THORATEC SWITZERLAND GMBH CENTRIMAG MOTOR, OUS; PUMP, BLOOD, CARDIOPULMONARY BYPASS, NON-ROLLER TYPE
|
Back to Search Results |
|
Model Number 201-10002 |
Device Problems
Unexpected Shutdown (4019); Excessive Heating (4030)
|
Patient Problem
Cardiopulmonary Arrest (1765)
|
Event Date 05/06/2020 |
Event Type
Injury
|
Manufacturer Narrative
|
This event occurred at (b)(6).No further information was provided.A supplemental report will be submitted when the manufacturer¿s investigation is complete.
|
|
Event Description
|
Related manufacturer report number: 3003306248-2020-00039.It was reported that the patient had recently been converted from venoarterial extracorporeal membrane oxygenation (va-ecmo) to centrimag left ventricular assist device (lvad) support.On (b)(6) 2020 the centrimag system stopped, there was a loss of rotational speed at the motor.Circulatory support was interrupted and the patient hemodynamically deteriorated which necessitated cpr to restore acceptable circulation.The physicians were unable to restore power to the centrimag motor due to a missing set rpm option on the screen of the primary console.The whole centrimag system was exchanged for a backup one.It was also noted that the centrimag motor was extremely hot during the event.After exchange to the backup centrimag system, circulatory support was re-established and the patient hemodynamically stabilized.The physicians reportedly did not remember any active alarms during the event.
|
|
Manufacturer Narrative
|
Section e2, e3: correction manufacturer's investigation conclusion: the reported event of the system stopping and being unable to restore motor speed as well as the motor being hot was not confirmed.The centrimag motor (serial #: (b)(6)) was returned for analysis to the edc and was evaluated and tested.The motor was functionally tested for 8 days and performed as intended.The motor cable underwent a resistance test and functioned as intended.The reported event was unable to be reproduced.Preventative maintenance was performed, and the motor was returned to the customer.The root cause for the reported event was unable to be conclusively determined through this analysis.The centrimag motor instructions for use (ifu) instructs to always have a back-up centrimag motor available and the centrimag blood pump ifu states "always have a spare centrimag blood pump, back-up console and equipment available for change out." additionally, the centrimag primary console operating manual warns "one back-up console and motor are required in the immediate vicinity of each patient whenever the centrimag blood pump is used.The back-up console must be connected to the back-up motor, have a battery charge sufficient for at least one hour of operation, be connected to ac power (except during transport) and be immediately available should the primary console or primary motor experience a malfunction." no further information was provided.The manufacturer is closing the file on this event.
|
|
Search Alerts/Recalls
|
|
|