Twiddler's syndrome with occult lead insulation damage in a child with epicardial pacemaker leads

We present a rare case of incidentally diagnosed Twiddler's syndrome in a child 7 years after implantation of a dual-chamber pacemaker system with epicardial leads. During revision, an insulation defect of the ventricular lead was evident, despite unremarkable prior pacemaker lead testing. The lead was repaired and a new generator was suture-fixated to prevent re-occurrence of generator manipulation.