The perfusion team inspected the cardioplegia line and found that the connector was securely attached and showed no obvious signs of damage at the time of inspection. However, an evident leak was present, and it was suspected that a small fracture within the table line had allowed to open the system to air, resulting in gradual venting when the aortic root vent flow was increased. The line was clamped prior to the connector and the bubble detector was put past the connector. Therefore the alarm did notify the team at the start of the event and the team took action to resolve the issue.

The line was retained following completion of the procedure and subsequently disinfected for further examination. On closer inspection, two small cracks were identified on the luer lock connector.

The incident has been reported to the manufacturer, and all required safety reporting processes and hospital incident reporting procedures have been completed. This was a good catch/near miss incident. The perfusion, surgical, and anaesthetic team communicated efficiently and in a calm and pragmatic approach the issue was resolved immediately with no harm done to the patient or any delays in the surgery.