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Catalog Number SGC0705 |
Device Problem
Adverse Event Without Identified Device or Use Problem (2993)
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Patient Problems
Low Blood Pressure/ Hypotension (1914); Hypoxia (1918); Perforation (2001)
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Event Date 02/15/2024 |
Event Type
Injury
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Event Description
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It was reported this was a mitraclip procedure to treat functional mitral regurgitation (mr) with a grade of 3+.One clip was successfully implanted, reducing the mr to a grade of <1.However, after removal of the steerable guide catheter (sgc), a right to left shunt was observed.It was noted that blood pressure and oxygen saturation (spo2) gradually decreased, the sgc was reinserted into the left atrium to suppress the shunt blood flow.Both blood pressure and spo2 increased.Once the external doctor arrived, an atrial septal defect (asd) closure device was implanted.There was no clinically significant delay in the procedure.
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Manufacturer Narrative
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The device was not returned for analysis.A review of the lot history record revealed no manufacturing nonconformities issued to the reported lot that would have contributed to this event.Based on available information, the cause of the reported perforation was unable to be determined.The reported hypoxia and hypotension were cascading events of the reported perforation.The reported patient effects of perforation and hypotension, as listed in the mitraclip system instructions for use, are known possible complications associated with mitraclip procedures.The reported unexpected medical intervention was a result of case-specific circumstances.There is no indication of a product quality issue with respect to manufacture, design, or labeling.
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Search Alerts/Recalls
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