1968; 99:(8)371-373

Biotronik Inc. Effecta pulse generators technical manual. 2011. (accessed 24 February 2020)

Böhm A, Pintér A, Duray G, Lehoczky D, Dudás G, Tomcsányi I, Préda I. Complications due to abandoned noninfected pacemaker leads. Pacing Clin Electrophysiol. 2001; 24:(12)1721-1724

Bracke F, van Gelder B, Dijkman B, Meijer A. Lead system causing twiddler's syndrome in patients with an implantable cardioverter-defibrillator. J Thorac Cardiovasc Surg. 2005; 129:(1)231-232

Carnero-Varo A, Pérez-Paredes M, Ruiz-Ros JA ‘Reel syndrome’. Circulation. 1999; 100:(8)e45-e46

Castillo R, Cavusoglu E. Twiddlers syndrome: an interesting cause of pacemaker failure. Cardiology. 2006; 105:(2)119-121

Chauhan A, Grace AA, Newell SA Early complications after dual chamber versus single chamber pacemaker implantation. Pacing Clin Electrophysiol. 1994; 17:(11)2012-2015

Connolly A, Gaehl E, Martin H, Morris J, Purandare N. Underdiagnosis of dementia in primary care: variations in the observed prevalence and comparisons to the expected prevalence. Aging Ment Health. 2011; 15:(8)978-984

National audit of cardiac rhythm management devices: April 2015–March 2016 (11th Annual Report). 2017. (accessed 2 March 2020)

Edhag O, Swahn A. Prognosis of patients with complete heart block or arrhythmic syncope who were not treated with artificial pacemakers. A long-term follow-up study of 101 patients. Acta Med Scand. 1976; 200:(6)457-463

Epstein AE, DiMarco JP, Ellenbogen KA ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Circulation. 2008; 117:(21)e350-408

Fahraeus T, Höijer CJ. Early pacemaker twiddler syndrome. Europace. 2003; 5:(3)279-281

Furman S. Defibrillator Twiddler's syndrome. Ann Thorac Surg. 1995; 59:544-551

Glikson M, Sueiman M, Luria DM Do abandoned leads pose risk to implantable cardioverter-defibrillator patients?. Heart Rhythm. 2009; 6:65-68

Gribbin GM, Gallagher P, Young AH The effect of pacemaker mode on cognitive function. Heart. 2005; 91:(9)1209-1210

Henrikson CA, Maytin M, Epstein LM. Think before you pull--not every lead has to come out. Circ Arrhythm Electrophysiol. 2010; 3:(4)409-412

Higgins SL, Suh BD, Stein JB, Meyer DB, Jons J, Willis D. Recurrent Twiddler's syndrome in a nonthoracotomy ICD system despite a Dacron pouch. Pacing Clin Electrophysiol. 1998; 21:(1)130-133

Guidelines for follow up of implantable cardiac devices for cardiac rhythm management. 2008. (accessed 25 February 2020)

Kristensson BE, Arnman K, Smedgård P, Rydén L. Physiological versus single-rate ventricular pacing: a double-blind cross-over study. Pacing Clin Electrophysiol. 1985; 8:(1)73-84

Kumar A, McKay CR, Rahimtoola SH. Pacemaker twiddler's syndrome: an important cause of diaphragmatic pacing. Am J Cardiol. 1985; 56:(12)797-799

Lal RB, Avery RD. Aggressive pacemaker twiddler's syndrome. Dislodgement of an active fixation ventricular pacing electrode. Chest. 1990; 97:(3)756-757

Lamas GA, Ellenbogen KA. Evidence base for pacemaker mode selection: from physiology to randomized trials. Circulation. 2004; 109:443-451

Lau CP, Tai YT, Lee PWH, Cheung B, Tang MO, Lam WK. Quality-of-life in DDDR pacing: atrioventricular synchrony or rate adaptation?. Pacing Clin Electrophysiol. 1994; 17:(11)1838-1843

Linde-Edelstam C, Nordlander R, Pehrsson SK, Rydén L. A double-blind study of submaximal exercise tolerance and variation in paced rate in atrial synchronous compared to activity sensor modulated ventricular pacing. Pacing Clin Electrophysiol. 1992; 15:(6)905-915

Lukl J, Doupal V, Heinc P. Quality-of-life during DDD and dual sensor VVIR pacing. Pacing Clin Electrophysiol. 1994; 17:(11)1844-1848

Menozzi C, Brignole M, Moracchini PV Intrapatient comparison between chronic VVIR and DDD pacing in patients affected by high degree AV block without heart failure. Pacing Clin Electrophysiol. 1990; 13:(12)1816-1822

Munawar M, Munawar D, Basalamah F, Pambudi J. Reel syndrome: a variant form of twiddler's syndrome. Journal of Arrhythmia. 2011; 27:(4)338-342

National Cardiac Audit Programme. National audit of cardiac rhythm management devices and ablation: 2016/17 summary report (12th CRM device audit report/10th catheter ablation report). British Heart Rhythm Society/National Institute for Cardiovascular Outcomes Research. 2019. (accessed 2 March 2020)

Newland GM, Janz TG. Pacemaker-twiddler's syndrome: a rare cause of lead displacement and pacemaker malfunction. Ann Emerg Med. 1994; 23:(1)136-138

