925 THE TWIDDLER'S SYNDROME: A CASE REPORT


 
 
 The Twiddler's syndrome is a rare condition of malfunctioning of a cardiovascular implantable elettronic device (CIED) due to the rotation of the device around its own long axis within its pocket. This brings to the leads wrapping around the device case and consequently dislocating, resulting in a deficit in sensing and pacing.
 
 
 
 We present the case of an 82-year-old woman, affect by atrial and conduction tissue disease for which was implanted a dual-chamber PaceMaker (PM). She arrived at the emergency department for asthenia and a traumatic syncopal episode, preceded by intense general malaise, nausea and vomiting. At EKG findings of electroinduced atrial rhythm, electroinduced ventricular rhythm with loss of capture and emergence of spontaneous rhythm, with subsequent resumption of capture. At device telemetry check, rise of ventricular and atrial pacing thresholds together with sporadic ventricular capture losses. Chest×Ray showed entanglement of leads around the PM case and retraction of the ventricular catheter.
 Therefore, the patient was admitted to the cardiology department, and the surgical pocket was revised with case extraction and leads debridement with subsequent optimization of their position. The next day, following device telemetry check, which showed good electrical parameters, and the follow-up chest X-Ray, which was normal, the patient was discharged.
 
 
 
 All physicians, particularly cardiologists, must pay close attention to the evaluation of patients with CIEDs. First of all, meticulous analysis of the EKG must be performed, which is capable of showing loss of capture and abnormal QRS morphologies due to cardiac pacing at abnormal locations. In addition, it is necessary to perform the telemetry check of the device, infact findings of sensing deficits and/or elevation of pacing thresholds indicate device malfunctioning, which is not necessarily due to leads injuries. Displacement of the leads can be easily detected with a chest X-ray, always remembering to rule out the presence of Twiddler syndrome, however rare it may be.
