Twiddler syndrome

Case contributed by Dachani Kansan Naider
Diagnosis almost certain


Syncope while resting on a chair. Permanent pacemaker for a history of recurrent syncope in the past.

Patient Data

Age: 80 years
Gender: Female

Chest x-ray

  • dual-lead cardiac pacemaker noted
  • the position of the pacemaker box has changed; it is currently located more medial and inferior when compared to prior study (refer below)
  • new intertwining leads identified at the superior lateral part of the pacemaker box
  • the cardiac apex lead appears to be slightly withdrawn when compared to the previous study (refer below)

Prior study for comparison

  • AP film
  • dual-lead cardiac pacemaker noted
  • intact pacing leads in expected positions

Case Discussion

The patient presented with the witnessed sudden loss of consciousness while resting on a chair, suspicious of cardiac syncope. She has a past medical history of recurrent syncope, which has resolved since the permanent pacemaker insertion five years ago.

Upon arrival at the Emergency Department, the patient was placed on cardiac monitoring, which showed a transient complete heart block. Chest X-ray was performed as part of the initial syncope workup and revealed findings suggestive of Twiddler's syndrome, correlating with clinical suspicion.

She was admitted to the cardiology team for pacemaker interrogation and repositioning of the leads. 

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