Recurrent twiddler's syndrome in a nonthoracotomy ICD system despite a dacron pouch

Twiddler's syndrome is a highly recognized yet rare complication of pacemaker and cardioverter defibrillator (ICD) implantation. We present a case in which persistent generator rotation resulted in lead dislodgment and inappropriate shocks in an initial ICD and recurrent lead fracture in a second ICD system. This case is unusual in that even with extensive surgical precautions including use of a Dacron pouch, generator rotation could not be prevented. Submuscular implantation and use of a smaller generator may prevent Twiddler's syndrome.