2009 Southern Regional Meeting Abstracts

Purpose of Study: First described in 1968, pacemaker twiddler syndrome is a rare but potentially lethal clinical entity that refers to the permanent malfunction of pacemaker due to the patient's manipulation of the pulse generator. Study purpose was to determine the clinical and pacing characteristics and short term outcomes associated with twiddler syndrome during a 24 month (July 05-07) period at a university hospital.
Methods Used: Retrospective chart review was done after obtaining IRB approval.
Summary of Results: Four patients presented with twiddler syndrome with complaints ranging from palpitations, dyspnea or fever. The mean age of these patients was 76.3 years, and all were men. The clinical characteristics and pacing variable are shown in the table. Episodes of non-sustained ventricular tachycardia were found in all patients. Loss of capture and inadequate pacing was seen on admission EKG. Mean QRS duration at admission was 156.3 milliseconds (r=105-200 ms).All had underlying coronary artery disease and ischemic cardiomyopathy. Three of the four patients had dementia (75%, p=0.024). The mean ejection fraction was 23.5% (r=20-29%). The pulse generator was infected in two (50%) patients. Femoral approach was used for temporary pacemaker insertion in all cases. Duration of temporary pacing as a bridge to permanent pacemaker was 3.25 days (range=2-5 days). Subsequently biventricular permanent pacemakers or ICD were placed. The mean duration of stay was 4.5 days.
Conclusions: Twiddler syndrome is a rare but a dangerous condition that results in lead dislocation or loss of capture with potential mortality. 75 % of twiddler patients in our study had underlying dementia which could predispose to unintended pulse generator manipulation and lead dislodgement. We should have high index of suspicion of this potentially lethal condition in elderly patients with PPM/ICD’s with underlying dementia presenting with arrthymias, including non-sustained ventricular tachycardia.

	PATIENT 1	PATIENT 2	PATIENT 3	PATIENT 4
Age(Years) Sex	86 Male	61 Male	90 Male	79 Male
Permanent Pacemaker Indication	Sick Sinus syndrome, Class IV CHF	Nonsustained Ventricular Tachycardia.	Sick Sinus syndrome, Class IV CHF	Sick Sinus syndrome, Class IV CHF
Leads -LV sensing -RV pacing	13 mV 0.7 V	10mV 0.7 V	11.9mV 0.5V	11.9mV 1.0V
Time from initial implant	3 months	1.5 months	16 months	9 months
Temporary pacing Length of stay	2 days 3 days	5 days 6 days	2 days 3 days	5 days 6 days