CTICasesTwiddler Syndrome with Pacemaker Lead Retraction and Phrenic Nerve Stimulation
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[...]. Twiddler Syndrome with Pacemaker Lead Retraction and Phrenic Nerve Stimulation. CTICases. Published March 27, 2015. https://str-case-explorer.pages.dev/c/afp4g
Imaging findings
An old radiograph from AICD placement showed no pneumothorax. A follow-up radiograph, obtained when the patient presented with diaphragmatic pacing, showed that the AICD lead had retracted and was twisted around itself and the generator within the chest wall. The lead was clearly not perforating the right ventricle.
Key takeaways
This is a classic presentation of Twiddler syndrome, where the pacemaker generator is manipulated (consciously or subconsciously), causing the lead to retract and twist. This can lead to phrenic nerve stimulation and diaphragmatic pacing (as seen here), or brachial plexus activation if it retracts further. It is more common in elderly or obese patients with looser connective tissue, often requiring a sub-pectoral pouch for replacement.
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