Unusual lead helix damage due to 'Selective' Reel syndrome.

Oblivious manipulation of the device by the patient is referred to as "Twiddler's" syndrome. It is characterized by the coiling of the pacemaker lead due to the rotation of the pacemaker generator on its long axis. However, the rotation of the pacemaker generator on its transverse axis with subsequent coiling of the pacemaker leads around the pulse generator is called as ''Reel syndrome''. In this case, we present a 69-year-old patient with 'selective' Reel syndrome and postulate the possible explanation for damaged atrial lead.

Case presentation

A 69-year-old man underwent primary prevention dual-chamber ICD (Fortify Assura, St Jude, Minn, USA) insertion due to ischemic cardiomyopathy. A prior left-sided procedure resulted in device infection. The current implant was performed on the right side following optimal antibiotic treatment. Both leads (atrial lead: Tendril™ STS pacing lead, St Jude Med, and ventricular lead: Durata™ defibrillation lead, St Jude Med) were active fixation. Three months later, the patient presented to clinic for routine check-up and atrial lead sensing and impedance significantly deteriorated. The patient had also intermittent phrenic nerve stimulation. Chest radiograph showed that the atrial lead had been retracted back into the superior vena cava. RV lead tip was still on the RV mid-septum as was placed at implantation (Fig. 1). The device was programmed to the VVIR mode and the patient was arranged for elective surgery for atrial lead revision. The patient underwent elective atrial lead revision one month later and fluoroscopic imaging on the day of procedure revealed atrial lead coiled in the device pocket, however; right ventricular lead remained in place (Fig. 2, Panel A). Extracted atrial lead showed a damaged helix (Fig. 2, Panel B). We revised the atrial lead (Tendril™ STS pacing lead, St Jude Med) and again secured the ICD to the underlying tissue in the base of the pocket to prevent this from recurring.

Fig. 1

Chest radiography (PA and left lateral views) showing retracted atrial lead (arrow) back into the superior vena cava and right atrium junction.

Fig. 2

A: Fluoroscopy cine imaging showing atrial lead coiled in the device pocket (arrow), however; right ventricular lead remained in place. B: Damaged extracted lead, note to the damaged helix.

The Reel syndrome, a recently described form of Twiddler's syndrome, occurs due to the rotation of the pacemaker generator on its transverse axis with subsequent coiling of the pacemaker lead(s) around the pulse generator [1].

When only one of the leads get retracted or displaced, this phenomenon is called [2]. There are few similar cases in the literature showing atrial lead displacement only, however the RV lead remained in place [2], [3], [4], [5]. The authors have explained this phenomenon with speculation that implanters subconsciously tighten the RV lead sutures more firmly than atrial lead given the fact that RV lead is the life-saving lead. Other reasons to be considered are: female gender, large pocket, obesity, children, elderly people and dementia. Their prevalence remains unknown [1]. The consequences of atrial lead displacement can be significant and could be listed as following: diaphragmatic nerve stimulation, loss of capture, inappropriate therapies due to either loss of atrial sensing and lack of better tachycardia discrimination or ventricular oversensing due to atrial lead dislodged to the ventricle, and even death. In our case, patient presented with phrenic nerve stimulation.

In our case, only atrial lead was displaced, however the RV lead was completely stable. In addition to that, extracted atrial lead showed a damaged helix. We remained uncertain whether the helix broke during traction or within the pocket during extraction.

Conflict of interest

No conflict of interest.

Disclosure of funding

Informed patient consent for publication was obtained.