MAUDE Adverse Event Report: EUROSETS S.R.L. ADVANCED MEMBRANE GAS EXCHANGE PMP STERILE; OXYGENATOR, CARDIOPULMONARY BYPASS

Model Number US5062

Device Problem Fluid/Blood Leak (1250)

Patient Problem No Clinical Signs, Symptoms or Conditions (4582)

Event Date 07/28/2023

Event Type  malfunction  

Manufacturer Narrative

No further information was provided.A supplemental report will be submitted once the manufacturer¿s investigation is completed.

Event Description

It was reported that when the customer was priming a eurosets oxygenator, a leak was noted.The product was pulled from use and there was no impact to the patient.

Event Description

Additional information was received that the leak was noticed very soon after priming.It was noted that the oxygenator's inlet and outlet pressures, and the pump speed at the time of the leak were unknown.There was no patient involved in the event.

Manufacturer Narrative

Manufacturer's investigation conclusion: evaluation of the returned oxygenator by the external manufacturer (eurosets) confirmed an oxygenator leak due to fiber breakage; however, a specific root cause for the fiber breakage could not be conclusively determined through this evaluation.The eurosets oxygenator, lot number 7559308, was returned to abbott where an initial visual inspection was performed.Caps were present on the gas inlet and outlet ports and the purge line was connected to its port.Visual inspection of the oxygenator revealed no obvious damage to the external housing, ports, or fibers.A few small droplets of clear liquid were observed within the top orange housing.The oxygenator was forwarded to eurosets for technical analysis.The oxygenator was set up in a circuit with a 500-milliliter reservoir of water and peristaltic pump.The oxygenator was filled with water via the peristaltic pump, and the water was circulated through the oxygenator at a flow of 6 liters per minute (lpm) for 10 minutes.A slow dripping was noticed in front of the blood outlet port.To identify the point of leakage, the device was sectioned by removing the lower housing, refilled with water, and then pressurized.The root cause of the leak was determined to be fiber breakage of the last winding of the fibers at the blood outlet port.The production documentation for the oxygenator lot was reviewed by eurosets and showed that all tests from the production process were compliant with the technical specifications.Devices are required to pass manufacturing inspections and specifications prior to release and no abnormalities were documented which would cause or contribute to the reported occurrence.This device passed all required testing.Eurosets confirmed that 100% of the oxygenators produced are tested to detect eventual leakages using a pressure of 150 kpa (kilopascals) which is 1.5 times the maximum blood pathway pressure indicated on the ifu (instructions for use).Devices that exhibit leaks are discarded prior to distribution.Eurosets determined that the issue occurred after eurosets¿ manufacturing and test phases.The eurosets amg (advanced membrane gas exchange) pmp (polymethylpentene) ifu warns that the extracorporeal circulation always has to be carefully and continuously checked.This document additionally states that a spare oxygenator must always be available during perfusion.If particular situations occur which may lead the person responsible for perfusion to determine that the safety of the patient may be compromised (including leaks), oxygenator replacement should be performed per the ifu guidelines.The production documentation for amg pmp oxygenator, lot number 7559308, was reviewed by the external manufacturer (eurosets) and showed that all tests from the production process were compliant with the technical specifications.The eurosets amg pmp instructions for use (ifu) is currently available.Under the list of warnings, the ifu warns that during use, a spare oxygenator must always be available and also warns that the device has to be carefully and continuously checked by qualified healthcare professionals throughout the procedure.Also, under the section titled ¿set up¿, the ifu warns to ¿carry out a visual inspection and carefully check the device before use.Transport and/or storage conditions other than those prescribed may have caused damage to the device.¿ under the section titled ¿oxygenator replacement¿, this document states that a spare oxygenator must always be available during perfusion.After 6 hours of use with blood or if particular situations occur, which may lead the person responsible for perfusion to determine the safety of the patient may be compromised (insufficient oxygenator performance, leaks, abnormal blood parameters, etc.), follow the procedure outlined in the ifu for oxygenator replacement.No further information was provided.The manufacturer is closing the file on this event.

• Brand Name: ADVANCED MEMBRANE GAS EXCHANGE PMP STERILE
• Type of Device: OXYGENATOR, CARDIOPULMONARY BYPASS
• Manufacturer (Section D): EUROSETS S.R.L.; strada statale 12, n°143; medolla, modena 41036 ; IT 41036
• Manufacturer (Section G): EUROSETS S.R.L.; strada statale 12, n°143; medolla, modena 41036 ; IT 41036
• Manufacturer Contact: bob fryc ; 6035 stoneridge drive; pleasanton, CA 94588 ; 7818528204
• MDR Report Key: 17550669
• MDR Text Key: 321688561
• Report Number: 2916596-2023-06022
• Device Sequence Number: 1
• Product Code: DTZ
• UDI-Device Identifier: 08034013782020
• UDI-Public: 08034013782020
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K141492
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Health Professional,Company Representative
• Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date: 11/03/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 08/15/2023
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: US5062
• Device Lot Number: 7559308
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 08/02/2023
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Date Manufacturer Received: 11/02/2023
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 05/10/2021
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1