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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: EDWARDS LIFESCIENCES EDWARDS COMMANDER DELIVERY SYSTEM WITH S3U; AORTIC VALVE, PROSTHESIS, PERCUTANEOUSLY DELIVERED

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EDWARDS LIFESCIENCES EDWARDS COMMANDER DELIVERY SYSTEM WITH S3U; AORTIC VALVE, PROSTHESIS, PERCUTANEOUSLY DELIVERED Back to Search Results
Model Number 9750CM26A
Device Problems Burst Container or Vessel (1074); Material Rupture (1546)
Patient Problems Calcium Deposits/Calcification (1758); Failure of Implant (1924); No Known Impact Or Consequence To Patient (2692)
Event Date 07/22/2020
Event Type  malfunction  
Manufacturer Narrative
Udi: (b)(4).Investigation is ongoing.
 
Event Description
As reported, during a transfemoral tavr case with a 26mm s3u valve, the valve was successfully deployed in the patient's annulus, but at the end of deployment the delivery system balloon ruptured.The valve was well-seated, no post-dilation was necessary.The patient had a small aortic root with a narrow, calcified stj.The rupture was most likely caused by calcification on the stj.There was no negative impact to the patient and the delivery system was able to be removed from the patient without any injury.The devices were discarded and are not available for return.The delivery system was prepped with -1 cc.
 
Manufacturer Narrative
Corrected data: f10, h6.Reference capa-20-00141.
 
Manufacturer Narrative
Imagery was provided by the site and the presence of calcification on the stj was observed.Calcification was also noted in the annulus and leaflet.A lot history review was performed and revealed no other complaints relating to ¿balloon ¿ burst¿.A dhr review was performed.The review of the work orders did not reveal any manufacturing non-conformance that would have contributed to the complaint event.A complaint history review is not required because the event was unable to be confirmed.The ifu, device preparation manual, and device training manual were reviewed for guidance and instruction on device preparation and usage.The valve should be deployed with the device provided by edwards lifesciences.Slow inflation should be used and may help with stability of the delivery system and thv during deployment.If the delivery system balloon bursts or leaks during deployment without thv embolization, take care when crossing the thv, tracking back over the arch and removing the delivery system.No ifu/training deficiencies were identified.During manufacturing of the commander delivery system, the delivery system and components are inspected several times throughout the manufacturing process.In addition, product verification testing was performed on a sampling basis and all testing met specifications.These inspections performed during manufacturing process and testing performed during product verification support that it is unlikely that a manufacturing non-conformance contributed to the reported events.The event was unable to be confirmed.Due to no device being returned for evaluation, no visual inspection, functional testing, or dimensional analysis was able to be performed.As such, a manufacturing non-conformance was unable to be determined.Review of the dhr, lot history and manufacturing mitigations provided no indication that manufacturing nonconformance was a contributing factor.A review of ifu/training materials revealed no deficiencies.As reported, ¿the patient had a small root with a narrow, calcified stj (25.4mm) and the height from the annulus to the stj was 20.2mm.The rupture was most likely caused by calcification on the stj.¿ the presence of calcification can create a challenging anatomy for balloon inflation.While the balloons are sufficiently designed and tested for rated burst pressures well above their inflation pressure, calcified nodules can compromise the structure of the balloon wall via mechanisms such as puncture, local overstretching, open cell impingement, or stress concentration.Available information suggests that patient factors (calcification) may have contributed to the complaint event.However, a definitive root cause was unable to be determined.Since no edwards defect was identified, no corrective/preventative actions are required.Additionally, since no product non-conformance was confirmed, a product risk assessment escalation is not required.
 
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Brand Name
EDWARDS COMMANDER DELIVERY SYSTEM WITH S3U
Type of Device
AORTIC VALVE, PROSTHESIS, PERCUTANEOUSLY DELIVERED
Manufacturer (Section D)
EDWARDS LIFESCIENCES
1 edwards way
irvine CA 92614
MDR Report Key10405444
MDR Text Key205344084
Report Number2015691-2020-13104
Device Sequence Number1
Product Code NPT
Combination Product (y/n)N
PMA/PMN Number
P140031
Number of Events Reported1
Summary Report (Y/N)N
Report Source Manufacturer
Source Type company representative,health
Remedial Action Other
Type of Report Initial,Followup,Followup
Report Date 07/22/2020
1 Device was Involved in the Event
1 Patient was Involved in the Event
Is this an Adverse Event Report? No
Is this a Product Problem Report? Yes
Device Operator Health Professional
Device Expiration Date04/16/2022
Device Model Number9750CM26A
Device Lot Number63131047
Was Device Available for Evaluation? No
Initial Date Manufacturer Received 07/22/2020
Initial Date FDA Received08/13/2020
Supplement Dates Manufacturer Received09/10/2020
07/23/2020
Supplement Dates FDA Received09/17/2020
11/06/2020
Is This a Reprocessed and Reused Single-Use Device? No
Patient Sequence Number1
Patient Age88 YR
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