MAUDE Adverse Event Report: EDWARDS LIFESCIENCES EDWARDS SAPIEN 3 TRANSCATHETER HEART VALVE; AORTIC VALVE, PROSTHESIS, PERCUTANEOUSLY DELIVERED

Model Number	9600TFX29A
Medical Device Problem Code	Degraded (1153)
Health Effect - Clinical Code	Cardiac Arrest (1762)
Date of Event	03/11/2026
Type of Reportable Event	Death
Event or Problem Description
As reported by the field clinical specialist (fcs), 10 years, 9 days post implant of a 29 mm sapien 3 valve in the aortic position, the 29 mm sapien 3 valve required intervention due to aortic stenosis.During the valve in valve procedure, the patient decompensated when pacing was tested.The patient may have had a lower ejection fraction than originally thought.Chest compressions were performed and epi was given in attempt to bring the pressure back up.After 20 minutes of chest compressions and no rise in blood pressure, it was determined that the patient expired.The commander system and valve were never inserted into the patient due to their passing.The death was not caused by any edwards devices during the case.The patient passed prior to even obtaining access so no valve was attempted or deployed.According to the medical records, the patient presented as an outpatient on (b)(6) 2026 to have a tee and right/left heart cath done as part of a transcatheter aortic valve replacement (tavr) workup for aortic stenosis and required intubation due to inability to lay flat due to nerve pain in their back.A right coronary artery (rca) stent was placed and the tee showed the ejection fraction (ef) 45-50%, moderate to severe aortic stenosis (as) with an aortic valve area (ava) of 0.48 cm^2, and a mean gradient (mg) of 26 mmhg.The patient was admitted due to multiple issues including inability to urinate and dizziness while standing.When the patient got up to walk with therapy, they had a dizzy spell with loss of pulse and after compressions for 1 minute return of spontaneous circulation (rosc) was achieved and patient was transferred to icu.The decision was made to expedite the tavr workup.The patient was taken to the cath lab anticipating a valve in valve, however the patient arrested and could not be resuscitated despite maximal effort.The preliminary cause of death was noted to be cardiac arrest and cardiogenic shock due to aortic stenosis.
Additional Manufacturer Narrative
Per the instructions for use (ifu), structural valve deterioration (wear, fracture, calcification, leaflet tear/tearing from the stent posts, leaflet retraction, suture line disruption of components of a prosthetic valve, thickening, stenosis), and device degeneration are known potential risks associated with the use of bioprosthetic heart valves.The ifu cautions that accelerated deterioration of the valve may occur in patients with an altered calcium metabolism.Long-term durability has not been established for the valve.Regular medical follow-up is advised to evaluate valve performance.Structural valve deterioration (svd) may be manifested as stenosis with thickened leaflets.Svd may be mild and not require any intervention or it may be moderate to severe.It can cause the heart to work harder to eject blood from the ventricle.Depending on the severity it could be an indication for valve replacement or medical intervention.Tissue calcification is a common failure mode.The mechanisms for bioprosthetic heart valve tissue calcification are not yet fully understood.Many factors can contribute to the onset and propagation of calcification including patient-related (e.G., patient age, disease state, immune status, and other co-morbidities), pharmacological, and intrinsic properties of the valve itself.It is widely understood that patients with chronic renal disease and prior history of calcific stenosis of the native valve may be predisposed to bioprosthetic calcification.During the manufacturing process, all sapien thv valves are 100% visually inspected for defects and 100% functionally tested for proper coaptation under physiological backpressure conditions prior to release for distribution.Therefore, it is highly unlikely that a manufacturing defect or device malfunction contributed to the event.In this case, there was no allegation or indication a manufacturing non-conformance contributed to this product problem.Investigation results suggest/indicate patient factors including coronary artery disease, hypertension, and hyperlipidemia could have caused or contributed to this event.A review of edwards lifesciences risk management documentation was performed for this case.The reported event is an anticipated risk of the transcatheter heart valve procedure, additional assessment of this adverse event is not required at this time.Complaint histories for all reported events are reviewed against trending control limits monthly, and any excursions above the control limits are assessed and documented as part of this monthly review.As such, neither a product risk assessment, nor corrective or preventative actions are required at this time.

• Brand Name: EDWARDS SAPIEN 3 TRANSCATHETER HEART VALVE
• Common Device Name: AORTIC VALVE, PROSTHESIS, PERCUTANEOUSLY DELIVERED
• Manufacturer (Section D): EDWARDS LIFESCIENCES; 1 edwards way; irvine CA 92614
• Manufacturer (Section G): EDWARDS LIFESCIENCES; 1 edwards way; irvine CA 92614
• Manufacturer Contact: renee van dorne ; 1 edwards way; irvine, CA 92614 ; 9492506385
• MDR Report Key: 24742202
• Report Number: 2015691-2026-13693
• Device Sequence Number: 8694593
• Product Code: NPT
• UDI-Device Identifier: 00690103194364
• UDI-Public: (01)00690103194364(17)160912
• Combination Product (Y/N): N
• Initial Reporter State: IN
• Initial Reporter Country: US
• PMA/510(K) Number: P140031
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2016
• Device Explanted Year: 2026
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Health Professional,User Facility
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 03/31/2026

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: Health Professional
• Device Expiration Date: 09/12/2016
• Device Model Number: 9600TFX29A
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/11/2026
• Initial Report FDA Received Date: 03/31/2026
• Was Device Evaluated by Manufacturer? (Y/N): No
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Death
• Patient Age: 89 YR
• Patient Sex: Male