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It was reported that on (b)(6) 2026, an 8-6mm amplatzer duct occluder was chosen for implant using a 6f amplatzer torqvue delivery system for patent ductus arteriosus (pda) closure.Prior to use, the delivery sheath was inspected for damage, kinks, or obstructions, and the device was flushed and prepared according to the instructions for use (ifu).During the procedure, a cobra-head configuration of the occluder was observed.The occluder and delivery system were flushed and immersed in saline solution three times.Following each flush, the occluder was recaptured into the delivery system and redeployed in an attempt to restore the device configuration.Despite these efforts, the device did not return to its original configuration.The deformed device was never released from the delivery cable while inside the patient.It was reported that there was no angulation or kink in the delivery system and no interaction with cardiac structures during deployment.On the final recapture attempt, the tip of the torqvue delivery system was damaged, rendering the delivery system unusable.As a result, both the amplatzer duct occluder and the 6f amplatzer torqvue delivery system were removed and replaced.An 8-6 mm amplatzer duct occluder (lot: 10716983) and a 6f amplatzer torqvue delivery system (lot: 11159205) were subsequently used to successfully complete the procedure.The patient remained hemodynamically stable throughout the procedure.There was no clinically significant delay in the procedure and no adverse patient effects were reported.
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