Catalog Number CDS0702-NTW |
Device Problems
Difficult to Remove (1528); Deformation Due to Compressive Stress (2889); Difficult to Open or Close (2921); Material Deformation (2976); Unintended Movement (3026)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 11/02/2023 |
Event Type
malfunction
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Manufacturer Narrative
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Investigation is not yet complete.A follow-up report will be submitted with all additional relevant information.
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Event Description
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It was reported that a patient presented with grade 4 functional mitral regurgitation (mr) for a mitraclip procedure.A ntw clip could not be implanted due to gradient issues.It was decided to remove and replace the clip with an nt.While retracting the ntw clip into the steerable guide catheter (sgc), it got stuck at the hemostasis valve.The clip could not be removed due to opened/deformed clip arms.The sgc was promptly removed from the heart to prevent air embolism.The hemostasis valve broke from the guide handle while trying to remove the clip.The procedure was able to be completed with one clip implanted, and an mr grade reduction to <1.There were no adverse patient effects or clinically significant delay.No additional information was provided.
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Manufacturer Narrative
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The device was not returned for analysis.A review of the lot history record revealed no manufacturing nonconformities issued to the reported lot.Additionally, a review of the complaint history identified no similar complaints reported from this lot.The investigation was unable to determine a cause for the reported difficulty removing the cds from the sgc (clip got stuck at the hemostasis valve).The reported inability to close the clip and deformed clip appear to be results of the clip getting stuck on the hemostasis valve.There is no indication of a product issue with respect to manufacture, design, or labeling.
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Search Alerts/Recalls
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