This will be filed to report a clip that deployed prematurely.It was reported that on (b)(6) 2023 a mitraclip procedure was performed to treat functional mitral regurgitation (mr) grade 4+.The first clip was implanted successfully.A second clip was then advanced.It was noted that after performing multiple grasping attempts, the clip separated from the actuator mandrel and was only connected to the lock and gripper lines.Subsequently, the physician elected to real the clip back to the steerable guide catheter (sgc) tip and retract the devices through the septum.The physician then attempted to remove the clip and sgc from the patient.During this removal, the clip further detached and was left in the patients groin.The physician retrieved the clip and the procedure was concluded with a resulting mr of grade 2+.On (b)(6) 2023 the patient was admitted to the emergency department with an infected groin access site.No additional information was provided.
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The reported premature activation, poor imaging, and positioning failure could not be replicated in a testing environment.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 similar complaints reported from this lot.Based on available information, the reported positioning failure appears to be due to procedural conditions.The reported premature activation appears to be due to the observed broken actuator coupler.The bent and broken actuator coupler appears to be due to procedural conditions.A cause for the difficult imaging could not be determined.A cause for the reported infection could not be determined.Additionally, infection is listed in the instructions for use (ifu) as a known possible complication associated with mitraclip procedures.The reported removal of foreign body, hospitalization, and unexpected medical intervention are the results of case-specific circumstances.There is no indication of a product issue with respect to manufacture, design, or labeling.
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