| Catalog Number |
IAB-06840-U |
| Medical Device Problem Code |
Device Alarm System (1012)
|
| Health Effect - Clinical Code |
No Clinical Signs, Symptoms or Conditions (4582)
|
| Date of Event |
09/19/2025
|
|
Type of Reportable Event
|
Malfunction
|
|
Additional Manufacturer Narrative
|
|
(b)(4).
|
| |
|
Event or Problem Description
|
|
It was reported "after the catheter into the patient, the pump alarmed helium loss alarm.After the balloon was withdrawn, it was found that the front end of the balloon was folding".Additional information states that the iab catheter was replaced into the same insertion site.No patient injury or consequence reported.The patient's current condition is reported as "fine".
|
| |
|
Additional Manufacturer Narrative
|
|
(b)(4).Returned for investigation was a 40cc 7.5fr ultraflex intraaortic balloon catheter (iabc) without the original packaging box.The sample was returned in a cardboard box and was in a ziploc bag.Upon return, the one-way valve was tethered to the short driveline tubing.The bladder was fully unwrapped.A kink to the central lumen was noted approximately 36cm from the iabc distal tip.The central lumen was noted broken at approximately 5.1cm from the iab distal tip.No blood was noted on the exterior surfaces of the returned sample.No obvious blood was noted within the helium pathway; the catheter was likely cleaned prior to return.The one-way valve was tested and passed.A vacuum was pulled on the one-way valve, and it held for at least 1 minute according to quality system document.An attempt to aspirate and flush the iabc central lumen using a 60cc lab- nventory syringe was unable to be successfully completed.Upon aspiration, water was unable to be consistently pulled into the syringe.The attempt to flush resulted in bladder inflation, indicating a crossover leak between the iabc helium pathway and iabc central lumen.The iabc was leak tested in accordance with testing methods from manufacturing procedure.A leak was immediately detected from the iabc distal tip and iabc luer end.The lea k from the iabc distal tip and iabc luer end are consistent with the previously confirmed broken central lumen.The iabc was leak tested again with the iabc distal tip and luer end blocked off; no other leaks were detected.A lab inventory 0.025in guidewire was back loaded through iabc distal tip.The guidewire met resistance and could not advance at approximately 5.1cm from the iabc distal tip, which is the location of the previously noted broken central lumen.No blood or debris was noted.The guidewire was front loaded through the iabc luer.The guidewire met resistance and could not advance at approximately 77cm from the iabc luer; which is the location of the previously noted broken central lumen.No blood or debris was noted on the guidewire.A device history record (dhr) review was conducted for the lot number/serial number with no relevant findings.The device passed all manufacturing specifications prior to release.The reported complaint for "the pump alarmed helium loss alarm" is confirmed.During the investigation, the intraaortic balloon catheter (iabc) central lumen was noted broken near the iabc distal tip, which can cause the reported alarm.Based on a review of the device history record (dhr), the product met specification upon release; however, the specifications were not met during the complaint investigation due to the broken central lumen.The root cause of the complaint is undetermined.No further action required at this time.This will be monitored for any developing trends.
|
| |
|
Event or Problem Description
|
|
It was reported "after the catheter into the patient, the pump alarmed helium loss alarm.After the balloon was withdrawn, it was found that the front end of the balloon was folding".Additional information states that the iab catheter was replaced into the same insertion site.No patient injury or consequence reported.The patient's current condition is reported as "fine".
|
| |
|
Search Alerts/Recalls
|