Nicholson WJ, Tuohy KA, Tilkemeier P. Twiddler's syndrome. N Engl J Med. 2003; 348:(17)1726-1727

National Institute for Health and Care Excellence. Dual-chamber pacemakers for symptomatic bradycardia due to sick sinus syndrome and/or atrioventricular block. Technology appraisal 88. 2014 (updated version of guidance published 2005). (accessed 25 February 2020)

Office for National Statistics. Living longer: caring in later working life. Examining the interplay between caring and working in later life in the UK. 2019. (accessed 18 March 2020)

Oldroyd KG, Rae AP, Carter R, Wingate C, Cobbe SM. Double blind crossover comparison of the effects of dual chamber pacing (DDD) and ventricular rate adaptive (VVIR) pacing on neuroendocrine variables, exercise performance, and symptoms in complete heart block. Heart. 1991; 65:(4)188-193

Pereira PL, Trübenbach J, Farnsworth CT, Huppert PE, Claussen CD. Pacemaker and defibrillator Twiddler's syndrome. Eur J Radiol. 1999; 30:(1)67-69

Rediker DE, Eagle KA, Homma S, Gillam LD, Harthorne JW. Clinical and hemodynamic comparison of VVI versus DDD pacing in patients with DDD pacemakers. Am J Cardiol. 1988; 61:(4)323-329

Roberts PR. Follow up and optimisation of cardiac pacing. Heart. 2005; 91:(9)1229-1234

Schmidt B, Brunner M, Olschewski M Pacemaker therapy in very elderly patients: long-term survival and prognostic parameters. Am Heart J. 2003; 146:(5)908-913

Scholten MF, Thornton AS, Theuns DA, Res J, Jordaens LJ. Twiddler's syndrome detected by home monitoring device. Pacing Clin Electrophysiol. 2004; 27:(8)1151-1152

Solti F, Moravcsik E, Rényi-Vámos F, Szabó Z. Pacemaker twiddler's syndrome (rotation of the pacemaker around the electrode cable, a rare complication of pacemaker therapy). Acta Chir Hung. 1989; 30:(3)231-236

Suga C, Hayes DL, Hyberger LK, Lloyd MA. Is there an adverse outcome from abandoned pacing leads?. J Interv Card Electrophysiol. 2000; 4:(3)493-499

Sulke N, Chambers J, Dritsas A, Sowton E. A randomized double-blind crossover comparison of four rate-responsive pacing modes. J Am Coll Cardiol. 1991; 17:(3)696-706

Toff WD, Camm AJ, Skehan JD Single-chamber versus dual-chamber pacing for high-grade atrioventricular block. N Engl J Med. 2005; 353:(2)145-155

Udink ten Cate FA, Adelmann R, Schmidt B, Sreeram N. Use of an active fixation lead and a subpectoral pacemaker pocket may not avoid Twiddler's syndrome. Ann Pediatr Cardiol. 2012; 5:(2)203-204

Udo EO, van Hemel NM, Zuithoff NPA, Dijk WA, Hooijschuur CAM, Doevendans PA, Moons KGM. Pacemaker follow-up: are the latest guidelines in line with modern pacemaker practice?. Europace. 2013; 15:(2)243-251

Yee R, Benditt DG, Kostuk WJ, Ko PT, Purves P, Klein GJ. Comparative functional effects of chronic ventricular demand and atrial synchronous ventricular inhibited pacing. Pacing Clin Electrophysiol. 1984; 7:(1)23-28

Extreme pacemaker reel syndrome in an elderly patient with cognitive impairment

26 March 2020
Volume 29 · Issue 6


Twiddler's syndrome is a rare cause of pacemaker failure, where patient manipulation of the pulse generator results in lead dislodgement or retraction. Variations in manifestation have been identified including reel syndrome, where rotation occurs around the transverse axis resulting in coiling of the leads, and ratchet syndrome where arm movement results in lead displacement. Device manipulation leading to device failure has been documented in up to 1.7% of implants, particularly in patients with large pockets or mental disorders. Such complications have serious consequences, particularly in pacing-dependent patients where loss of capture may result in asystole. This article reviews the case of an 84-year-old patient presenting at 8-month pacemaker follow-up in complete heart block with no evidence of pacemaker function.

Twiddler's syndrome, first described by Bayliss et al (1968), is a rare cause of pacemaker failure, where patients manipulate the pulse generator resulting in lead dislodgement or retraction. Characterised by rotation of the device (Figure 1), this action results in a twisting of the leads, leading to lead dislodgement and cessation of pacing, and can often cause lead fracture or insulation failure (Abrams et al, 1995; Pereira et al, 1999; Bali et al, 2013). Variations in manifestation have been identified, including reel syndrome, where rotation occurs around the transverse axis resulting in a coiling of the leads around the device (Carnero-Varo et al, 1999), and ratchet syndrome where arm movement results in lead displacement (Arias et al, 2012). Device manipulation leading to device failure has been documented in 0.07-1.7% of implants (Fahraeus and Höijer, 2003; Balaschak, 2012) with a higher incidence in patients who have large pacemaker pockets, or in those who have psychiatric disorders or mental health problems (Castillo and Cavusoglu, 2006; Barold and Stroobandt, 2009). Such complications have serious consequences, particularly in pacing-dependent patients where loss of capture may result in asystole.

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