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Model Number 518-039 |
Device Problem
Break (1069)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 03/04/2021 |
Event Type
malfunction
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Manufacturer Narrative
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Patient date of birth and age unavailable.Patient weight unavailable.(b)(4).Device evaluation: the device was evaluated on 24 mar 2021 by a cross functional team.Two portions of the lld were returned to the manufacturer, comprising the lld in its entirety along with a portion of the lead present on the distal portion of the broken lld.The lld was fractured just distal of the wave feature, located on the mandrel of the device.The fractured area appears to have been stretched and then snapped.The lead, present around the distal portion of the broken lld, was cut and removed in order to fully evaluate this segment.In the area of fractured on the proximal portion of the broken lld, it also appears to have been stretched and snapped.The cause of why the lld broke in this area could not be determined; however, there was no indication of a design or production process related failure.The pulling force applied to the device exceeded the mandrel's strength.This failure has been determined to be use related, as traction was applied to the lld that exceeded the mandrel's strength, causing the lld to fracture.
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Event Description
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A lead extraction procedure commenced to remove a right ventricular (rv) lead due to non function.A spectranetics lead locking device was inserted into the rv lead to provide traction to aid in the lead's extraction.It was reported that during the procedure, the lld broke inside the lead with use of traction.The physician then attempted to extract the lead by using just suture, tied to the insulation of the lead, then used a cook medical bulldog device to attempt the extraction.However, the lead tip would still not release from the rv.The physician placed a new lead within the patient, and chose to cut and cap the rv lead and abandoned it within the patient's body.Both portions of the lld were able to be removed, so the lld was removed in its entirety from the lead and from the patient's body.The procedure was completed with no reported patient harm.Due to the lld breaking within the lead, this report is being submitted due to the potential for complication with recurrence.The lld portions, comprising the entire lld, were returned to the manufacturer for evaluation.
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Manufacturer Narrative
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B1): has been corrected to "product problem".H1): has been corrected to "malfunction".There was no reported injury to the patient; these fields were incorrectly populated on the initial mdr.Corrections to b1 and h1 now made to accurately reflect the event.
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Search Alerts/Recalls
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