Male pre-schooler with history of hypoplastic left heart syndrome diagnosed in utero, with coronary artery to left ventricular fistulae.He had undergone multiple cardiac surgeries including coil closure of the fistulae, norwood/sano procedures, bidirectional glenn procedure with banding of the right ventricle to pulmonary artery conduit, atrial septectomy and tricuspid valve repair for tricuspid regurgitation.The patient was undergoing a right and left heart catheterization procedure with angiography and possible coil embolization of significant venovenous or aortopulmonary collateral vessels.The high-pressure iv tubing was hooked up to the power-injector pump system to deliver the dye solution for angiography; the pump reached 852 psi when the tubing fractured at the luer-lock connection to the patient's iv line.The luer lock assembly came apart from the base.A second set of tubing was prepared, and when infusion was started, it reached 677 psi when the luer connector came apart at the same place.Tubing is listed as capable of administering up to 1200 psi.
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