We present the case of a 71-year-old man suffering from severe ventricular dysfunction due to a revascularized previous myocardial infarction in 2004, who goes to the emergency department with a ventricular tachycardia. Fifteen days after implanting an implantable automatic defibrillator in secondary prevention (Fig. 1A), the patient returns to consult on this occasion due to persistent hiccups and discomfort in the associated epigastric area. A chest radiograph was performed showing a rotation in the generator along its transverse axis, with the consequent winding of the device cables around the generator (Detail Fig. 1B). This caused torsion and displacement of the right ventricular electrode to the superior cava (*), which produced phrenic stimulation in the mediastinum and caused sudden contractions of the diaphragm and associated hypo.
Twiddler syndrome is a rare complication in patients with cardiac stimulation devices. It was initially described in patients with pacemakers, such as “subconscious, inadvertent or deliberate spontaneous rotation of the generator by the patient, leading to a pacemaker displacement and malfunction”. Subsequently there have been some references in patients with defibrillators. In many cases, the cause goes unnoticed, although obesity, the female gender, the pocket of the large device and elderly patients with mental illness are predisposing factors. Upon suspicion, the most important and simple diagnostic method to identify cable displacement is to perform a chest X-ray and compare it with those previously performed.
