It is imperative that practitioners recognize the signs and symptoms of twiddler’s syndrome (e.g., fatigue syncope dizziness palpitations and shortness of breath, such as dyspnea, paroxysmal nocturnal dyspnea, or orthopnea). Because of the vast number of pacemakers, AICDs, and combination units implanted annually in the United States, both syndromes are likely to be seen in a busy urban ED.Īlthough the incidence of twiddler’s syndrome is slightly higher than that of reel syndrome, both need to be considered during a workup of pacemaker failure.
This definition also includes pacemaker-defibrillator combination units.Ī related scenario, reel syndrome, involves the manipulation of a generator on a transverse plane. It looked as though the entire generator had been flipped over and then turned 30°.įirst described in 1968 by Bayliss and associates, twiddler’s syndrome is the conscious or unconscious longitudinal manipulation by the patient of a pacemaker generator or automatic implantable cardioverter/defibrillator (AICD) generator. The orientation of the pacer appeared to have changed. The clinicians compared the original chest x-ray ( Figure 1) with one taken one month later ( Figure 2). In attempting to determine the cause of the increased resistance, we considered the possibility that the leads might no longer be implanted in the heart. Although the rationale was sound, the dizziness and syncopal episodes were not temporally connected to the onset of these medications.Ī representative from the pacemaker manufacturer determined that the device’s generator was firing normally, but the leads demonstrated very high resistance.
Dicyclomine and quetiapine can both cause dizziness, and quetiapine can cause QT-interval prolongation. AnalysisĪt the outset, medication side effects were of primary concern. A cranial CT scan revealed no active disease. The pacemaker generator implanted in the left subpectoral region was present along with the leads, which appeared to extend into the heart. A chest x-ray demonstrated clear lung fields bilaterally. Liver, pancreatic, and heart enzymes were all unremarkable. ResultsĮlectrolytes were within normal limits except sodium, which was slightly low by 2 mEq/L. The telemetry monitor indicated possible periodic loss of capture and sensing. Another 12-lead ECG taken several hours later suggested intermittent pacing with loss of capture. No pacemaker activity was noted at this time. There were no audible murmurs, clicks, or rubs on auscultation. Capillary refill was two seconds mucous membranes were pink and moist.Ī 12-lead ECG showed a possible old inferior wall myocardial infarction (age undetermined). Peripheral pulses were regular and normal bilaterally. Telemetry revealed heartbeat in the 70s and a normal sinus rhythm. She appeared somewhat agitated and uncomfortable. No complications were associated with either procedure, and the patient went home following a two-day hospital stay. Past surgical procedures included the recent pacemaker insertion, which coincided with a cardiac catheterization. Her current medications included atenolol 50 mg and enalapril 5 mg in the morning, benztropine 1 mg and haloperidol every night, amiodarone 200 mg and quetiapine 200 mg b.i.d., and dicyclomine 20 mg t.i.d. R’s medical history included hypertension, coronary artery disease, irritable bowel syndrome, bradyarrhythmias, and unspecified psychiatric problems.