MAUDE Adverse Event Report: LIVANOVA USA INC CARDIOPLEGIA ADAPTERS, VESSEL CANULAE, AND AORTIC ROOT CANNULAE; CATHETER, CANNULA AND TUBING, VASCULAR, CARDIOPULMONARY BYPASS

Model Number AR-XXXXX

Device Problem Disconnection (1171)

Patient Problem No Patient Involvement (2645)

Event Date 07/31/2020

Event Type  malfunction  

Manufacturer Narrative

Patient information were not provided.A review of the dhr did not identify any deviations or non-conformities relevant to the reported issue.The involved device has been requested at livanova usa inc for investigation.Investigation is ongoing.If any additional information pertinent to the reported event is obtained, it will be provided in a supplemental report.

Event Description

Livanova usa inc has been informed that, during a procedure, the luerlock connection has detached from the skewer.There is not report of any patient injury.

Manufacturer Narrative

The complained cannulae have been returned to livanova usa for investigation.Visual inspection of the two units confirmed the reported issue: cannula trocar needle was detached from the luer lock cap.A review of the dhr did not identify any deviation, non-conformity or material issue relevant to the reported failure.Livanova investigation suggested that the most probable root cause of the disconnection is ascribable root cause investigation results highlighted that the uv dispense and curing process is related to the 100% inspection by the assembler to ensure the cure.The process as a consequence is variable and require a well-trained assembler.As a part of continuous improvement project, in (b)(6) 2019 the standard operating procedure for the manufacturing of the complained cannula has been revised including additional check for first piece in curing trocar to luer bond and additional 100% inspection of adhesive cure for trocar to luer bond with needle to test for softness.Manufacturing personnel has been trained on the new revision of the procedure on (b)(6) 2019.In addition, in order to ensure a more stable and precise process for dispensing uv adhesive and uv curing, an equipment has been modified to dispense a fixed amount of uv adhesive and modifying uv curing process.The validation of the equipment, which now includes an integrated semi-automatic dispenser and uv flood light system, has been completed on (b)(6) 2020.Field data monitoring is started and is planned to be completed by (b)(6) 2021.At the moment, all the complained devices were manufactured before the implementation of the new curing equipment.Based on livanova health hazard assessment, the overall risk is considered acceptable also after the implementation of the manufacturing personnel re-training in september.Nevertheless improvement action is now implemented and the field data monitoring is on going.Livanova will keep monitoring the market.

Event Description

See initial report.

• Brand Name: CARDIOPLEGIA ADAPTERS, VESSEL CANULAE, AND AORTIC ROOT CANNULAE
• Type of Device: CATHETER, CANNULA AND TUBING, VASCULAR, CARDIOPULMONARY BYPASS
• Manufacturer (Section D): LIVANOVA USA INC; 14401 w 65th way; arvada 80004
• MDR Report Key: 10458332
• MDR Text Key: 204535883
• Report Number: 1718850-2020-00036
• Device Sequence Number: 1
• Product Code: DWF
• UDI-Device Identifier: 00803622103056
• UDI-Public: (01)00803622103056(240)230228(17)AR-11114(10)2004800054
• Combination Product (y/n): N
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: health professional
• Remedial Action: Other
• Type of Report: Initial,Followup
• Report Date: 07/31/2020

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Expiration Date: 02/28/2023
• Device Model Number: AR-XXXXX
• Device Catalogue Number: AR-11114
• Device Lot Number: 2004800054
• Was Device Available for Evaluation?: Yes
• Was the Report Sent to FDA?: No
• Initial Date Manufacturer Received: 07/31/2020
• Initial Date FDA Received: 08/27/2020
• Supplement Dates Manufacturer Received: 10/02/2020
• Supplement Dates FDA Received: 10/30/2020
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1