MAUDE Adverse Event Report: EDWARDS LIFESCIENCES LLC EDWARDS TRANSFEMORAL SHEATH; PROSTHESIS, MITRAL VALVE, PERCUTANEOUSLY DELIVERED

Model Number TF SHEATH UNKNOWN

Device Problem Adverse Event Without Identified Device or Use Problem (2993)

Patient Problem Hematoma (1884)

Event Date 07/01/2021

Event Type  Injury  

Manufacturer Narrative

This report provides data from thv/tvt registry and summarizes 1 events of hematoma - access site for the sapien 3 ultra heart valve in the mitral position.The 'time to event' (tte, in days) for this event was 0.Due to the limited information and the data received, edwards cannot confirm which esheath was used in this case, the axela or esheath introducer set.The udi for both devices are referenced below.The device identification (di) numbers for edwards axela sheath is (b)(4).The device identification (di) numbers for edwards esheath introducer set are (b)(4), (b)(4).The instructions for use (ifu) list hemorrhage requiring transfusion or intervention as a potential risk associated with the overall transcatheter valve replacement procedure, including potential access complications associated with standard cardiac catheterization.The majority of transfemoral access related bleeding complications are related to diseased ileo-femoral vessels and/or procedural technique during the insertion or removal of the sheath and/or dilators.There are cases where the bleeding is significant and more complex intervention or transfusion is required to treat/prevent a permanent injury from occurring.The thv physician training manuals instruct on procedural considerations for sheath insertion with regards to proper screening critical to reducing vascular complications.The ifu contraindicates patients with ilio-femoral vessel characteristics that would preclude safe placement of sheaths such as severe obstructive calcification or severe tortuosity.Pre-procedure screening and assessment of the femoral/iliac artery internal diameters will enable the clinician to determine if the valve can be delivered transfemorally.In this case, specific procedural details are not available to determine potential contributing factors to the event, or if the event is related to an edwards device; however, a transfusion of blood was reported in the registry.By varc definition, this meets criteria for major vascular complication therefore, the event is being reported.The ifu and training manuals have been reviewed and no inadequacies have been identified with regards to warnings, contraindications, and the directions/conditions for the successful use of the device.Complaint histories for all reported events are reviewed against trending control limits on a monthly basis, and any excursions above the control limits are assessed and documented as part of this monthly review.No corrective or preventative actions are required at this time.

Event Description

Thv/tvt registry summary reporting for adverse event submission for q3 2021 data extract for mitral serious injuries for the sapien 3 ultra valve.This report summarizes 1 hematoma - access site event for the sapien 3 ultra valve.This event is for an (b)(6) -year-old male patient.

Manufacturer Narrative

Resubmitting corrected mdr to provide exemption number in provided field.No new information to report.

• Brand Name: EDWARDS TRANSFEMORAL SHEATH
• Type of Device: PROSTHESIS, MITRAL VALVE, PERCUTANEOUSLY DELIVERED
• Manufacturer (Section D): EDWARDS LIFESCIENCES LLC; 1 edwards way; irvine CA 92614
• Manufacturer (Section G): EDWARDS LIFESCIENCES LLC; 1 edwards way; irvine CA 92614
• Manufacturer Contact: renee van dorne ; 1 edwards way; irvine, CA 92614 ; 9492506385
• MDR Report Key: 12721138
• MDR Text Key: 283680328
• Report Number: 2015691-2021-06055
• Device Sequence Number: 1
• Product Code: NPU
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: P140031
• Number of Events Reported: 1
• Summary Report (Y/N): Y
• Report Source: Manufacturer
• Source Type: Health Professional,User Facility
• Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date: 11/17/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 10/29/2021
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Health Professional
• Device Model Number: TF SHEATH UNKNOWN
• Device Catalogue Number: N/A
• Device Lot Number: N/A
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Date Manufacturer Received: 11/09/2021
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1
• Patient Outcome(s): Other
• Patient Age: 85 YR
• Patient Sex: Male