MAUDE Adverse Event Report: MEDTRONIC, INC. MITRAL AP MECHANICAL HEART VALVE; HEART-VALVE, MECHANICAL

Model Number 501DM20

Device Problems Incomplete Coaptation (2507); Mechanical Jam (2983)

Patient Problem Host-Tissue Reaction (1297)

Event Date 12/25/2019

Event Type  Injury  

Manufacturer Narrative

Product analysis: no product was returned.Conclusion: without the return of the product, no definitive conclusion can be made regarding the clinical observation.Implant date: only year valid.If information is provided in the future, a supplemental report will be issued.

Event Description

Medtronic received information that approximately 4 years post implant of this 20mm mitral mechanical valve implanted in a 5 year old pediatric patient, the valve was explanted and replaced with a mechanical valve of the same size but different model.The reason for replacement was reported as pannus overgrowth that led one leaflet to become stuck.No additional adverse patient effects were reported. .

• Brand Name: MITRAL AP MECHANICAL HEART VALVE
• Type of Device: HEART-VALVE, MECHANICAL
• Manufacturer (Section D): MEDTRONIC, INC.; 3800 annapolis lane; minneapolis MN 55447
• Manufacturer (Section G): MEDTRONIC, INC.; 3800 annapolis lane; minneapolis MN 55447
• Manufacturer Contact: paula bixby ; 8200 coral sea street ne; mounds view, MN 55112 ; 7635055378
• MDR Report Key: 9673573
• MDR Text Key: 177973586
• Report Number: 3008592544-2020-00007
• Device Sequence Number: 1
• Product Code: LWQ
• Combination Product (y/n): N
• Reporter Country Code: JA
• PMA/PMN Number: P990046
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: distributor,foreign,health pr
• Reporter Occupation: Physician
• Type of Report: Initial
• Report Date: 02/05/2020

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 02/05/2020
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Health Professional
• Device Model Number: 501DM20
• Device Catalogue Number: 501DM20
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Date Manufacturer Received: 01/09/2020
• 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
• Patient Outcome(s): Required Intervention
• Patient Age: 9 YR