| Model Number |
406849 |
| Medical Device Problem Codes |
Material Puncture/Hole (1504); Improper or Incorrect Procedure or Method (2017)
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| Health Effect - Clinical Code |
No Clinical Signs, Symptoms or Conditions (4582)
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| Date of Event |
06/14/2025
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Type of Reportable Event
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Malfunction
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Event or Problem Description
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During a supraventricular tachycardia procedure, the sheath was punctured when attempting to perform transseptal puncture.Puncture was attempted using a sheath, interatrial septum heartbeat, and needle.Repeated attempts did not break through the interatrial septum.It was found that the heart rate was a distorted and the sheath had a puncture.The needle was exchanged, and the interatrial septum was then crossed.The procedure was successfully completed with no adverse patient consequences.
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Additional Manufacturer Narrative
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One 8.5f fast-cath introducer sheath and dilator were received for evaluation.The dilator had been perforated proximal to the distal tip.A needle/stylet assembly from current inventory was inserted and advanced through the dilator/sheath assembly; however, the needle could not advance past the location of the perforation.The device history record was reviewed to ensure that each manufacturing and inspection operation was performed.The swartz/fast-cath transseptal guiding introducer instructions for use (ifu) states, ¿during insertion, always use the stylet to facilitate needle passage through the dilator/sheath assembly.Failure to use the stylet may inhibit advancement of the needle and may result in inadvertent needle puncture of the dilator/sheath assembly or skiving of material from the inner surface of the dilator.¿ the cause of the perforation is consistent with not following the instructions for use.
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Search Alerts/Recalls
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