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It was reported that a patient underwent a cardiac ablation procedure with an thermocool smarttouch sf and a catheter sensor error was noted.When the cable was switched out, the issue was not resolved.When the catheter was replaced, the issue resolved.There was no patient consequence.This event was originally assessed as not mdr reportable.The device was returned to johnson & johnson medtech (j&j medtech) for evaluation.Following j&j medtech procedures, a visual inspection and screening test of the returned device were performed.Visual analysis revealed a hole in the surface of the pebax and reddish material inside.This finding is mdr reportable.
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The device was returned to johnson & johnson medtech (j&j medtech) for evaluation.Visual inspection and screening test of the returned device were performed following j&j medtech procedures.Visual analysis revealed a hole in the surface of the pebax and reddish material inside.A force test was performed, and the device was recognized and visualized correctly; however, error 106 displayed on screen.Due to this condition, the handle of the device was dissected, and resistance of the sensor pads on the printed circuit board (pcb) was measured and the results were found out of specifications.A dissection was performed right after at the tip area, and an open circuit was identified.In addition, further investigation of the peek housing section revealed that there was insufficient adhesive (polyurethane: pu) on the wires.A manufacturing record evaluation was performed for the finished device batch number, and no internal actions were identified.The sensor error reported by the customer was confirmed.The potential cause of the open circuit could not be determined.The root cause of the adhesive condition was traced to the manufacturing process.The potential cause of the pebax damage could be related to the manipulation of the device during the procedure; however, this cannot be conclusively determined.The pebax condition is unrelated to the reported event.The carto® 3 system instructions for use (ifu) contain the following information: the force sensor of the catheter is disconnected.If the problem persists, replace the catheter cable or the catheter.The instruction for use state: 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¿s quality process, all devices are manufactured, inspected, and released to approved specifications.Internal correction actions are being implemented to address manufacturing opportunities related to the force sensor issues.This report is being submitted pursuant to the provisions of 21 cfr, part 803.This report may be based on information which has not been investigated or verified prior to the required reporting date.This report does not reflect a conclusion by biosense webster, inc., or its employees that the report constitutes an admission that the product, biosense webster, inc., or its employees caused or contributed to the potential event described in this report.If information is obtained that was not available for the initial report, a follow-up report will be filed as appropriate.Manufacturer's reference number: (b)(4).
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