BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    QDOT MICRO¿ CATHETER

    MDR report key: 22186258 · Received June 11, 2025

    Report

    Report Number
    2029046-2025-01896
    Event Type
    Malfunction
    Date Received
    June 11, 2025
    Date of Event
    April 14, 2025
    Report Date
    July 30, 2025
    Manufacturer
    BIOSENSE WEBSTER INC
    Product Code
    OAE
    UDI-DI
    10846835016758
    PMA / PMN Number
    P210027
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    GM
    Reporter Occupation
    OTHER
    Health Professional
    N

    Narratives

    Additional Manufacturer Narrative · 0

    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).

    Additional Manufacturer Narrative · 0

    ON 4-JUL-2025, THE BWI PRODUCT ANALYSIS LAB RECEIVED THE DEVICE FOR EVALUATION. THE PRODUCT INVESTIGATION WAS SUBSEQUENTLY COMPLETED. IT WAS REPORTED THAT A PATIENT UNDERWENT A CARDIAC ABLATION PROCEDURE WITH A QDOT MICRO¿ CATHETER AND AFTER ABLATION, THE DOCTOR NOTICED SOME CHARRING ABOVE THE ELECTRODE. THE EXACT LOCATION OF THE CHARRING WAS BETWEEN TIP ELECTRODE AND ELECTRODE 2 AT THE PLASTIC RING SEPARATING THE ELECTRODES. NO ERROR MESSAGES, TEMPERATURE ISSUES, OR FLOW ISSUES PRECEDED THE CHAR ISSUE. THERE WAS NO EXCESSIVE FORCE OR ABLATION TIMES USED. THE PHYSICIAN AIMED FOR 5-15 GRAMS OF FORCE. DEVICE EVALUATION DETAILS: THE DEVICE WAS RETURNED TO JOHNSON & JOHNSON MEDTECH (J&J) FOR EVALUATION. A VISUAL INSPECTION EVALUATION, TEMPERATURE, IMPEDANCE AND IRRIGATION TEST OF THE RETURNED DEVICE WAS PERFORMED FOLLOWING J&J MEDTECH PROCEDURES. VISUAL INSPECTION OF THE RETURNED SAMPLE REVEALED NO CHAR RESIDUES IN THE ELECTRODES. A TEMPERATURE AND IMPEDANCE TEST IN QMODE AND QMODE+ WAS PERFORMED AND NO TEMPERATURE OR IMPEDANCE ISSUES WERE OBSERVED. ALSO, AN IRRIGATION TEST WAS PERFORMED AND NO OCCLUSIONS WERE DETECTED. A MANUFACTURING RECORD EVALUATION WAS PERFORMED FOR THE FINISHED DEVICE 31416942L NUMBER, AND NO INTERNAL ACTIONS RELATED TO THE REPORTED COMPLAINT CONDITION WERE IDENTIFIED. THE CHAR / THROMBUS ISSUE REPORTED BY THE CUSTOMER COULD NOT BE CONFIRMED DURING THE PRODUCT INVESTIGATION; OTHER ISSUES OR CIRCUMSTANCES MAY HAVE OCCURRED DURING THE USAGE OF THE DEVICE THAT COMPROMISED ITS PERFORMANCE. THE INSTRUCTIONS FOR USE (IFU) CONTAIN THE FOLLOWING INFORMATION: DO NOT USE THE TEMPERATURE SENSOR TO MONITOR TISSUE TEMPERATURE OR TO GUIDE POWER TITRATION DURING ABLATION. THE TEMPERATURE SENSOR LOCATED WITHIN THE TIP SECTION OF THE CATHETER DOES NOT REFLECT EITHER ELECTRODE-TISSUE INTERFACE OR TISSUE TEMPERATURE DUE TO THE COOLING EFFECTS OF THE SALINE IRRIGATION OF THE ELECTRODE. THE TEMPERATURE DISPLAYED ON THE RF (RADIOFREQUENCY) GENERATOR IS THE TEMPERATURE OF THE COOLED ELECTRODE, NOT TISSUE TEMPERATURE. THE TEMPERATURE SENSOR IS USED TO VERIFY THAT THE IRRIGATION FLOW RATE IS ADEQUATE. BEFORE INITIATING THE APPLICATION OF RF ENERGY, A DECREASE IN ELECTRODE TEMPERATURE CONFIRMS THE ONSET OF SALINE IRRIGATION OF THE ABLATION ELECTRODE. MONITORING THE TEMPERATURE FROM THE ELECTRODE DURING THE APPLICATION OF RF ENERGY ENSURES THAT THE IRRIGATION FLOW RATE IS BEING MAINTAINED. USING TIP TEMPERATURE TO GUIDE ABLATION COULD RESULT IN DEEPER LESIONS AND INCREASED RISK FOR COLLATERAL DAMAGE. WHEN RF ENERGY IS INTERRUPTED FOR EITHER A TEMPERATURE OR AN IMPEDANCE RISE (THE SET LIMIT IS EXCEEDED), THE CATHETER SHOULD BE REMOVED, AND THE TIP CLEANED OF COAGULUM, IF PRESENT. WHEN CLEANING THE TIP ELECTRODE, BE CAREFUL NOT TO TWIST THE TIP ELECTRODE WITH RESPECT TO THE CATHETER SHAFT; TWISTING MAY DAMAGE THE TIP ELECTRODE BOND AND LOOSEN THE TIP ELECTRODE, OR MAY DAMAGE THE CONTACT FORCE SENSOR. A SIGNIFICANT CHANGE IN THE BASELINE READING AFTER CLEANING MIGHT INDICATE A DAMAGED CONTACT FORCE SENSOR. MAKE SURE THE IRRIGATION HOLES ARE NOT PLUGGED PRIOR TO REINSERTION. AS PART OF THE JOHNSON & JOHNSON MEDTECH QUALITY PROCESS, ALL DEVICES ARE MANUFACTURED, INSPECTED, AND RELEASED TO APPROVED SPECIFICATIONS. IF ADDITIONAL INFORMATION IS RECEIVED REGARDING THIS EVENT, A SUPPLEMENTAL 3500A REPORT WILL BE SUBMITTED TO THE FDA. MANUFACTURER'S REFERENCE NUMBER: (B)(4).

