ST. JUDE MEDICAL SWARTZ BRAIDED TRANSSEPTAL GUIDING INTRODUCER, SL1, 63 CM LENGTH, 8.5F; INTRODUCER, CATHETER
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Model Number 407453 |
Device Problem
Adverse Event Without Identified Device or Use Problem (2993)
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Patient Problems
Death (1802); Cardiac Perforation (2513)
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Event Date 11/16/2020 |
Event Type
Death
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Manufacturer Narrative
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The results of the investigation are inconclusive since the device was not returned for analysis.The device history record was reviewed to ensure that each manufacturing and inspection operation was performed.Based on the information received, the cause of the reported incident could not be conclusively determined.Per the ifu, cardiac perforation is a known risk during the use of this device.
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Event Description
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During the ventricular tachycardia ablation procedure, the patient had a cardiac perforation and subsequently died.An hd grid was inserted through a sl1 introducer.A transseptal puncture was performed using a non-abbott guidewire and the sheath passed successfully into what was believed to be the left pulmonary vein, although the location was not certain after switching the guidewires out for the sheath.Resistance was felt while trying to cross into the mitral valve.The sheath was retracted and advanced again, and it was possible it perforated the left atrial appendage at this time.The hd grid did not move where expected, and it became clear during mapping that it was in the pericardial space.An effusion was identified via transthoracic echocardiography, a pericardiocentesis was performed on the table and the patient was prepped for surgery to repair the perforation from the sheath.The bleeding later stabilized, and no surgery was needed.The patient died overnight from pulseless electrical activity.There were no performance issues with any abbott device.
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Event Description
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Related mfr number: 3005334138-2020-00589.
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Search Alerts/Recalls
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