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It was reported that during a cryo ablation procedure, physical damage was observed as the balloon catheter's tip and shaft was kinked, preventing the mapping catheter from passing through.The physician attempted to straighten the kink by pulling back on the blue pull wire "stretch" lever on the handle, which temporarily straightened the kink, but the kink returned upon release.The balloon catheter was replaced which resolved the issue.The case was completed with cryo.No patient complications have been reported as a result of this event.
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Product event summary: the afapro28 balloon catheter with lot number 18242 was returned and analyzed.No anomalies were identified during external visual inspection of the balloon, shaft, and handle segments.The catheter smart chip data was reviewed.Data indicated the catheter was never used (no application performed).The catheter was recognized and passed the electrical integrity verifications and performance test.The catheter completed the inflation, ablation, and thawing phases with no console system notices generated.No performance issues were identified.Pressure and flow were in range and temperature curve had no oscillation or overshoot.However, during inflation, a kinked guidewire lumen was observed inside the balloon segment.Pressure testing and inspection of sub-components of the balloon, handle, and shaft segments was performed.During inspection of the shaft segment, a guide wire lumen kink/twist was observed 1.25 inches proximal to the catheter tip.Pressure testing did not identify any leakage from the kink.In conclusi on, the balloon catheter failed the returned product inspection due to a kink/twist observed on the guide wire lumen.Medtronic submits this report to comply with fda regulations 21 cfr parts 4 and 803.Medtronic has made reasonable efforts to provide as much relevant information as is available to the company as of the submission date of this report.This report does not constitute an admission or a conclusion by fda, medtronic, or its employees that the device, medtronic, or its employee caused or contributed to the event described in the report.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.Medtronic will submit a supplemental report if additional relevant information becomes known.
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