Catalog Number D134805 |
Device Problem
Patient Device Interaction Problem (4001)
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Patient Problem
Cardiac Tamponade (2226)
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Event Date 03/01/2024 |
Event Type
Injury
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Manufacturer Narrative
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The biosense webster, inc.Product analysis lab received the device for evaluation.The analysis has begun but is not completed at this time.When the investigational analysis has been completed, a supplemental 3500a report will be submitted.This report is being submitted pursuant to the provisions of 21 cfr, part 803.This report may be based on information which has not been investigated or verified prior to the required reporting date.This report does not reflect a conclusion by biosense webster, inc., or its employees that the report constitutes an admission that the product, biosense webster, inc., or its employees caused or contributed to the potential event described in this report.If information is obtained that was not available for the initial report, a follow-up report will be filed as appropriate.Manufacturer's reference number: (b)(4).
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Event Description
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It was reported that a patient underwent an atrial fibrillation (afib) cardiac ablation procedure with a thermocool® smart touch® sf bi-directional navigation catheter and the patient experienced cardiac tamponade treated with a pericardiocentesis.Transseptal puncture performed with versacross needle and ablation was performed.It was reported towards the end of the procedure, after almost completing pulmonary vein isolation (pvi), with only a few ablations left to go, the patient became hypotensive.Using ultrasound, a pericardial effusion was noticed.A pericardiocentesis was performed and the patient stabilized.Approximately 800cc of fluid was drained.Correct settings utilized and no error messages on equipment during the procedure.
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Manufacturer Narrative
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It was reported that a patient underwent an atrial fibrillation (afib) cardiac ablation procedure with a thermocool® smart touch® sf bi-directional navigation catheter and the patient experienced cardiac tamponade treated with a pericardiocentesis.Transseptal puncture performed with versacross needle and ablation was performed.It was reported towards the end of the procedure, after almost completing pulmonary vein isolation (pvi), with only a few ablations left to go, the patient became hypotensive.Using ultrasound, a pericardial effusion was noticed.A pericardiocentesis was performed and the patient stabilized.Approximately 800cc of fluid was drained.Correct settings utilized and no error messages on equipment during the procedure.Device evaluation details: the device was returned to biosense webster (bwi) for evaluation.A visual inspection and revision of all features were performed following bwi procedures.Visual analysis revealed no damage or anomalies on the device.The device features were reviewed, and no issues were observed during the product investigation.A manufacturing record evaluation was performed for the finished device number lot 31226514l and no internal action related to the complaint was found during the review.No malfunction was observed during the product analysis.The root cause of the adverse event remains unknown.There may have been other circumstances or issues that occurred during the use of the device that could not be replicated during the analysis.The instruction for use (ifu) states that careful catheter manipulation must be performed to avoid cardiac damage, perforation or tamponade.As part of biosense webster¿s quality process, all devices are manufactured, inspected, and released to approved specifications.If additional information is received regarding this event, a supplemental 3500a report will be submitted to the fda.Manufacturer's reference number: (b)(4).
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Search Alerts/Recalls
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