CTICasesTwiddler Syndrome — ICD Lead Coiling and Proximal Migration
Imaging findings
Sequential chest radiographs taken immediately after ICD implantation, 4 months later, and approximately 5 months after implantation show progressive coiling of the ICD lead near the generator pocket with corresponding proximal migration of the lead tip from the right ventricular apex toward and ultimately proximal to the tricuspid valve. The generator device itself does not demonstrate clear rotation in the anterior-posterior plane. The coiling pattern is explained by the patient repeatedly flipping or rotating the generator in its pocket around its vertical axis.
Key takeaways
Twiddler syndrome refers to progressive coiling and proximal retraction of pacemaker or ICD leads caused by patient manipulation of the generator device, producing loss of cardiac pacing or defibrillation capture. The generator need not be visibly rotated in the AP projection if it is being rotated around its vertical axis, which would still cause lead coiling. Serial radiographs demonstrating progressive lead coiling with corresponding migration of the tip away from the intended position are diagnostic. Repositioning and secure pocket closure are required to prevent recurrence.
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