One bipolar pacing catheter with attached monoject 1.3 cc limited volume syringe was returned for evaluation.Clotted blood was observed on the catheter.As received, the catheter tip was found to be bent.Visual examination also found that there was a gap between the proximal electrode and catheter body due to a slipped proximal bushing; however, the balloon inflated clear and concentric with 1.3 cc air and remained inflated for 5 minutes without leakage.Continuity testing confirmed full open conditions of the proximal circuit and the distal circuit.A cut down of the catheter body was performed just proximal of the proximal electrode to expose the pacing leadwires.The distal lead wire was found to be detached around the solder joint and the proximal lead wire was found to be broken at the 1.1 cm area from the catheter tip.No other visible damage or inconsistency was observed from the balloon, windings or returned syringe.Balloon inflation test was performed using returned syringe with 1.3 cc air by holding the balloon under water.Visual examination was performed under microscope at 20x magnification and with the unaided eye.Customer report of pacing issue was confirmed.An investigation has been initiated to consider any potential manufacturing factors that may have contributed to this complaint 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.Reference mdr 2015691-2019-03046.
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