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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: LIVANOVA DEUTSCHLAND HEATER-COOLER SYSTEM 3T CONTROLLER, TEMPERATURE, CARDIOPULMONARY BYPASS

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LIVANOVA DEUTSCHLAND HEATER-COOLER SYSTEM 3T CONTROLLER, TEMPERATURE, CARDIOPULMONARY BYPASS Back to Search Results
Model Number 16-02-85
Device Problem Microbial Contamination of Device (2303)
Patient Problem Bacterial Infection (1735)
Event Type  Injury  
Manufacturer Narrative
Patient information was not provided. Livanova deutschland manufactures the heater-cooler system 3t. The incident occurred in (b)(6). If any additional information pertinent to the reported event is received, it will be provided in a supplemental report.
 
Event Description
Through literature review livanova became aware of 13 patients mycobacterium abscessus infections at (b)(6) hospital. Within the article it is stated that the hospital used heater-cooler 3t systems. Reportedly all patient had extensive preoperative comorbidities and complicated postoperative courses in addition to mycobacterium abscessus infection. Data presented in the article were collected between august 2013 and may 2014 and between december 2014 and june 2015. Moreover, within the article it is stated that despite changes of the instruction for use in 2010 recommending filtered tap water, it was found that water changes were performed with unfiltered tap water for the devices in use at the hospital and that the disinfection procedure was not applied according to the ifu. Cultures from biofilms of heater-cooler devices were negative fro m. Abscessus while the culture from biofilm of the faucet used to fill the units was positive to m. Abscessus. Reportedly, on early may 2015, the hospital changed the approach and followed the ifu.
 
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Brand NameHEATER-COOLER SYSTEM 3T
Type of DeviceCONTROLLER, TEMPERATURE, CARDIOPULMONARY BYPASS
Manufacturer (Section D)
LIVANOVA DEUTSCHLAND
lindberghstr. 25
munich 80309
GM 80309
MDR Report Key10200052
MDR Text Key196954903
Report Number1718850-2020-01101
Device Sequence Number1
Product Code DWC
Combination Product (y/n)N
Reporter Country CodeUS
Number of Events Reported1
Summary Report (Y/N)N
Report Source Distributor
Reporter Occupation Other Health Care Professional
Type of Report Initial
Report Date 05/29/2020
1 Device was Involved in the Event
1 Patient was Involved in the Event
Date FDA Received06/26/2020
Is this an Adverse Event Report? Yes
Is this a Product Problem Report? No
Device Operator
Device Model Number16-02-85
Was Device Available for Evaluation? No Answer Provided
Is the Reporter a Health Professional? Yes
Was the Report Sent to FDA? No
Event Location No Information
Date Manufacturer Received05/29/2020
Was Device Evaluated by Manufacturer? No Answer Provided
Is the Device Single Use? No Answer Provided
Is This a Reprocessed and Reused Single-Use Device? No
Type of Device Usage

Patient Treatment Data
Date Received: 06/26/2020 Patient Sequence Number: 1
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