BIOSENSE WEBSTER, INC. (JUAREZ) PENTARAY NAV ECO HIGH-DENSITY MAPPING CATHETER; CATHETER, INTRACARDIAC MAPPING, HIGH-DENSITY ARRAY
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Model Number D-1282-11-S |
Device Problem
Noise, Audible (3273)
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Patient Problem
No Known Impact Or Consequence To Patient (2692)
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Event Date 03/18/2016 |
Event Type
malfunction
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Manufacturer Narrative
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No device was received for analysis at the time of submission of the initial 3500a.Since the product was not returned for analysis, no product failure analysis can be conducted and no determination of possible contributing factors could be made.As such, the investigation will be closed.If the complaint device is received in the future we will reopen the complaint and perform the investigation as appropriate.The device history record (dhr) for the lot number 17318633l has been reviewed and it was verified that device was manufactured in accordance with documented specifications and procedures.(b)(4).
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Event Description
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It was reported that a patient underwent a procedure with two pentaray navigational eco catheters.During connection of the pentaray navigational catheter, there was noise on the surface ecg and the intracardiac (ic) signals.They were unable to see the major signal (pqrs wave).The issue was observed on all channels on both the carto system and the recording system.They were unable to monitor the patient's heart rhythm.Therefore, they disconnected the 20 pole cable from the patient interface unit (piu).The noise disappeared so they replaced the cable.However, the issue continued.Therefore, they replaced the catheter twice and then the issue resolved.The procedure was completed with no patient consequence.Since the patient's heart rhythm was not visible to the operator, this event has been assessed as a reportable malfunction.Lack of monitoring of cardiac rhythm while devices are intracardiac might lead to undetected cardiac rhythm that can be life threatening.
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Manufacturer Narrative
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Originally the lot number was reported as 17318633l.However, the product was received with the lot number of 17073704l.On (b)(6) 2016 it was clarified that the correct lot number for this complaint is 17073704l.Therefore, the correct manufacturer date is (b)(6) 2014 and the correct expiration date is (b)(6) 2017.(b)(4).Manufacturer's ref.No: (b)(4) it was reported that a patient underwent a procedure with two pentaray navigational eco catheters.During connection of the pentaray navigational catheter, there was noise on the surface ecg and the intracardiac (ic) signals.They were unable to see the major signal (pqrs wave).The issue was observed on all channels on both the carto system and the recording system.They were unable to monitor the patient's heart rhythm.Therefore, they disconnected the 20 pole cable from the patient interface unit (piu).The noise disappeared so they replaced the cable.However, the issue continued.Therefore, they replaced the catheter twice and then the issue resolved.The procedure was completed with no patient consequence.Upon receipt, the catheter was visually inspected and it was found in normal conditions.The catheter was tested for electrical performance and current leakage was observed on electrodes.Further examination revealed that catheter internal connector pins were covered by corrosion and all the internal electrical components were found wet causing the electrical malfunction.An irrigation test was performed and the catheter failed; irrigation leakage was found.Further inspection revealed that the irrigation tubing was broken at the piston/shaft transition area contributing to the electrical current leakage failure.The device history record (dhr) was reviewed and no anomalies were found related to this complaint.In addition, the dhr review verifies that the device was manufactured in accordance with documented specification and procedures.The reported customer complaint has been verified.Based on available analysis results, it could not be identified whether the issue is related to an internal or an external cause.
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