MAUDE Adverse Event Report: ABBOTT MEDICAL AMPLATZER SEPTAL OCCLUDER; TRANSCATHETER SEPTAL OCCLUDER

Catalog Number 9-ASD-008

Device Problem Difficult to Fold, Unfold or Collapse (1254)

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

Event Date 03/18/2024

Event Type  malfunction  

Event Description

It was reported that a 8mm amplatzer septal occluder was selected for implant on (b)(6) 2024 using a 7f amplatzer torqvue delivery system to treat the atrial septal defect.A 9mm amplatzer septal occluder was selected for implant using a 7f amplatzer torqvue delivery system.Both devices were deployed into the patient at the same time.During implant the 8mm occluder took on a cobra shape.The device was removed from the patient and replaced with a new 9mm amplatzer septal occluder.During implant the first 9mm occluder took on a cobra shape.The device was removed from the patient and replaced with a new 10mm amplatzer septal occluder.There were no interactions with cardiac structures.There were no angulations or kinks noted in the delivery system.The patient remained hemodynamically stable throughout the procedure.There were no clinically significant delays in the procedure.There were no adverse effects to the patient.The patient status was stable.

Manufacturer Narrative

Investigation is not yet complete.A follow-up report will be submitted with all additional relevant information.

Manufacturer Narrative

An event of device deformity could not be confirmed.The device was returned to abbott for investigation and the device met functional specifications when analyzed under non-physiological conditions.It was indicated that there was no anatomical interference, there was no angulation or kink in the delivery system upon deployment, and a 7f delivery sheath was used.The device history record was reviewed to ensure that each manufacturing and inspection operation was performed and the product met all defined manufacturing specifications.A fluoroscopy cineogram is shown with one aso device already deployed within the inter-atrial septum with traction being applied to the right atrium disc, while a second device is being deployed from another delivery sheath.The second device being deployed shows tendency to form a cobra deformation, while the first device already deployed within the inter-atrial septum shows a normal configuration with the right atrial disc bulging due to traction.The cause of the reported incident could not be conclusively determined.However, per the instructions for use, the recommended the sheath size delivery system for use with a 8 mm amplatzer septal occluder is an 6f, and use of a larger than recommended sheath could have contributed to the device deformation.There is no indication of a product quality issue with respect to labeling design or manufacturing of the device.

• Brand Name: AMPLATZER SEPTAL OCCLUDER
• Type of Device: TRANSCATHETER SEPTAL OCCLUDER
• Manufacturer (Section D): ABBOTT MEDICAL; 5050 nathan lane n; plymouth MN 55442
• Manufacturer (Section G): ST. JUDE MEDICAL #3014918977; edificio #44 calle 0, ave. 2; el coyol alajuela 1897- 4050; CS 1897-4050
• Manufacturer Contact: karen krouse ; 5050 nathan lane n; plymouth, MN 55442 ; 6517565400
• MDR Report Key: 19088633
• MDR Text Key: 340623612
• Report Number: 2135147-2024-01645
• Device Sequence Number: 1
• Product Code: MLV
• UDI-Device Identifier: 00811806010052
• UDI-Public: (01)00811806010052(17)271031(10)8775813
• Combination Product (y/n): N
• Reporter Country Code: CH
• PMA/PMN Number: P000039
• Number of Events Reported: 1
• 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: 05/15/2024

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 Catalogue Number: 9-ASD-008
• Device Lot Number: 8775813
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 04/04/2024
• Is the Reporter a Health Professional?: Yes
• Initial Date Manufacturer Received: 03/18/2024
• Initial Date FDA Received: 04/11/2024
• Supplement Dates Manufacturer Received: 04/23/2024
• Supplement Dates FDA Received: 05/15/2024
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 11/24/2022
• 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
• Treatment: 7F AMPL TORQ DS [9-ITV07F45/80, LOT: 8984706]