THORATEC SWITZERLAND GMBH CENTRIMAG 2ND GENERATION PRIMARY CONSOLE WITH EMTEC PEDIATRIC FLOW PROBE, OUS; CONTROL, PUMP SPEED, CARDIOPULMONARY BYPASS
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Model Number 201-90701 |
Device Problem
Failure to Align (2522)
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Patient Problem
No Known Impact Or Consequence To Patient (2692)
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Event Date 12/23/2018 |
Event Type
Injury
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Manufacturer Narrative
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Approximate age of device: will be provided upon investigation closure.No further information was provided.A supplemental report will be submitted when the manufacturer's investigation is completed.
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Event Description
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The patient was implanted with a centrimag device on an unspecified date.It was reported that both centrimag 2nd generation consoles experienced a "pump not inserted error" while in use on a patient.Circuit lines were checked for occlusions.The pump head was checked for correct placement to motor.The pump head was removed and re-seated in the pump motor; however, the alarm persisted.The account attempted to disable the alarm but it did not clear.The pump head was then inserted on a spare/back-up centrimag motor with a different console, bi-ventricular assist commenced immediately, and returned to full flow.No injury nor adverse outcome was a result of the event.No further information was provided.A supplemental report will be submitted when the manufacturer's investigation is completed.
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Manufacturer Narrative
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Section d10: additional information.Section h3: additional information.Manufacturer investigation conclusion: the report of a "pump not inserted" error was confirmed through the analysis of a data log file retrieved from the returned centrimag 2nd gen primary console.Per the log file, the console was supporting a pump at a speed of approximately 3900rpm and a flow of approximately 3.9lpm for over 43.75 hours.At approximately 11:20am on (b)(6) 2018 the console alarmed with a pump not inserted:m3 alarm and speed dropped to 0rpm.Approximately 4 seconds later the fault cleared.Soon after, speed was adjusted and the system resumed pump support.However, at approximately 11:27am the log file captured a second pump not inserted:m3 alarm and pump speed again dropped to 0rpm.The system was powered down approximately 8 minutes later.The root cause of these events could not be conclusively determined based on the log file analysis.The returned console was evaluated and tested by the service depot.The reported issue could not be verified nor duplicated during testing.The console was tested for an extended period of time with both a test motor and flow probe as well as with its related motor, and flow probe.The console performed as intended and no "pump not inserted" errors nor any other alarms were reproduced at any point.Full functional checkout was performed per the centrimag 2nd gen primary console service process and the unit passed all tests.The returned console was found to function as intended.As a result, the root cause of the events captured in the log file could not be conclusively determined nor correlated to a console related issue.The console was due for its routine battery maintenance, which was performed successfully.The serviced and tested console was returned to the customer site.Reports of similar events will continue to be tracked and monitored.No further information was provided.The manufacturer is closing the file on this event.
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