| Model Number |
407439 |
| Medical Device Problem Code |
Material Puncture/Hole (1504)
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| Health Effect - Clinical Code |
No Clinical Signs, Symptoms or Conditions (4582)
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| Date of Event |
07/23/2025
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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 pulmonary vein isolation procedure, a sheath puncture occurred.The sheath was placed into the right atrium for transseptal puncture.The stylet of the brk needle was advanced through the dilator with some resistance noted.A few attempts were done unsuccessfully, and the stylet would not advance through the dilator.Friction was noted on the outside of the dilator and when flushed and a hole was noted in the dilator.The sheath was exchanged and the procedure continued with no consequences to the patient.
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Additional Manufacturer Narrative
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Additional information: d9, g3, h2, h3, h6.One 8.5f swartz braided introducer sheath and dilator were received for evaluation.Visual inspection revealed the dilator had been perforated proximal to the distal tip; the sheath was not punctured.The dilator and sheath were flushed with fluid and the dilator was inserted into the sheath; no resistance or anomalies were noted.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 cause of the reported dilator perforation could not be conclusively determined.
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Search Alerts/Recalls
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