After much discussion with the ED physicians the patient admitted to "fooling around" with the pulse generator, not being aware that the leads could be dislodged.

A biventricular pacemaker usually has three leads: one is guided to the right ventricle, one to the left ventricle via the coronary sinus, and the third (variably present) is guided to the right atrium.

Twiddler syndrome refers to malfunction of a pacemaker due to the patient's manipulation of the pulse generator or wires. It begins with the patient's deliberate or subconscious spinning of the pacemaker's pulse generator in a spacious pocket. The leads are dislodged, and ventricular pacing ceases ¹.