BIOSENSE WEBSTER INC OPTRELL, 48 ELECTRODES, D-F; CATHETER, ELECTRODE RECORDING, OR PROBE, ELECTRODE RECORDING
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Model Number D140901 |
Device Problems
Display or Visual Feedback Problem (1184); Contamination /Decontamination Problem (2895)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 09/16/2022 |
Event Type
malfunction
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Event Description
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A patient underwent an ablation procedure with a optrell catheter for which biosense webster¿s product analysis lab identified during microscopic analysis that electrodes a1 and a2 were lightly lifted and foreign material was found under the electrodes.The finding was identified on (b)(6) 2022.It was reported that the splines of the optrell catheter were disappearing on the carto 3 system.The medical team tried disconnecting the ultrasound catheter with no resolution.They turned off the trueref electrode with no resolution.They reset the visualization matrix and the issue still remained.After replacing the catheter cable, the issue persisted.There was also issues with visualization so the physician requested to switch to the octaray catheter.No other issues were reported using the octaray catheter.No patient consequences were reported.Visualization issue is not mdr-reportable.Foreign material is mdr-reportable.
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Manufacturer Narrative
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The product investigation was completed.Device evaluation details: visual analysis revealed no damage or anomalies on the device.A magnetic sensor functionality test was performed and the device was recognized on the system; however, the device could not be visualized but the noise was observed on electrodes a1 and a2.A microscopic examination reveals that this electrode was lifted by a polyurethane-based material related to the introduced causing an open circuit on the tip area.This open circuit could be related to the improper visualization of the device.A manufacturing record evaluation was performed for the finished device 30842502m number, and no internal actions related to the reported complaint condition were identified.The issue reported by the customer was confirmed.It should be noted that product failure is multifactorial.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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Manufacturer Narrative
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On 20-jun-2023, bwi received additional information indicating that the abbott esl 0/1 short sheath was used during the procedure.It has been added to the concomitant products section.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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