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It was reported that for a pulse field ablation (pfa) procedure to treat a persistent atrial fibrillation a farawave ablation catheter was selected for use.The catheter was prepared with no issues noted.No spline bunching, fluid leakage, or guidewire resistance was observed during preparation.After six applications were delivered in basket configuration within the left superior pulmonary vein, the physician observed excessive fluid on the patient drape and catheter handle.No air was observed entering the patient.The catheter was removed from the patient, and upon inverting the handle, fluid was observed exiting from the orange slider switch.The catheter was replaced and the procedure was successfully completed using the replacement device.No patient complications occurred, and the patient remained stable throughout the procedure.
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D2a: common device name: percutaneous cardiac ablation catheter for treatment of atrial fibrillation with irreversible electroporation; reported here as the common device name exceeded the character limit for designated field.Investigation summary:
with all the available information, boston scientific concludes the reported leak was confirmed.Laboratory analysis of the returned farawave found that during the flow testing, a leak was confirmed at the flush port region.Subsequent dissection and microscopy revealed that the flush port was damaged and separated from the flush tubing, which caused the leak.Device history record review:
the manufacturing batch record review confirmed that the device met all material, assembly, and performance specifications.Device technical analysis:
upon device return and inspection, no outer abnormalities were observed on the main catheter body.Functional testing was preformed and a guidewire was successfully inserted through the catheter.Deployment was tested multiple times, and deployment to basket and flower was functional with no unusual resistance noted.Flow test found that flushing through the irrigation port was tested.During irrigation, a leak was observed in the luer of the catheter.The catheter was dissected for further inspection of the leak source.It was revealed that the flush port was damaged and partially separated from the flush tubing, which created a leak consistent.Under microscope and with uv light, separation and discontinuity between the flush port and the flush tubing were observed.Labeling review:
based on the information provided, there is no evidence that the device was used in a manner inconsistent with the labelled indications/instructions for use.Investigation conclusion:
based on all the available information, the cause of the reported leak was likely attributed to the device design.During the flow testing, a leak was confirmed at the flush port region.Subsequent dissection and microscopy revealed that the flush port was damaged and separated from the flush tubing, which caused the leak.
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