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Catalog Number 19AGFN-756 |
Device Problems
Fracture (1260); Incomplete Coaptation (2507); Physical Resistance/Sticking (4012)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 01/29/2024 |
Event Type
malfunction
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Manufacturer Narrative
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Investigation is not yet complete.A follow-up report will be submitted with all additional relevant information.
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Event Description
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It was reported that on (b)(6) 2024, a 19mm regent aortic mechanical heart valve was chosen for implantation.Before implantation, a resection was performed which completely decalcified the leaflet.Using the sizing ring, the annulus was measured to be 19mm.When the suture was passed through the sewing cuff and knotted, it was noticed that the ring was fractured and a disc was stuck.The valve was removed.There had been resistance while rotating.Holder handle was fully inserted into the orifice at a 90 degree angle.All pieces of the fractured ring were removed from the anatomy.The physician decided to enlarge the aortic ring via the yang technique and implant a replacement 23mm regent aortic valve.There were no adverse patient consequences or clinically significant delay.The patient remained hemodynamically stable throughout the procedure.The patient remained on cardiopulmonary bypass throughout the procedure without intervention.There was a reported delay that resulted in no patient consequences.
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Event Description
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It was reported that on (b)(6) 2024, a 19mm regent aortic mechanical heart valve was chosen for implantation.Before implantation, a resection was performed which completely decalcified the leaflet.Using the sizing ring, the annulus was measured to be 19mm.When the suture was passed through the sewing cuff and knotted, it was noticed that the ring was fractured and a disc was stuck.The valve was removed.There had been resistance while rotating.Holder handle was fully inserted into the orifice at a 90 degree angle.All pieces of the fractured ring were removed from the anatomy.The physician decided to enlarge the aortic ring via the yang technique and implant a replacement 23mm regent aortic valve.There were no adverse patient consequences or clinically significant delay.The patient remained hemodynamically stable throughout the procedure.The patient remained on cardiopulmonary bypass throughout the procedure without intervention.There was a reported delay that resulted in no patient consequences.
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Manufacturer Narrative
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An event of the orifice being fractured and the disk being stuck was reported.The investigation found that the orifice was fractured near the one pivot guard of the valve.The piece of the orifice that had fractured was returned and was of an irregular shape.The device history record was reviewed to ensure that each manufacturing and inspection operation was performed, and the product met all specifications.While the root cause of the leaflet dislodgement could not be conclusively determined, there was no evidence of the material defect in the carbon coating that may have caused or contributed to the damaged orifice.The damage may have been caused by some external force applied to the valve which overstressed the carbon material.Please note per the instructions for use, " 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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Search Alerts/Recalls
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