| Catalog Number |
AI-07155-KS |
| Medical Device Problem Code |
Material Integrity Problem (2978)
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| Health Effect - Clinical Code |
Insufficient Information (4580)
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| Date of Event |
01/28/2026
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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 " the biggest problem is the tuohy that is supposed to tighten onto the pacing catheter does not get tight enough to keep the catheter in place, which allows the catheter to move with minimal effort.Blood backup into the swandom almost immediately after placement and continued after checking the tuohy was as tight as possible.Once a pressure bag was hooked up to the one patient, the entire swandom filled with fluid (it was described as looking like a long water balloon).The patient did fine until the next day; we got lucky that the catheter didn't move enough that it stopped capturing".
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Additional Manufacturer Narrative
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(b)(4).
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Event or Problem Description
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It was reported " the biggest problem is the tuohy that is supposed to tighten onto the pacing catheter does not get tight enough to keep the catheter in place, which allows the catheter to move with minimal effort.Blood backup into the swandom almost immediately after placement and continued after checking the tuohy was as tight as possible.Once a pressure bag was hooked up to the one patient, the entire swandom filled with fluid (it was described as looking like a long water balloon).The patient did fine until the next day; we got lucky that the catheter didn't move enough that it stopped capturing".
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Additional Manufacturer Narrative
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(b)(4).The product was not returned for investigation.The customer submitted video was reviewed and shows an unused device which is deemed as a representative sample.In the video, the user fully tightened the tuohy borst adapter while the catheter was fully inserted; however, the catheter was moving freely and did not lock in position, which is consistent with the reported event.A device history record (dhr) review was conducted for the lot number with no relevant findings.The device passed all manufacturing specifications prior to release.The reported complaint that the "locking mechanism, even when fully tightened, does not secure the pacing wire in place" is confirmed based on the customer video provided with the complaint report.In the video, the user fully tightened the tuohy borst adapter while the catheter was fully inserted; however, the catheter was moving freely and did not lock in position.The device noted in the video was an unused device which is deemed as a representative sample.The product was not returned for investigation.Based on a review of the device history record (dhr), the product met specification upon release; however, the specifications were not met during the complaint investigation due to the defective tuohy borst adapter.The root cause of the complaint is undetermined.No further action required at this time.The reported complaint will be monitored for any developing trends.
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Search Alerts/Recalls
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