Use of an antimicrobial pouch/envelope in the treatment of Twiddler's syndrome.

Background: "Twiddler's syndrome" occurs when a patient consciously or subconsciously manipulates their pacemaker/defibrillator pulse generator, often resulting in lead dislodgement and device system malfunction. Once dislodgement has occurred, corrective measures include resecuring the system to the pectoralis fascia with redundant anchoring sutures. Unfortunately, patients with Twiddler's syndrome tend to have a high rate of recurrence. This study presents a case series of patients with Twiddler's syndrome and evaluates the strategy of using a nonabsorbable antimicrobial pouch to prevent recurrent lead dislodgement events.

Methods: Pacemaker and defibrillator operative reports were reviewed at a single institution over a time period of 16 years. Historical, fluoroscopic, and intraoperative findings were used to identify 21 patients with strong evidence for Twiddler's syndrome. Patient charts were retrospectively analyzed, and a cohort of 13 patients who received a nonabsorbable antimicrobial pouch was compared to a cohort of eight patients who received other corrective measures.

Results: The rate of "retwiddling" events was 0% in the antimicrobial pouch group versus 50% in the suture-only group (P < 0.05).

Conclusions: Among patients requiring device system revision for Twiddler's syndrome, the use of nonabsorbable antimicrobial pouches was associated with significantly fewer recurrences of lead dislodgement events.