Unique presentation of Twiddler’s syndrome

Figure 1 Automatic implantable cardioverter defibrillator interrogation showing gradually increasing pacing impedance over a period of 8 mo (arrow).

Figure 2 Chest X-ray. A: Normal appearing lead without any twirling; B: A visible twirling is seen at right atrio-ventricular junction (arrow).

Figure 3 Antero-posterior fluoroscopic images. A: Twisting of leads at right atrio-ventricular junction (arrow); B: Near generator in shoulder area (arrow).

Figure 4 Antero-posterior chest X-ray after successful placement of new ventricular lead (arrow). Abandon ventricular lead can be also be seen.