Twiddler-, Reel-, and Ratchet-syndrome: an alternative approach to address the underlying mechanism of complication in cardiac implantable electronic devices

The circumstances leading to the origins of "Twiddler", "Reel", and "Ratchet" in patients with cardiac implantable electronic devices (CIED) have not yet been fully determined. This retrospective study was performed to address different mechanisms that lead to impairment of implanted leads within the context of "Twiddler", "Reel", and "Ratchet". From 2004 and 2023, 5966 patients underwent CIED procedures at our institution. 31 patients with lead impairment by rotation were identified with evidence of pulse generator mobility, lead dislodgement with retraction and / or associated coiling of the lead(s) radiographically or intraoperatively. A review of the literature from 1963 to 2024 identified 216 cases from 165 publications. In less than half of our patients lead retraction could be attested, and a minority of patients had clinical symptoms attributable to lead impairment by rotation. Psychiatric comorbidities and patients´ manipulation could not be ascertained. Thorough follow-up of all patients with CIEDs appears mandatory. Precise implantation techniques from the outset may limit lead impairment by rotation.