Abstract
Twiddler syndrome is a form of pacemaker lead dislocation caused by the coiling of the pacemaker leads due to pulse generator rotation on its long axis. Similar to Twiddler syndrome, Reel syndrome occurs due to rotation of the pulse generator on its transverse axis, leading to lead dislocation or fracture, followed by clinical symptoms of dislodged leads. We report a case of 75 years old woman with Reel syndrome presenting with syncope.
Keywords: Reel syndrome, Diaphragmatic pacing, Dislodged leads
An elderly female with dual chamber pacemaker implantation for Sick Sinus Syndrome presented two weeks later with pre-syncope and twitching in right epigastrium synchronous with heartbeats.
Pacemaker interrogation revealed high lead resistance and absent ventricular capture. On fluoroscopy leads were seen coiled transversely around the pulse generator with lead tips in right subclavian vein [Figs. 1 and 2]. Revision procedure was performed to reposition leads in right atrium and right ventricle. During first implantation and subsequent revision procedure, the standard suturing technique was used. Of note – three sutures were placed on the lead sleeve and the pulse generator was fixed to the underlying fascia to prevent migration. On subsequent follow-ups, pacemaker function remains normal.
Fig. 1.
On fluoroscopy leads seen coiled transversely around rotated pulse generator with lead tips in right subclavian vein.
Fig. 2.
The ‘twisted’ leads.
Reel syndrome is caused by the torsion of the pulse generator on its transverse axis with subsequent coiling of the pacemaker leads around the pulse generator1 and may lead to electrode dislocation, lead fracture, syncope and even death. Rare symptoms are diaphragmatic pacing due to phrenic nerve stimulation,2 brachial plexus stimulation, thoracic muscle contraction and dysphonia.3
In our patient, the culprit causative factor was vigorous manipulation by an over-enthusiastic masseuse as opposed to previous hitherto described causes of Reel's syndrome like spontaneous torsion of the pulse generator or surreptitious/subconscious ‘twiddling’ by the patient.
Recognizing this complication early in pacemaker-dependent patients can prevent life threatening complications and is therefore of paramount importance.
Conflicts of interest
All authors have none to declare.
References
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