MAUDE Adverse Event Report: CHRISTOPH MIETHKE GMBH & CO KG PROGAV W/SHUNTASSIST.20 + DIST.CATH.; HYDROCEPHALUS MANAGEMENT

Model Number	FV420T
Medical Device Problem Code	Mechanical Problem (1384)
Health Effect - Clinical Code	Hydrocephalus (3272)
Date of Event	09/14/2017
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
This complaint was reopened in reference to (b)(4).Investigation: ( description incoming product condition) we received the valve inserted in an unknown liquid in the provided return kit.Results: first, we performed a visual inspection of the valve.Except for scratches, no significant deformations or damage of the valve was detected.Next, we tested the permeability, adjustability, as well as the brake functionality and brake force.The valve was not permeable.It was not possible to adjust the valve due to the defect of the brake.Additionally, the brake function and force test could not be performed.Significant outside pressure, for example by too much force from the adjustment tool or by a fall or impact to the head of the patient, can cause a lowering of the housing diaphragm, which is supposed to hold the rotor in its position, and impair its function.The brake is defective.Because the valve was not permeable, a computer controlled test was not possible.Finally, we have dismantled the valve.There were no visible deposits observed inside the valve that could explain the overdrainage or the defect of the rotor.The blockage detected remains unclear.Based on our investigation, we confirm the defect of the brake at the time of our investigation.The cause of the defect of the rotor could not be determined through our investigation.We can exclude a defect at the time of release.The valve met all specifications of the final inspections when released from christoph miethke (b)(4).No further actions required.
Event or Problem Description
According to the complainant a progav was operating in over-drainage and had a defect postoperatively.The valve was implanted (b)(6) 2015.It was revised on (b)(6) 2017 and was returned to the manufacturer.Further details were not provided.Patient data : weight: (b)(6) and height: 96 cm.
Additional Manufacturer Narrative
This complaint was reopened in reference to (b)(4).Investigation: ( description incoming product condition) we received the valve inserted in an unknown liquid in the provided return kit.Results: first, we performed a visual inspection of the valve.Except for scratches, no significant deformations or damage of the valve was detected.Next, we tested the permeability, adjustability, as well as the brake functionality and brake force.The valve was not permeable.It was not possible to adjust the valve due to the defect of the brake.Additionally, the brake function and force test could not be performed.Significant outside pressure, for example by too much force from the adjustment tool or by a fall or impact to the head of the patient, can cause a lowering of the housing diaphragm, which is supposed to hold the rotor in its position, and impair its function.The brake is defective.Because the valve was not permeable, a computer controlled test was not possible.Finally, we have dismantled the valve.There were no visible deposits observed inside the valve that could explain the overdrainage or the defect of the rotor.The blockage detected remains unclear.Based on our investigation, we confirm the defect of the brake at the time of our investigation.The cause of the defect of the rotor could not be determined through our investigation.We can exclude a defect at the time of release.The valve met all specifications of the final inspections when released from christoph miethke (b)(4).No further actions required.
Event or Problem Description
According to the complainant a progav was operating in over-drainage and had a defect postoperatively.The valve was implanted (b)(6) 2015.It was revised on (b)(6) 2017 and was returned to the manufacturer.Further details were not provided.Patient data : weight: (b)(6) and height: 96 cm.

• Brand Name: PROGAV W/SHUNTASSIST.20 + DIST.CATH.
• 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: 13063031
• Report Number: 3004721439-2021-00830
• Device Sequence Number: 11178078
• Product Code: JXG
• UDI-Device Identifier: 04041906132170
• UDI-Public: 4041906132170
• 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): 12/22/2021

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: 06/30/2020
• Device Model Number: FV420T
• Device Catalogue Number: FV420T
• Device Lot Number: 20027218
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 09/26/2017
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 10/11/2017
• Initial Report FDA Received Date: 12/22/2021
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 07/15/2015
• 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: 4 YR
• Patient Sex: Unknown