Editorial Type:
Article Category: Research Article
 | 
Online Publication Date: Jun 01, 2017

Evaluation of Chest Pain after Implantable Cardioverter-Defibrillator Placement

MD,
MD, and
MD
Page Range: 226 – 227
DOI: 10.14503/THIJ-17-6293
Save
Download PDF

A 65-year-old woman with a history of congestive heart failure presented at the emergency department with right-sided upper-chest and shoulder discomfort. Two months prior, she had been given a single-lead Fortify Assura™ VR 1357-40Q implantable cardioverter-defibrillator (ICD) (St. Jude Medical, now part of Abbott Laboratories; St. Paul, Minn). She described her symptoms, which had started 6 hours before admission, as off-and-on pain of mild-to-moderate severity that was not associated with exertion or respiration. She reported no shortness of breath, cough, fever, chills, or dizziness. An electrocardiogram (ECG) was obtained upon presentation (Fig. 1).

Fig. 1. Fig. 1. Fig. 1.
Fig. 1.

Citation: Texas Heart Institute Journal 44, 3; 10.14503/THIJ-17-6293

What are the differential diagnoses?

Focus on ECGs: Answer #9

Answer

Differential diagnoses include ICD lead malfunction (fracture, dislodgment, or perforation), ventricular undersensing with safety pacing (by the ICD), and sinus rhythm with motion artifact. The ECG (Fig. 2) shows sinus rhythm at a rate of 58 beats/min with QRS criteria for left ventricular hypertrophy and independent small deflections (asterisks) at a regular rate of 40 beats/min. These deflections are low-amplitude complexes followed by T waves in leads I, II, and V1. In other leads, they look very small, suggesting artifact or perhaps pacemaker stimuli with undersensing and failure to capture. The pacing stimulus appears at the beginning of the third QRS with no change in QRS configuration, suggesting a pseudofusion beat.

Fig. 2. Fig. 2. Fig. 2.
Fig. 2.

Citation: Texas Heart Institute Journal 44, 3; 10.14503/THIJ-17-6293

The current chest radiograph (Fig. 3A), when compared with one obtained after device implantation (Fig. 3B), was consistent with Twiddler syndrome, a very rare cause of pacemaker malfunction. This syndrome was first reported in patients with pacemakers1 and later in patients with ICDs.2,3 Rotation of the generator inside the pocket due to patient manipulation or loose anchoring of the device can cause the lead to retract into the superior vena cava or subclavian vein. Our patient's ICD generator had rotated in the pocket. When this happens, the location of the lead might cause intermittent twitching of the shoulder muscle or diaphragm by stimulating the brachial plexus or the phrenic nerve, respectively—and indeed the patient's symptoms were twitching of the shoulder and upper-chest muscles.

Fig. 3. Fig. 3. Fig. 3.
Fig. 3.

Citation: Texas Heart Institute Journal 44, 3; 10.14503/THIJ-17-6293

References

  • 1.

    Bayliss CE
    ,
    BeanlandsDS
    ,
    BairdRJ.
    The pacemaker-twiddler's syndrome: a new complication of implantable transvenous pacemakers. Can Med Assoc J1968;99(
    8
    ):371–3.

  • 2.

    Boyle NG
    ,
    AnselmeF
    ,
    MonahanKM
    ,
    BeswickP
    ,
    SchugerCD
    ,
    ZebedeJ
    ,
    JosephsonME.
    Twiddler's syndrome variants in ICD patients. Pacing Clin Electrophysiol1998;21(
    12
    ):2685–7.

  • 3.

    Nicholson WJ
    ,
    TuohyKA
    ,
    TilkemeierP.
    Twiddler's syndrome. N Engl J Med2003;348(
    17
    ):1726–7.

  • Download PDF
Fig. 1.
Fig. 1.

Fig. 2.
Fig. 2.

Fig. 3.
Fig. 3.

Contributor Notes

Section Editors: Yochai Birnbaum, MD Mohammad Saeed, MD James M. Wilson, MD

From: Department of Cardiology (Drs. Birnbaum, Gahremanpour, and Saeed), Texas Heart Institute and Baylor–St. Luke's Medical Center; and Section of Cardiology (Drs. Birnbaum and Saeed), Department of Medicine, Baylor College of Medicine; Houston, Texas 77030

Address for reprints: Amir Gahremanpour, MD, Northwest Houston Heart Center, 308 Holderrieth Blvd., Tomball, TX 77375, E-mail: agaseman@outlook.com