MAUDE Adverse Event Report: TERUMO CARDIOVASCULAR SYSTEMS CORPORATION HERC FLEX 360 DEVICE ASSY; UNIVERSAL STABILIZER ARM

Model Number	T401162
Medical Device Problem Code	Physical Resistance/Sticking (4012)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	06/28/2021
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Terumo has not received the device for evaluation; therefore, the investigation has yet to be completed.Terumo plans on submitting a follow-up report when the investigation is complete and when more information becomes available.(b)(4).
Event or Problem Description
The user facility reported to terumo cardiovascular that the arm links stuck.It is unknown when this event occurred.Due to the unknown information for this event, it is being reported.Terumo continues to attempt to gain more information regarding this event from the user facility.The product was changed out.Procedure was completed successfully.
Event or Problem Description
The product was not changed out.
Additional Manufacturer Narrative
This follow-up report is submitted, to fda in accord with applicable regulations.And as indicated, by terumo cardiovascular systems in the initial report submitted to the fda on july 21, 2021.Upon further investigation of the reported event.The following information is new and/or changed: b5: (updated describe event or problem).D4: (additional device information, added exp date).G3: (date received by manufacturer).G6: (indication that this is a follow-up report).H2: (follow-up, due to correction and additional information).H4: (device manufacture date).H6: (identification of evaluation codes 3331, 4114, 174, 12).Type of investigation #1: 3331, analysis of production records.Type of investigation #2: 4114, device not returned.Investigation findings: 174, material and/or chemical problem identified.Investigation conclusions: 12, cause traced to device design.The affected sample was not returned.Therefore, a thorough investigation could not be conducted.An engineering investigation and has been completed.And design changes have been implemented to prevent recurrence.All available information has been placed on file in quality management for appropriate tracking, trending, and follow-up.

• Brand Name: HERC FLEX 360 DEVICE ASSY
• Common Device Name: UNIVERSAL STABILIZER ARM
• Manufacturer (Section D): TERUMO CARDIOVASCULAR SYSTEMS CORPORATION; 125 blue ball road; elkton MD 21921
• MDR Report Key: 12207757
• Report Number: 1124841-2021-00175
• Device Sequence Number: 4507653
• Product Code: MWS
• UDI-Device Identifier: 00699753450943
• UDI-Public: (01)00699753450943
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: N/A
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 09/16/2021

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
• Operator of Device: Health Professional
• Device Expiration Date: 02/07/2024
• Device Model Number: T401162
• Device Catalogue Number: N/A
• Device Lot Number: T00272
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Initial Date Received by Manufacturer: 07/05/2021
• Supplement Date Received by Manufacturer: 09/14/2021
• Initial Report FDA Received Date: 07/21/2021
• Supplement Report FDA Received Date: 09/16/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1