MAUDE Adverse Event Report: BOSTON SCIENTIFIC CORPORATION DYNAMIC XT; CATHETER, ELECTRODE RECORDING, OR PROBE, ELECTRODE RECORDING

Model Number 86706

Device Problem Adverse Event Without Identified Device or Use Problem (2993)

Patient Problems Air Embolism (1697); Chest Pain (1776); Fistula (1862)

Event Date 06/21/2022

Event Type  Death  

Manufacturer Narrative

It was indicated that the device will not be returned for evaluation; therefore, a failure analysis of the complaint device could not be completed.

Event Description

Patient death.A patient underwent an ablation procedure involving a intellamap orion catheter, intellanav stablepoint catheter, a dynamic xt catheter, on (b)(6) 2022.The procedure was completed successfully with no complications.One week post procedure, the patient presented to the emergency room with chest pain.No medical interventions were performed and the patient was discharged.A week later the patient went to the emergency room again and was hospitalized in intensive care.The patient was diagnosed with an esophageal atrio fistula and air embolism.The patient expired on (b)(6) 2022.No official cause of death was reported.

Event Description

Patient death.A patient underwent an ablation procedure involving a intellamap orion catheter, intellanav stablepoint catheter, a dynamic xt catheter, on (b)(6) 2022.The procedure was completed successfully with no complications.One week post procedure, the patient presented to the emergency room with chest pain.No medical interventions were performed and the patient was discharged.A week later the patient went to the emergency room again and was hospitalized in intensive care.The patient was diagnosed with an esophageal atrio fistula and air embolism.The patient expired on (b)(6) 2022.No official cause of death was reported.Additional information received indicated that the patient was receiving ablation treatment for persistent atrial fibrillation.

Manufacturer Narrative

It was indicated that the device will not be returned for evaluation; therefore, a failure analysis of the complaint device could not be completed.Additional information was added to b5 and b7.

• Brand Name: DYNAMIC XT
• Type of Device: CATHETER, ELECTRODE RECORDING, OR PROBE, ELECTRODE RECORDING
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; 300 boston scientific way; marlborough MA 01752
• Manufacturer (Section G): BOSTON SCIENTIFIC DE COSTA RICA S.R.L.; 302 parkway, global park; la aurora, heredia ; CS
• Manufacturer Contact: timothy degroot ; 4100 hamline avenue north; dc a330; saint paul, MN 55112 ; 6515826168
• MDR Report Key: 15076497
• MDR Text Key: 296324111
• Report Number: 2134265-2022-08062
• Device Sequence Number: 1
• Product Code: DRF
• Combination Product (y/n): N
• Reporter Country Code: FR
• PMA/PMN Number: K921872
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Foreign,Health Professional,Company Representative
• Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date: 09/15/2022

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Health Professional
• Device Model Number: 86706
• Device Catalogue Number: 86706
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Initial Date Manufacturer Received: 06/22/2022
• Initial Date FDA Received: 07/21/2022
• Supplement Dates Manufacturer Received: 08/17/2022
• Supplement Dates FDA Received: 09/15/2022
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Is the Device Single Use?: Yes
• Type of Device Usage: Unknown
• Patient Sequence Number: 1
• Treatment: INTELLAMAP ORION CATHETER, MAPPING; INTELLAMAP ORION CATHETER, MAPPING; INTELLANAV STABLEPOINT CATHETER, ABLATION; INTELLANAV STABLEPOINT CATHETER, ABLATION
• Patient Outcome(s): Death