MAUDE Adverse Event Report: CHRISTOPH MIETHKE GMBH & CO KG SHUNTASSISTANT 15; HYDROCEPHALUS MANAGEMENT

Model Number	FV250T
Medical Device Problem Code	Infusion or Flow Problem (2964)
Health Effect - Clinical Code	Hydrocephalus (3272)
Date of Event	07/19/2021
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Investigation: visual inspection: the following observations were made during the visual inspection: protein deposits on the product.Permeability test: the test showed that the shuntassistant is permeable.Computer control test: the computer controlled test showed the opening pressure of the shuntassistant, at a reference flow rate of 20 ml/h in a vertical position of the valve, to be 13.00 cmh2o.This is within the specified tolerance of 13 cmh2o +4/-2 cmh2o.Internal inspection of product: in order to verify whether the investigated valve was compromised by the known risks of hydrocephalus therapy, e.G.By a build-up of natural substances (protein, blood, or tissue particles) in the cerebrospinal fluid, we have dismantled the valve.After dismantling of the valve, no deposits were found in shuntassistant.Results: based on our investigation results, we cannot identify a deviation of the function in the valve.During our investigation the valve met all specifications.At the time of the investigation, it was not clear to us how the mentioned functional impairment occurred.No functional deviations were detected.We can exclude a defect at the time of release.The valve met all specifications of the final inspection when released from christoph miethke (b)(4).From our point of view, no further regulatory actions are required.The same event: medwatch#3004721439-2021-00221.
Event or Problem Description
It was reported that a shuntassistant (#fv250t) was implanted during a procedure performed on (b)(6) 2021.According to the complainant, the vlave was believed to have a blockage.The patient underwent a revision procedure on (b)(6) 2021.The complainant device was returned to the manufacturer for evaluation.No patient complications were reported as a result of the revision procedure.No further patient data are available.The same event: medwatch#3004721439-2021-00221.

• Brand Name: SHUNTASSISTANT 15
• Common Device Name: HYDROCEPHALUS MANAGEMENT
• Manufacturer (Section D): CHRISTOPH MIETHKE GMBH & CO KG; ulanenweg 2; potsdam, 14469 ; GM 14469
• MDR Report Key: 12331156
• Report Number: 3004721439-2021-00222
• Device Sequence Number: 4981201
• Product Code: JXG
• UDI-Device Identifier: 04041906113100
• UDI-Public: 4041906113100
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: K110206
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2021
• Device Explanted Year: 2021
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,user f
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 08/17/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Expiration Date: 10/18/2023
• Device Model Number: FV250T
• Device Catalogue Number: FV250T
• Device Lot Number: 20039616
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 08/03/2021
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 07/19/2021
• Initial Report FDA Received Date: 08/17/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention