FDA Adverse Event Malfunction Summary report: N

CATHETER, RECORDING, ELECTRODE, REPROCESSED

MDR report key: 23554775 · Received November 13, 2025

Report

Report Number
MW5178911
Event Type
Malfunction
Date Received
November 13, 2025
Date of Event
October 21, 2025
Report Date
November 12, 2025
Manufacturer
SURGICAL INSTRUMENT SERVICE AND SAVINGS INC. / MEDLINE RENEWAL
Product Code
NLH
Product Problem
Yes
Report Source
Voluntary report
Reporter Location
MN, US
Reporter Occupation
UNKNOWN
Health Professional
*

Narratives

Description of Event or Problem · 0

DURING AN ATRIAL FIBRILLATION PROCEDURE FOR PVI, A PERICARDIAL EFFUSION OCCURRED AND THE PATIENT EXPIRED. THE DIAGNOSTIC CATHETERS WERE PLACED IN THE HIS AND RIGHT ATRIUM CORONARY SINUS POSITION AND TRANSSEPTAL PUNCTURE WAS DONE SUCCESSFULLY. AFTERWARDS THE MAPPING CATHETER WAS PLACED IN THE LEFT ATRIUM AND STEERING WAS NOTED TO BE DIFFICULT. A CARDIAC ULTRASOUND SHOWED A PERICARDIAL EFFUSION IN THE PATIENT. A PERICARDIOCENTESIS WAS THEN PERFORMED. DURING THE NEXT HOUR APPROXIMATELY 1.5 LITERS BLOOD WERE WITHDRAWN FROM THE PERICARDIUM. THE EMERGENCY TEAM ENTERED THE ROOM AND SOON THE PATIENT SHOWED ASYSTOLE. THE EMERGENCY TEAM BEGAN WITH CPR, HOWEVER THE PATIENT DID NOT RECOVER AND EXPIRED IN THE CATH LAB. THE PHYSICIAN STATED THAT THERE WERE NO PRODUCT PERFORMANCE ISSUES WITH ANY (B)(6) PRODUCTS USED IN THIS CASE. ACCORDING TO THE PHYSICIAN THE CAUSE OF THE EFFUSION AND OF THE PATIENT'S DEATH ARE NOT CLEARLY KNOWN BUT THAT THE PERFORATION COULD HAVE POTENTIALLY OCCURRED AFTER TRANSSEPTAL PUNCTURE ON THE LEFT ATRIUM ROOF. "THIS REPORT REFLECTS INFORMATION RECEIVED BY FDA IN THE FORM OF A NOTIFICATION PER 803.22 (B)(2)".

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
228188 CATHETER, RECORDING, ELECTRODE, REPROCESSED CATHETER, RECORDING, ELECTRODE, REPROCESSED NLH SURGICAL INSTRUMENT SERVICE AND SAVINGS INC. / MEDLINE RENEWAL

Patients

Seq Age Sex Outcome Treatment
1 NA Unknown