BIOSENSE WEBSTER INC DECANAV ELECTROPHYSIOLOGY CATHETER; CATHETER, ELECTRODE RECORDING, OR PROBE, ELECTRODE RECORDING
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Model Number R7D282CT |
Device Problem
Patient Device Interaction Problem (4001)
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Patient Problem
Vascular Dissection (3160)
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Event Date 01/06/2022 |
Event Type
Injury
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Event Description
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It was reported that a male patient underwent a cardiac ablation procedure with a thermocool® smart touch® sf bi-directional navigation catheter (stsf) and a decanav electrophysiology catheter (decanav).And suffered vascular dissection requiring surgical intervention and prolonged hospitalization.It was reported that ablation was discontinued because aortic dissection was suspected.This occurred after 120 minutes since they entered, awhile after the catheter was delivered to the left ventricle via the aortic approach.The procedure was discontinued as a precaution.Since the patient complained of back pain during surgery, dissection was suspected.Echography and coronary angiography did not lead to a definitive diagnosis.The procedure was discontinued as a precaution.After discharge, a ct scan was performed, and the patient was diagnosed with aortic dissection.The physician commented that ¿i may have created a separation when we brought the catheter to the lv." additional information was received on 17-jan-2022.It was reported that the patient was under observation during hospitalization.As far as the treatment for aortic dissection, the patient underwent surgical operation.The biosense webster, inc.(bwi) products that come in direct contact with the vessel where the aortic dissection occurred were the thermocool® smart touch® sf bi-directional navigation catheter (stsf) and the decanav electrophysiology catheter (decanav).Additional information was received on 25-jan-2022.It was reported that the adverse event occurred on (b)(6) 2022.This adverse event was discovered during use of biosense webster products.The physician¿s opinion on the cause of this adverse event is that it is procedure related.The patient outcome of the adverse event is unchanged.
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Manufacturer Narrative
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Initial reporter phone: (b)(6).If additional information is received regarding this event, a supplemental 3500a report will be submitted to the fda.Biosense webster manufacturer's reference number (b)(4) has two reports: mfr # 2029046-2022-00192 for product code r7d282ct (decanav electrophysiology catheter).Mfr # 2029046-2022-00191 for product code d134805 (thermocool® smart touch® sf bi-directional navigation catheter).
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Manufacturer Narrative
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The device evaluation was completed on 02-mar-2022.It was reported that a male patient underwent a cardiac ablation procedure with a thermocool® smart touch® sf bi-directional navigation catheter (stsf) and a decanav electrophysiology catheter (decanav) and suffered vascular dissection requiring surgical intervention and prolonged hospitalization.It was reported that ablation was discontinued because aortic dissection was suspected.This occurred after 120 minutes since they entered, awhile after the catheter was delivered to the left ventricle via the aortic approach.The procedure was discontinued as a precaution.Since the patient complained of back pain during surgery, dissection was suspected.Echography and coronary angiography did not lead to a definitive diagnosis.The procedure was discontinued as a precaution.After discharge, a ct scan was performed, and the patient was diagnosed with aortic dissection.The physician commented that ¿i may have created a separation when we brought the catheter to the lv." device evaluation details: the product was returned to biosense webster inc.(bwi) for evaluation.Bwi conducted a visual inspection and an evaluation of all features of the catheter.Visual analysis of the returned sample revealed that no damage or anomalies were observed on the decanav electrophysiology catheter.The magnetic sensor functionality was performed in accordance with bwi procedures.The catheter was visualized and recognized, and no errors were observed.An electrical test was performed on the catheter, and it was found within specifications.No electrical malfunction was observed.In addition, the product was deflecting correctly.No malfunctions were observed during the product analysis.A manufacturing record evaluation was performed for the finished device 30627781m number, and no internal actions related to the reported complaint condition were identified.As part of bwi¿s quality process, all devices are manufactured, inspected, and released to approved specifications.No malfunction was observed during the product analysis.The instructions for use (ifu) states that careful catheter manipulation must be performed to avoid cardiac damage, perforation, or tamponade.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.If additional information is received regarding this event, a supplemental 3500a report will be submitted to the fda.Biosense webster manufacturer's reference number pc-001049637 has two reports: (1) mfr # 2029046-2022-00192 for product code r7d282ct (decanav electrophysiology catheter) (2) mfr # 2029046-2022-00191 for product code d134805 (thermocool® smart touch® sf bi-directional navigation catheter).
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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.If additional information is received regarding this event, a supplemental 3500a report will be submitted to the fda.Biosense webster manufacturer's reference number (b)(4) has two reports: (1) mfr # 2029046-2022-00192 for product code r7d282ct (decanav electrophysiology catheter) (2) mfr # 2029046-2022-00191 for product code d134805 (thermocool® smart touch® sf bi-directional navigation catheter).
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