One bipolar pacing catheter with detached monoject 1.3 cc limited volume syringe was returned for evaluation.Continuity testing found that a short condition occurred in the y-adaptor between the proximal and distal leadwires.No open or short condition was observed in the leadwires between distal of the y-adaptor and the electrodes.No visible damage or inconsistency was observed from the proximal and distal leadwire extension tubes.No visible damage to the catheter body, balloon, windings, or returned syringe was observed.The balloon inflated clear and concentric and remained inflated for 5minutes without leakage.Balloon inflation test was performed using returned syringe with 1.3 cc air by holding the balloon under water.Visual examinations were performed under microscope at 20x magnification and with the unaided eyes.A device history record review was completed and documented that device met all specifications upon distribution.Customer report of pacing issue was confirmed.An investigation has been initiated to consider any potential manufacturing issues that may have contributed to this event and implement any necessary corrective actions.Swan-ganz pacing thermodilution (td) catheters serve as diagnostic and therapeutic tools in the management of critically ill patients.There are multiple failure modes that may require the exchange of a pacing catheter.Since proper functioning of the pacing catheter depends on the electrical continuity of its electrodes and internal wires, care should be exercised when handling the catheter.Stretching, kinking, or forceful wiping of the catheter may result in damage.After stable pacing has been confirmed, the proximal end of the catheter should be secured to the insertion site to prevent undue movement that could result in tip dislodgment and loss of capture, or catheter migration.Care should be taken not to kink the catheter body when securing it.In this complaint, it could not be determined if procedural factors or device handling may have contributed to the reported event.Complaint histories for all reported events are reviewed against trending control limits on a monthly basis, and any excursions above the control limits are assessed and documented as part of this monthly review.
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