A 65-year-old woman with a cardiac resynchronisation therapy-defibrillator underwent routine device interrogation, revealing abnormalities in the atrial lead (reduced amplitude and occasional detection failure) and the right ventricular lead (increased pacing threshold) 13 months post-implantation. This prompted a chest X‑ray due to suspected lead dislodgement (Fig. 1b).
The X‑ray revealed twisted and macro-dislodged leads, along with pulse generator rotation, indicative of both Twiddler and Reel syndromes. These syndromes result from specific mechanisms of macro-dislodgement caused by movements of the generator or leads ([1]; Fig. 1c).
Potential risk factors are debated and include a psychiatric history, obesity, advanced age, an oversized pocket, manual manipulation, and the absence of generator fixation [2]. In our patient, the last two factors were present. Suturing the generator may be the most effective preventive strategy [3], although it is considered optional [4].
Even in the presence of risk factors, there are no specific guidelines recommending increased follow-up, reimplantation procedures, or routine radiography. However, routine imaging can be useful in identifying dislodgement [5] and is therefore advisable in conjunction with routine electrical testing. Lead revision is definitively recommended in cases of lead dysfunction [4].
Conflict of interest
P. Rossignon, R. Tajildin and E. Famdie declare that they have no competing interests.
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