A 92 YEAR-OLD WOMAN WHO TOOK A TURN FOR THE WORSE. V. Tsai 1 , R. Ziegelstein 1 ; 1 Johns Hopkins University, Baltimore, MD (Tracking ID #75756) LEARNING OBJECTIVES: To call attention to the possibility that moving a patient soon after a cardiac procedure can result in malposition and malfunction of a permanent pacemaker. CASE INFORMATION: A 92-year-old woman was found unresponsive in her nursing home bed. She was in complete heart block with a ventricular rate in the 20s±30s. Soon after arrival to the hospital, she sustained an asystolic arrest and required emergency temporary pacemaker therapy. The patient did not regain consciousness after electrical pacing at 60 beats per minute. The patient's health care agent consented to the implantation of a permanent pacemaker. After the procedure, a chest radiograph showed an appropriately placed dual chamber permanent pacemaker. The patient did not regain consciousness nor spontaneous movement. Nursing staff turned the patient every two hours to avoid pressure sores. Several days later, a chest radiograph showed that the pacemaker generator was rotated and in the opposite configuration from that noted on the original film. There was no evidence of electrode dislodgment or pacemaker malfunction. IMPLICATIONS/DISCUSSION: Pacemaker-twiddler's syndrome is an unusual complication of permanent pacemaker implantation, first described by Bayliss, et al. in 1968 . It is usually characterized by partial or total loss of pacemaker function secondary to rotation of the pulse generator in its subcutaneous pocket and subsequent electrode dislodgment. The rotation is related to manipulation of the generator by the patient, either consciously or unconsciously. The present report differs from previous cases, since the pacemaker generator rotation could not have been induced by the patient, but was likely the result of routine turning of the patient by the nursing staff in an effort to prevent pressure ulcers. The possibility that turning immobile patients soon after device implantation will result in malposition and malfunction of pacemaker or cardioverter-defibrillator generators is important to recognize, since these devices are being used in an increasing number of elderly patients. Caution should be exercised while moving elderly bedbound patients in the first few days after their cardiac procedure, in order to prevent a potentially life-threatening condition.