MAUDE Adverse Event Report: CHRISTOPH MIETHKE GMBH & CO KG GAV W.DISTAL CATH.10/40; HYDROCEPHALUS MANAGEMENT

Model Number	FV320T
Medical Device Problem Code	Infusion or Flow Problem (2964)
Health Effect - Clinical Code	Hydrocephalus (3272)
Date of Event	08/26/2016
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
This complaint was reopened in reference to (b)(4).Investigation: visual inspection: no significant deformations or other abnormalities of the valves were detected during the visual inspection.Permeability test a permeability test has shown that the valve is permeable with difficulty.Results: first, we performed a visual inspection of the progav®.No significant deformations or damage of the valve were detected during the visual inspection.Next, we tested the permeability of the valve.The valve was permeable with difficulty finally, we have dismantled the valve.Inside the valve we have found a build-up of substances (likely protein).Based on our investigation, we confirm the occlusion in the valve, likely due to the deposits observed inside the valve.As described in scientific literature, the problem encountered is one of the known, inevitable risks of hg-therapy by shunt implants.We can exclude a defect at the time of release.The valve met all specifications of the final inspection when released from christoph miethke gmbh & co.Kg.No further regulatory actions are required from our point of view.
Event or Problem Description
It was reported that a gav w.Distal cath.10/40.(#fv320t) was implanted during a procedure performed on (b)(6) 2010.According to the complainant, the valve was believed to be blocked.The patient underwent a revision procedure on (b)(6) 2016.The complainant device was returned to the manufacturer for evaluation.No patient complications were reported as a result of the revision procedure.Patient information age: (b)(6).Weight: (b)(6).Height: 163 cm.

• Brand Name: GAV W.DISTAL CATH.10/40
• Common Device Name: HYDROCEPHALUS MANAGEMENT
• Manufacturer (Section D): CHRISTOPH MIETHKE GMBH & CO KG; ulanenweg 2; potsdam, 14469 ; GM 14469
• MDR Report Key: 12450704
• Report Number: 3004721439-2021-00628
• Device Sequence Number: 3420584
• Product Code: JXG
• UDI-Device Identifier: 04041906126001
• UDI-Public: 4041906126001
• Combination Product (Y/N): N
• Initial Reporter Country: GM
• PMA/510(K) Number: K031303
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2010
• Device Explanted Year: 2016
• 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): 09/09/2021

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 Model Number: FV320T
• Device Catalogue Number: FV320T
• Device Lot Number: 20010027
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 08/30/2016
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 09/06/2016
• Initial Report FDA Received Date: 09/09/2021
• 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
• Patient Age: 17 YR
• Patient Weight: 84