MAUDE Adverse Event Report: CHRISTOPH MIETHKE GMBH & CO KG PROGAV SYS PED.W/SA 20 A.BURRH.RES.; HYDROCEPHALUS MANAGEMENT

Model Number	FV448T
Medical Device Problem Code	Mechanical Problem (1384)
Health Effect - Clinical Code	Hydrocephalus (3272)
Date of Event	07/14/2017
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
This complaint was reopened in reference to (b)(4).Investigation: (description incoming product condition) the valve was returned submerged in an unknown liquid in the provided returnkit.Result: first we performed a visual inspection of the progav.Except scratches, no significant deformations or damage of the valve were detected during the visual inspection.Next we tested the permeability, adjustability, brake functionality and brake force.Both valves have a blockage, therefore a computer controlled test was not possible.The progav was not adjustable throughout the normal range.The brake functionality test has shown that the brake function is operational, however the braking force cannot be measured due to the non-adjustability of the valve.Finally, we dismantled the valves.Inside both valves we have found slight build-up of substances (likely protein).Based on our investigation, we confirm the presence of deposits in the system at the time of investigation.It is possible that the deposits observed inside the valve caused the malfunction.As described in scientific literature, the problem encountered is one of the known, inevitable risks of hc-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 miehtke (b)(4).No further actions required.
Event or Problem Description
According to the complainant a progav operated in overdrainage postoperatively.The valve was implanted on (b)(6) 2015.It was removed on (b)(6) 2017 due to the malfunction and returned to the manufacturer.Further details were not provided.Height: 120 cm.

• Brand Name: PROGAV SYS PED.W/SA 20 A.BURRH.RES.
• Common Device Name: HYDROCEPHALUS MANAGEMENT
• Manufacturer (Section D): CHRISTOPH MIETHKE GMBH & CO KG; ulanenweg 2; potsdam, 14469 ; GM 14469
• Manufacturer (Section G): CHRISTOPH MIETHKE GMBH & CO KG; ulanenweg 2; potsdam, 14469 ; GM 14469
• Manufacturer Contact: joerg knebel ; ulanenweg 2; potsdam, 14469 ; GM 14469
• MDR Report Key: 12927878
• Report Number: 3004721439-2021-00802
• Device Sequence Number: 14649543
• Product Code: JXG
• UDI-Device Identifier: 04041906132682
• UDI-Public: 4041906132682
• Combination Product (Y/N): N
• Initial Reporter Country: GM
• PMA/510(K) Number: K103003
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2015
• Device Explanted Year: 2017
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Health Professional,User Facility
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 12/03/2021

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: 06/30/2019
• Device Model Number: FV448T
• Device Catalogue Number: FV448T
• Device Lot Number: 4506340058
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 08/14/2017
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 08/16/2017
• Initial Report FDA Received Date: 12/03/2021
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 11/27/2014
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 8 YR
• Patient Sex: Unknown
• Patient Weight: 35 KG