During an ablation procedure, the catheter spline was torn, exposing the nitinol frame.As the catheter was attempted to be withdrawn from the right inferior pulmonary vein (ripv) it didn't move.The sheath was unable to be advanced over the catheter so the sheath and catheter were withdrawn together.As the catheter was withdrawn from the ripv, the sheath pulled back into the right atrium and the catheter became entangled in the fossa ovalis.A fluoroscopic image was reviewed, revealing that the positioning of the electrodes wasn't as expected.After several minutes of manipulation, the catheter withdrew from the left atrium and finally into the sheath.The sheath was then removed and confirmed a shifted electrode and torn spline.There were no adverse consequences to the patient.
|