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Logo of thijTexas Heart Institute JournalSee also Cardiovascular Diseases Journal in PMCSubscribeSubmissionsTHI Journal Website
Tex Heart Inst J. 2009; 36(5): 505.
PMCID: PMC2763476

The Twiddling Andersen

To the Editor:

Jefferies and colleagues, in a recent issue of the Texas Heart Institute Journal, 1 described a case of defibrillator “twiddling” that partially dislodged the implanted electrodes. While references to the twiddling problem were made, there was no reference to a technique that can prevent both twiddling and device erosion—encasing the implanted pulse generator in a polyester-mesh pouch.2,3

We have used this pouch regularly for 35 years and have not seen any significant complication, except for an extremely rare reaction to the fibrous material. We continue to use the pouch in very thin patients in whom there is little overlying fibro-adipose tissue, and in patients whose implants are not placed beneath the pectoralis major muscle. Since making use of the pouch, we have not again seen twiddling or erosion of a device.

It would have been appropriate to report that there is a satisfactory method available to prevent twiddling and its complications.

Victor Parsonnet, MD
Director, Pacemaker & Defibrillator Center, Director of Surgical Research, Newark Beth Israel Medical Center, Newark, New Jersey


1. Jefferies JL, Kim JJ, Belmont JW, Friedman RA. The twidling Andersen. Tex Heart Inst J 2009;36(4):349–51. [PMC free article] [PubMed]
2. Parsonnet V. A stretch fabric pouch for implanted pacemakers. Arch Surg 1972;105(4):654–6. [PubMed]
3. Parsonnet V, Bernstein AD, Neglia D, Omar A. The usefulness of a stretch-polyester pouch to encase implanted pacemakers and defibrillators. Pacing Clin Electrophysiol 1994;17 (12 Pt 1):2274–8. [PubMed]

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