MAUDE Adverse Event Report: BIOSENSE WEBSTER INC CARTO 3 SYSTEM; COMPUTER, DIAGNOSTIC, PROGRAMMABLE

Catalog Number	FG540000
Medical Device Problem Code	Display or Visual Feedback Problem (1184)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	01/12/2026
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The hardware investigation has begun but it has not been completed at this time.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).
Event or Problem Description
It was reported that a patient underwent an atrioventricular nodal reentrant tachycardia ablation procedure with a carto 3 system and near the end of the procedure a map shift was noted.No error was noted on the carto 3 system.A quadripolar was at the same place of the right atrium (tagged his) since the beginning of the procedure; however, there was a 10mm downward map shift.There was no patient movement, coughing, arm repositioning, or cardioversion prior to noting the map shift.There were no changes to the patient's breathing as well.The procedure was continued to completion since the medical team was finished ablating by the time they noticed the issue.No patient consequences were reported.
Additional Manufacturer Narrative
On 1-mar-2026, the product investigation was completed.It was reported that a patient underwent an atrioventricular nodal reentrant tachycardia ablation procedure with a carto 3 system and near the end of the procedure a map shift was noted.No error was noted on the carto 3 system.A quadripolar was at the same place of the right atrium (tagged his) since the beginning of the procedure; however, there was a 10mm downward map shift.There was no patient movement, coughing, arm repositioning, or cardioversion prior to noting the map shift.There were no changes to the patient's breathing as well.The procedure was continued to completion since the medical team was finished ablating by the time they noticed the issue.No patient consequences were reported.Device investigation details: it was reported that during a procedure, a map shift occurred, right at the end of the procedure.There was no harm to the patient, and the medical team managed to finish the procedure with no issues as there was no need to ablate anymore.The manufacturer investigated the issue.The data was requested for investigation, but no data related to the issue was provided.As a result, it was not possible to reproduce or analyze the issue.The root cause of the reported map shift issue was not determined.A manufacturing record evaluation was performed for the carto 3 system # (b)(6), and no internal actions related to the reported complaint condition were identified.If additional information is received regarding this event, a supplemental 3500a report will be submitted to the fda.Manufacturer's reference number: (b)(4).

• Brand Name: CARTO 3 SYSTEM
• Common Device Name: COMPUTER, DIAGNOSTIC, PROGRAMMABLE
• Manufacturer (Section D): BIOSENSE WEBSTER INC; 31 technology drive, suite 200; irvine CA 92618
• Manufacturer (Section G): BIOSENSE WEBSTER (ISRAEL) LTD.; 4 hatnufah street; yokneam 20667 17; IS 2066717
• Manufacturer Contact: henry boden ; 31 technology dr; irvine, CA 92618 ; 9497882078
• MDR Report Key: 24272693
• Report Number: 2029046-2026-00391
• Device Sequence Number: 10022289
• Product Code: DQK
• UDI-Device Identifier: 10846835000870
• UDI-Public: (01)10846835000870(17)200907(10)3035665
• Combination Product (Y/N): N
• Initial Reporter Country: FR
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional,Company Representative
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 03/26/2026

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Catalogue Number: FG540000
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 01/20/2026
• Supplement Date Received by Manufacturer: 03/01/2026
• Initial Report FDA Received Date: 02/05/2026
• Supplement Report FDA Received Date: 03/26/2026
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 09/07/2020
• Is the Device Labeled for Single Use? (Y/N): No
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Reuse
• Patient Sequence Number: 1
• Patient Sex: Unknown