A 76-yr-old man with unipolar ventricular pacemaker, previously implanted in the right ventricular apex, presented with syncopal attack and twitching of the right pectoralis muscle. He finally was diagnosed as having Twiddler's syndrome. The patient had a pulse rate of 36/min and cannon waves in the neck veins. Chest radiography showed a dislodged pacing lead completely wrapped around the pulse generator. After uncoiling the lead it was positioned in the right ventricular apex and the pulse generator implanted and sewed tightly in a smaller pocket. After six months follow-up there was no further twiddling or pacemaker dysfunction.

Background: Lead-related infections that might develop after pacemaker implantation associated with high mortality and morbidity rates are challenging to manage and pose high-cost. Patients with lead-related infections usually present with fever, chills and fatigue and the treatment can be challenging unless the implant system is extracted. Case presentation: A 66-year old male patient who underwent dual chamber pacemaker and implantable cardioverter defibrillator was admitted to the emergency service with a six-week history of complaints of hiccups and fever. After a detailed investigation, lead-related infective endocarditis was the diagnosis. The patient was initiated on antibiotic therapy and lead extraction was performed. Conclusions: Patients with signs of infection who underwent pacemaker implantation may present with atypical symptoms such as hiccup. In these cases, imaging, particularly echocardiography, should be performed as soon as possible and the localization of the pacemaker leads and signs of infective endocarditis should be investigated.

There are several reports of pacemaker migration from the site of implantation. pacemakers can erode the skin and become exposed, migrate toward the axilla or breast and protrude from the abdominal wall into the peritoneal cavity. Intraabdominal migration of an epicardial pacemaker generator is a rare but potentially life-threatening complication. We report a case of a 53- year-old woman in whom the generator silently migrated from the sheath of the rectus abdominis muscle in the upper abdominal wall down into the peritoneal cavity.

Erosive dermatitis is a skin reaction associated with implantable cardiac devices (ie، pacemakers and cardioverter defibrillators). We report a 65-year-old man with a history of several cerebrovascular attacks who developed an erythematous crusted erosive patch over the pacemaker site after implantation of two subsequent pacemakers. We suggest that physical irritation may be a trigger factor for both pacemakers and changing the type of pacemaker is not important in some cases.

Background: The advancement of technology in recent decades has been lead to use the electrophysiology cardiac devices. Although these devices are used increasingly, but the frequency of subclinical infection is unknown. We investigate bacterial infections due to implantable cardioverter defibrillator (ICDs) in patients with endocarditis.Materials and Methods: Population of the study was considered among all adult patients in whom the cardiac electrophysiology device was removed. Associated infection endocarditis defined by the Duke criteria.35 pacemakers (PM) were aseptically removed from these patients during January 2012 to November 2014. Intraoperative swabs from the different part of devices were collected, cultured in BHI (Brain Heart Infusion Broth) and then bacterial classical cultures were done under aerobic and anaerobic conditions. Biochemical and differential media were used to detect the bacteria species. Data analysis was performed by using SPSS version 16 software.Results: 13 cases of 35 patients with endocarditis diagnosed by modified Duke Criteria and removed pacemaker had positive culture. Of the 13 cases with infection 43% were identified as gram positive and 57% had gram negative bacteria.Conclusion: Based on our study and similar studies, bacteria can colonize in electrophysiology devices which can lead to bacterial infections.

Background- Permanent abnormalities of the hearts conductive system may lead to ‎hemodynamic disturbances and require pacemaker implantation. Pediatric pacing ‎involves unique challenges because of the patients size, growth and development and ‎the frequent coexistence of congenital structural heart diseases‏.‏‎‎ Methods- In this study, 97 patients, who received permanent pacemaker implantation ‎from 1991 to 2001, were reviewed retrospectively using patients records. Attention ‎was paid to the implantation type, etiology of pacemaker replacement and the ‎occurrence of any complication related to underlying cardiac structural anomaly‏.‏‎ ‎ Results- During a mean follow-up period of 5.3 years (range 1-14 years), 155 ‎operations were performed for pacemaker implantation or replacement. Etiologies for ‎pacemaker implantation acquired atrioventricular block in 55 patients (59.7%), ‎congenital atrioventricular block in 33 patients (34%), malfunction of sinoatrial node ‎in 6 cases, second-degree atrioventricular block in 6 patients and myocarditis in one ‎patient. Epicardial and endocardial pacemakers were implanted for 70 patients ‎‎(72.2%) and 27 patients (27.8%), respectively. Congenital heart disease was observed ‎in 62 patients (63.9%). In 44 patients, replacement was performed one to three times. ‎Lead malfunction was the reason of pacemaker replacement in 88.7%. Complications ‎were observed in 8% of epicardial and 15% of endocardial pacemaker implantations‏.‏‎ ‎‎‎ Conclusion- The 4-year survival rate of epicardial and endocardial pacemakers was ‎‎44.8% and 53.3%, respectively, but there appeared to be no statistical relationship ‎between the pacemaker type and its survival rate and also the prevalence of ‎complications. Also, congenital heart disease and a simultaneous implantation of ‎pacemaker at the time of corrective surgery did not play as a risk factor in decreasing ‎the pacemaker survival rate. (Iranian Heart Journal 2002, 2003; 3(4)&4(1): 38-43).‎