This is filed to report atrial perforation difficult to remove.It was reported this was a mitaclip procedure to treat degenerative mitral regurgitation (mr) with a grade of 4.It was noted there was a very tortuous venous access.The steerable guide catheter (sgc) was inserted and advanced into the left atrium (la).It was noted that due to the tortuous venous access, the sgc was difficult to advance and became kinked.Therefore, the sgc was removed and replaced.The new sgc was inserted and advanced into the la.It was noted that transseptal access was difficult.An xtw clip was inserted into the la, but at this time it was observed when rotating the guide handle, the tip of the guide did not move.It was noted that a generation 3 sgc was used with a generation 4 clip delivery system (cds).Due to the inability to steer the sgc, the physician decided to pull the clip back into the sgc and remove the devices.However, the sgc was unintentionally retracted into the right atrium (ra) and the clip remained in the la.This caused difficulty retracting the cds into the sgc.By using force, the physician was able to pull the clip through the transeptal puncture.Once in the ra, the clip was able to be retracted into the sgc and both devices were removed.Once removed, it was observed a left to right shunt was present.No additional devices were inserted, and the procedure was discontinued.Mr remained at a grade of 4.There was no clinically significant delay in the procedure.No additional information was provided.
|
The device was not returned for analysis.A review of the lot history record identified no manufacturing nonconformities issued to the reported lot that would have contributed to this event.Additionally, a review of the complaint history identified no other complaint reported from this lot.It should be noted that per mitraclip instructions for use (ifu) states that ¿release the sleeve fastener and retract the clip delivery system (cds) approximately 10 cm into the guide by pulling only on the sleeve handle¿ should be performed before, ¿carefully retract the guide tip into the right atrium (ra).The guide may be straightened further with the +/- knob if desired¿.Based on the information provided within this complaint, the sgc was inadvertently retracted into the ra without retracting the cds into the guide.Therefore, the reported improper or incorrect procedure or method appears to be due to user error.All available information was investigated, and the reported difficult to remove is a cascading effect of failure to follow steps.The reported positioning failure and difficult to advance was due to challenging patient anatomical condition.The reported unintended movement was an outcome of procedural circumstance.The reported perforation was due to troubleshooting steps during the procedure.Perforation is listed in the mitraclip system instructions for use as a known possible complication associated with mitraclip procedures.There is no indication of product issue with respect to manufacture, design or labeling.
|