Block h6: device code a06 captures the reportable event of loss of visualization inside the patient.Block h10 investigation summary: based on the available information, boston scientific corporation concludes that the probable cause for the reported event was determined to be manufacturing deficiency, which indicates that the failure mode is attributable to the manufacturing process.An investigation to address this problem is in progress.Device history record: a review of the manufacturing documentation for this device revealed that no anomalies or deviations related to the event occurred during manufacturing.Device technical analysis: the returned device was visually inspected.No evidence of any damage or defect was observed on the shaft or tip of the device.No fogging or condensation was noted on or in the lens.No issues with the device handle were noted.No damage to the umbilicus cable, connector, or its ports were observed.An image assessment was performed by connecting the device to an exalt controller; a live, clear image displayed.The scope was tested for articulation.When the scope was articulated right or up, the image was lost; the 5-dot screen displayed, and then the exalt splash screen.The reported event was confirmed.The scope was unplugged and plugged back in, the light emitting diode (led) was turned off from the controller, and articulation testing was repeated.The image was lost again, indicating a likely issue with the distal camera wires, unrelated to the led wires.The handle was opened to inspect internal components.No damage or defects to the printed circuit board assembly (pcba) or camera wires in the handle were observed.Using a digital multimeter in continuity mode, connections between the umbilicus and the handle were tested for resistance and continuity.All tests passed, including led continuity through the device, resistance between ground and the clock (scl) and data (sda) lines were approximately 600ohms, no short was found between power and ground.The camera wire at the distal tip was visualized under real-time x-ray and potential damage was found in the form of a kink, when viewed through the intact catheter.The camera cable was removed from the scope, and it was noted that the cable was kinked at approximately 10mm proximal to the distal tip.The wire was x-rayed again and a kink in the twin-ax camera wire was observed.The distal end of the camera cable was stripped to access the wires.The twin-ax camera cable was noted to be kinked, and potential damage to the external braid and/or lvds wires within was observed under x-ray imaging.The twin-ax wire was stripped and the low voltage differential signaling (lvds) wires inside were accessed; damage to the red lvds wire jacket was observed.Labeling review: a product labeling review identified that the device was used per the directions for use (dfu) / product label.There is no evidence that the device was misused, or that there was any issue with translation, wording, or graphics.Investigation conclusion: the probable cause for the reported event was determined to be manufacturing deficiency, which indicates that the failure mode is attributable to the manufacturing process.
|