‘Twiddling’ of the pacemaker resulting in lead dislodgement

Twiddler’s syndrome is a rare condition in which patient manipulation of the pulse generator within its pocket may result in coiling of the lead and lead dislodgement, thereby causing pacemaker malfunction. Retraction of the electrode may cause phrenic nerve stimulation resulting in diaphragmatic stimulation and a sensation of abdominal pulsations. As the leads are further wrapped around the generator, rhythmic arm twitching may occur as a result of pacing of the brachial plexus.1 Twiddler’s syndrome was first described by Bayliss et al in 1968 as a complication of pacemaker implantation.2 It has also been reported with implantable cardioverter-defibrillators (ICDs)3 and cardiac resynchronisation therapy (CRT).4 This is a case report of an elderly lady with Twiddler’s syndrome resulting in pacemaker malfunction secondary to lead retraction, who emphatically denied any manipulation of her device. She subsequently underwent lead repositioning and appropriate counselling.peer-reviewe

A large pericardial effusion and bilateral pleural effusions as the initial manifestations of Familial Mediterranean Fever

Familial Mediterranean Fever (FMF) is a condition characterized by recurrent febrile poly-serositis. Typical presentations of the disease include episodes of fever, abdominal pain and joint pains. Chest pain is a less common presentation. We report a case of FMF which presented with a large pericardial effusion and bilateral pleural effusions in a lady who had no positive family history and negative genetic testing.peer-reviewe

The prognostic role of stress echocardiography in a contemporary population and the clinical significance of limited apical ischaemia

Introduction: In this study, we aim to reassess the prognostic value of stress echocardiography (SE) in a contemporary population and to evaluate the clinical significance of limited apical ischaemia, which has not been previously studied. Methods: We included 880 patients who underwent SE. Follow-up data with regards to MACCE (cardiac death, myocardial infarction, any repeat revascularisation and cerebrovascular accident) were collected over 12 months after the SE. Mortality data were recorded over 27.02 ± 4.6 months (5.5–34.2 months). We sought to investigate the predictors of MACCE and all-cause mortality. Results: In a multivariable analysis, only the positive result of SE was predictive of MACCE (HR, 3.71; P = 0.012). The positive SE group was divided into 2 subgroups: (a) inducible ischaemia limited to the apical segments (‘apical ischaemia’) and (b) ischaemia in any other segments with or without apical involvement (‘other positive’). The subgroup of patients with apical ischaemia had a significantly worse outcome compared to the patients with a negative SE (HR, 3.68; P = 0.041) but a similar outcome to the ‘other positive’ subgroup. However, when investigated with invasive coronary angiography, the prevalence of coronary artery disease (CAD) and their rate of revascularisation was considerably lower. Only age (HR, 1.07; P < 0.001) was correlated with all-cause mortality. Conclusion: SE remains a strong predictor of patients’ outcome in a contemporary population. A positive SE result was the only predictor of 12-month MACCE. The subgroup of patients with limited apical ischaemia have similar outcome to patients with ischaemia in other segments despite a lower prevalence of CAD and a lower revascularisation rate

2018 ESC/ESH Guidelines for the management of arterial hypertension

No abstract available