Through follow-up communication, livanova learned that arterial line connection was not secured with a tie band.Leakage occurred during procedure and change-out of the device was completed within 3-4 minutes.Surgical phase when product was replaced was not specified.Based on collected information, a disconnection of the arterial line was therefore excluded as failure mode.In addition, since no problem was detected during priming phase, a mechanical damage of the oxygenator outlet port was also excluded as cause of the event.Pictures of the device showing the absence of tie band on arterial line tubing was provided.Analysis of complaints database revealed no other similar cases notified for batch concerned from the market.Taking into account above findings, it can be concluded that root cause of reported issue was a faulty connection of the line tubing onto oxygenator outlet port by customer, which was gradually loosened after opening the blood flow rate which is higher than priming flow rate.Circuit connections to oxygenator are charged to customer since affected item is a finished product with no venous nor arterial lines pre-connected.Finally, ifu's of product recommend to verify all connections and secure them with cable tie prior to starting the procedure in this regard.The risk is in the acceptable region.No specific action was currently deemed necessary.Livanova will keep monitoring the market.
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