Twiddler's syndrome

An 82-year-old woman with severely impaired mental status, presented to the Emergency department aft er sustaining a femoral fracture following syncope. She had a history of sick sinus syndrome treated with a dual chamber pacemaker 11 months earlier and has been lost to follow-up since. On clinical examination she was agitated and disorientated. ECG depicted under-sensing and non-capture of both electrodes. Chest radiography demonstrated coiling of both pacing leads within the generator pocket and displacement of their tips into the right atrium-superior vena cava junction (Figure 1). Patient was immediately transferred to the electrophysiology laboratory and underwent lead removal and successful re-implantation of two new pacing leads. Lead dislodgment is a serious complication and usually occurs within the fi rst six weeks post pacemaker implantation (1). Twiddler ’ s syndrome is the most commonly described mechanism of dislodgment due to conscious or