Pacemaker twist: Twiddler's syndrome

SUMMARY Two clinically asymptomatic cases of cardiac pacemaker twist or Twiddler's syndrome are presented. These examples illustrate that not all cases of pacemaker twist are symptomatic and need intervention. Both patients had unipolar pacemaker systems inserted for second degree heart block and sick sinus syndrome, respectively. The diagnosis of pacemaker twist was made on routine chest radiograph, requested for conditions unrelated to pacemaker dysfunction. No manipulation of pacemakers was documented. The recognition and documentation of radiological signs of pacemaker twist is important as a baseline for follow up especially if symptoms of pacemaker dysfunction arise.