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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: MEDTRONIC, INC EVEREST INFLATION DEVICE 30ATM; ADAPTOR, STOPCOCK, MANIFOLD, FITTING, CARDIOPULMONARY BYPASS

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MEDTRONIC, INC EVEREST INFLATION DEVICE 30ATM; ADAPTOR, STOPCOCK, MANIFOLD, FITTING, CARDIOPULMONARY BYPASS Back to Search Results
Model Number AC3200
Device Problem Display or Visual Feedback Problem (1184)
Patient Problem No Clinical Signs, Symptoms or Conditions (4582)
Event Type  malfunction  
Event Description
An attempt was made to use one everest inflation device during a shunt procedure.The device was inspected with no issues noted.The device was prepped per ifu with no issues noted.The everest was connected to a balloon device when the issue occurred.It was reported that there was difficulty contracting the balloon device.The issue occurred when the mating device was in the patient. the patient is alive with no injury.
 
Manufacturer Narrative
Product analysis summary: one everest inflation device returned for analysis with stopcock attached.No damage was noted to the syringe body, tube, joints or manometer housing.The stopcock was removed with no issues and with no damage noted.As received the gauge needle was at approx.0 atm.Using the returned stopcock, an attempt was made to pressurise device with water, however the needle was unresponsive and did not move from approx.0atm.Pressure was released, and an attempt was made to apply vacuum/negative pressure.It was not possible to perform negative pressure as the lead screw retracted without resistance and air entered the syringe chamber.Upon visual inspection a crack was noted on the plunger tip.Medtronic is submitting this report to comply with fda reporting regulations under 21 cfr parts 4 and 803.This report is based upon information obtained by medtronic, which the company may not have been able to fully investigate or verify prior to the date the report was required by the fda.Medtronic has made reasonable efforts to obtain more complete information and has provided as much relevant information as is available to the company as of the submission date of this report.This report does not constitute an admission or a conclusion by fda, medtronic, or its employees that the device, medtronic, or its employee caused or contributed to the event described in the report.In particular, this report does not constitute an admission by anyone that the product described in this report has any ¿defects¿ or has ¿malfunctioned¿.These words are included in the fda 3500a form and are fixed items for selection created by the fda to categorize the type of event solely for the purpose of regulatory reporting.Medtronic objects to the use of these words and others like them because of the lack of definition and the connotations implied by these terms.This statement should be included with any information or report disclosed to the public under the freedom of information act.
 
Manufacturer Narrative
Medtronic is submitting this report to comply with fda reporting regulations under 21 cfr parts 4 and 803.This report is based upon information obtained by medtronic, which the company may not have been able to fully investigate or verify prior to the date the report was required by the fda.Medtronic has made reasonable efforts to obtain more complete information and has provided as much relevant information as is available to the company as of the submission date of this report.This report does not constitute an admission or a conclusion by fda, medtronic, or its employees that the device, medtronic, or its employee caused or contributed to the event described in the report.In particular, this report does not constitute an admission by anyone that the product described in this report has any ¿defects¿ or has ¿malfunctioned¿.These words are included in the fda 3500a form and are fixed items for selection created by the fda to categorize the type of event solely for the purpose of regulatory reporting.Medtronic objects to the use of these words and others like them because of the lack of definition and the connotations implied by these terms.This statement should be included with any information or report disclosed to the public under the freedom of information act.
 
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Brand Name
EVEREST INFLATION DEVICE 30ATM
Type of Device
ADAPTOR, STOPCOCK, MANIFOLD, FITTING, CARDIOPULMONARY BYPASS
Manufacturer (Section D)
MEDTRONIC, INC
37a cherry hill dr
danvers MA 01923
Manufacturer (Section G)
MEDTRONIC, INC
37a cherry hill dr
danvers MA 01923
Manufacturer Contact
alison sweeney
parkmore business park west
galway 
EI  
091708096
MDR Report Key15758085
MDR Text Key307738025
Report Number1220452-2022-00084
Device Sequence Number1
Product Code DTL
Combination Product (y/n)N
Reporter Country CodeJA
PMA/PMN Number
K153038
Number of Events Reported1
Summary Report (Y/N)N
Report Source Manufacturer
Source Type Foreign,Health Professional,Company Representative
Reporter Occupation Physician
Type of Report Initial,Followup
Report Date 01/05/2023
1 Device was Involved in the Event
1 Patient was Involved in the Event
Is this an Adverse Event Report? No
Is this a Product Problem Report? Yes
Device Operator Health Professional
Device Expiration Date12/22/2023
Device Model NumberAC3200
Device Catalogue NumberAC3200
Device Lot Number60337844
Was Device Available for Evaluation? Device Returned to Manufacturer
Date Returned to Manufacturer08/29/2022
Is the Reporter a Health Professional? Yes
Initial Date Manufacturer Received 10/11/2022
Initial Date FDA Received11/09/2022
Supplement Dates Manufacturer Received12/09/2022
Supplement Dates FDA Received01/05/2023
Was Device Evaluated by Manufacturer? Yes
Date Device Manufactured12/22/2021
Is the Device Single Use? Yes
Is This a Reprocessed and Reused Single-Use Device? No
Type of Device Usage Initial
Patient Sequence Number1
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