| Model Number |
H749394672000 |
| Medical Device Problem Codes |
Entrapment of Device (1212); Nonstandard Device (1420); Intermittent Loss of Power (4016)
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| Health Effect - Clinical Code |
No Clinical Signs, Symptoms or Conditions (4582)
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| Date of Event |
10/03/2025
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Type of Reportable Event
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Malfunction
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Event or Problem Description
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It was reported that the burr was stuck in the lesion.The target lesion was located in the moderately tortuous and severely calcified mid left anterior descending artery.A 2.00mm rotapro was selected for use and speed was set at 180,000 rpm.After 2 ablations, the device stalled and the burr became stuck within the lesion.The proximal part of the drive shaft was cut and the device was released by utilizing the guide catheter to press on the area where the burr was stuck.The burr and guidewire were then removed as one unit.The procedure was completed using another of the same device.There were no patient complications.
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Additional Manufacturer Narrative
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Device evaluated by manufacturer.The complaint device was received for product analysis.A visual inspection of the device found that the distal end of the coil was stretched, kinked and detached.The returned wire was able to be removed from the rotapro with no resistance or issue proximally as the distal end of the wire failed to return.The wire was fed into the returned guide catheter to confirm the burr was not lodged within the device.The wire was able to be inserted and failed to encounter any resistance.The burr to the rotapro failed to return for further analysis.After destructive testing was performed, it was found that the drive shaft (turbine) was corroded, indicating the presence of dried saline within the device.During device-to-device interaction test, when the rotapro advancer was connected to the rotapro console and the ablation button was pressed, the device stalled and did not run.No other issues were identified during the product analysis.
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Event or Problem Description
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It was reported that the burr was stuck in the lesion.The target lesion was located in the moderately tortuous and severely calcified mid left anterior descending artery.A 2.00mm rotapro was selected for use and speed was set at 180,000 rpm.After 2 ablations, the device stalled and the burr became stuck within the lesion.The proximal part of the drive shaft was cut and the device was released by utilizing the guide catheter to press on the area where the burr was stuck.The burr and guidewire were then removed as one unit.The procedure was completed using another of the same device.There were no patient complications, and patient is stable post procedure.
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Search Alerts/Recalls
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