Twiddler syndrome in a pt with implantable cardioverter defi
The present case has been published in BMJ. A 20-year-old woman with long-QT syndrome received a submuscular Fortify DR-St Jude implantable cardioverter defibrillator (ICD) after an episode of cardiac arrest. She felt an ICD pocket vibration 23 months later due to a high lead impedance and loss of capture.

Chest radiography (figure 1A,B) showed both lead displacement and winding of the leads beside the ICD generator. These findings were confirmed during surgery (figure 1C). The patient strongly denied any box manipulation. She was discharged after new leads implantation with no complications.

Learning points
• Twiddler syndrome is defined as generator rotation with lead twisting and secondary malfunction of the leads.

• The causes of this syndrome are not always clear. However, predisposing factors include the creation of a large subcutaneous pocket, obesity, unconscious repetitive movements of the left arm, manipulation of the pocket or the adoption of repeated poor postural positions. Majority of cases were related during the first year of implant, but rarely can happen lately.

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