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It was reported that a patient underwent an atrial fibrillation ablation procedure with a qdot micro¿ catheter and post procedure the bwi product analysis lab identified a separation between the pebax and third electrode.During the procedure, the qdot catheter had high force readings observed on the carto 3 system during the procedure.The force would rise up to 50-60 grams when the medical team would come on ablation.They were able to zero the qdot catheter.The catheter cable was replaced without resolution.The catheter was replaced, the issue resolved.The procedure was continued.No patient consequences were reported.
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The product investigation was completed.Device evaluation details: the device was returned to johnson & johnson medtech (j&j) for evaluation.A visual inspection and screening test of the returned device was performed following johnson & johnson medtech procedures.Visual analysis revealed a separation between pebax and the third electrode, and a reddish material inside it.The device was connected to the carto 3 system, and no errors were observed.The force feature of the device was evaluated and the force values and the vector were observed within specifications.No force issues were observed.A manufacturing record evaluation was performed for the finished device number lot 31448364l and no internal action related to the complaint was found during the review.The reddish material inside the pebax could be also related to the force issue reported by the customer; therefore, the customer complaint was confirmed.The potential cause of the pebax damage could be related to the manufacturing process.The instructions for use (ifu) states: when cleaning the tip electrode, be careful not to twist the tip electrode with respect to the catheter shaft; twisting may damage the tip electrode bond and loosen the tip electrode, or may damage the contact force sensor.In addition, in order to prevent damage to the catheter tip, use the insertion tube supplied with the catheter to advance or retract the catheter through the hemostasis valve of the sheath.After insertion, slide the insertion tube back toward the handle.As part of johnson & johnson medtech quality process, all devices are manufactured, inspected, and released to approved specifications.This product issue will be addressed through johnson & johnson medtech quality system.Internal actions are being implemented to address manufacturing opportunities related to the force sensor sleeve insolation to prevent fluids to get inside into the device.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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