    Description of Event or Problem · 0

    IT WAS REPORTED THAT A PATIENT UNDERWENT A CARDIAC ABLATION PROCEDURE WITH A QDOT MICRO¿ CATHETER AND AFTER ABLATION, THE DOCTOR NOTICED SOME CHARRING ABOVE THE ELECTRODE. THE EXACT LOCATION OF THE CHARRING WAS BETWEEN TIP ELECTRODE AND ELECTRODE 2 AT THE PLASTIC RING SEPARATING THE ELECTRODES. NO ERROR MESSAGES, TEMPERATURE ISSUES, OR FLOW ISSUES PRECEDED THE CHAR ISSUE. THERE WAS NO EXCESSIVE FORCE OR ABLATION TIMES USED. THE PHYSICIAN AIMED FOR 5-15 GRAMS OF FORCE. THE GENERATOR PARAMETERS WERE AS FOLLOWS: ¿ QMODE+. ¿ 90W. ¿ TEMPERAURE TARGET: 55°C. ¿ TEMPERATURE CUT OFF: 65°C. THE PATIENT WAS ANTICOAGULATED WITH AN ACT (ACTIVATED CLOTTING TIME) OF >300, A VALUE WHICH WAS MAINTAINED THROUGHOUT THE CASE. THE IRRIGATION FLUID USED WAS HEPARINIZED NORMAL SALINE. THE PHYSICIAN DEEMED THE CHARRING PRESENT TO BE AN INCREASED RISK TO THE PATIENT. HOWEVER, NO PATIENT CONSEQUENCES WERE REPORTED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    82355 QDOT MICRO¿ CATHETER CATHETER, PERCUTANEOUS, CARDIAC ABLATION, FOR TREATMENT OF ATRIAL FIBRILLATION OAE BIOSENSE WEBSTER INC 31416942L 10846835016758

    Patients

    Seq Age Sex Outcome Treatment
    1 NA Unknown NGEN PUMP, EU CONFIGURATION.| NGEN RF GENERATOR.| UNK_CARTO 3.