On (b)(6) 2019, 29mm sjm masters series valve expanded cuff was selected for implant and after implanting the valve, one of the leaflets were obstructed.The physician attempted to rotate the valve which lead to the leaflet to break and caused extended procedure time.The valve was exchanged for a 27mm sjm masters series valve expanded cuff.No patient consequences were reported.
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The reported event of a dislodged leaflet was confirmed.One leaflet was dislodged from the orifice and returned with the valve.No other damage was noted.The device history record was reviewed to ensure that each manufacturing and inspection operation was performed and the product met all specifications at the time of commercialization.The cause of the leaflet dislodgment could not be conclusively determined.Please note, per the instructions for use artmt100045600 version a, "using the valve holder/rotator and an sjm valve holder handle, rotate the valve in situ to the desired position.The valve should rotate freely.If resistance is noted, the valve holder/ rotator may not be properly seated in the valve, the valve may not be in the fully closed position, or the valve may be oversized.If the valve does not rotate freely, do not force valve rotation.".
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