MAUDE Adverse Event Report: MAQUET CARDIOVASCULAR LLC ACROBAT-I STABILIZER Z; STABILIZER, HEART

Model Number	ACROBAT-I STABILIZER Z
Medical Device Problem Code	Positioning Problem (3009)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	02/07/2022
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Trackwise id (b)(4).The device has not yet been returned to maquet cardiac surgery for evaluation.We are following up with the customer for the return of the device.A supplemental report will be submitted if the device is received.
Event or Problem Description
The hospital reported that during a coronary artery bypass procedure using acrobat-i positioner z, even if they turned the knob, they couldn't fix it just by turning it, so they used a new product and finished the operation.When it occurred, it was fixed to the blade.The knob is turning in the right direction.There was no harm to the patient.
Additional Manufacturer Narrative
Trackwise # (b)(4).
Additional Manufacturer Narrative
Trackwise (b)(4).The investigation including the following contents has been conducted: 1.Analysis of production: (3331): the dhr of the reported lot 3000190786 has been reviewed.No non-conformity indicating the reported failure was observed.All the products had been performed 100% mechanical function test during production.They all passed the function test, which demonstrate the knob can be tighten and also can tighten the link arm.2.Trend analysis: (4110): (b)(4).There¿s no similar complaint reported for this lot 3000190786.3.Testing of actual/suspected device & testing of raw/starting materials: (10 & 4105) returned product evaluation: the device was received on june.21st, 2022, the following contents have been done: 1) physical inspection: no visual defects were observed on the product; 2) functional test: assemble the device securely onto a reference retractor blade by sliding the positioner base onto the rail and locking the lever.Evaluate the knob for its ability to tighten the flexlink arm while the locking lever in both the locked and unlocked positions.The knob was rotating normally, the knob can be tightened and flexlink arm can be tightened.3) disassemble the device and check the assembly status according to the applicable manufacturing process instructions knob assembly (b)(4).It is found that the lead-in thread on acme nut was broken.4) verify 2 to 4 threads of the acme screw are exposed past the housing mount.It shows about 3 threads out of the housing mount, the returned product is conforming to this requirement.5) check the pilot crimping and its position, the pilot crimping is conforming, without defects on it, and its position is there without moving.6) the dimension of the relevant components are measured and within drawing specification, no deficiency indicating the knob tighten and flexlink arm tighten issue was observed.There's no non-conformity observed indicating the acme nut thread broken or defect from raw material inspection.All the products had been performed 100% mechanical function test during production.They all passed the function test which demonstrate the knob can be tighten and also can tighten the link arm.Complaint historical data (4109) has been reviewed, the failure knob difficult/ unable to tighten-arm does not lock happened before and has been investigated.The knob rotating idling or stuck was caused because of the misalignment of acme nut and acme screw lead in thread, when rotating the knob by pulling the arm forward with extreme strength, or rotating anti-clockwise rapidly for several circles and then rotating the knob clockwise rapidly, or rotating the knob leaner with too much strength, the acme screw could not be well engaged or even not engaged with acme nut, then rotating become stuck or idling, which resulted in the knob could not be tighten, and link arm could not be tightened.Based upon the above evaluation, there¿s no deficiency identified from production relevant to the mechanical issue- knob difficult/ unable to tighten-arm does not lock prior to this complaint.It is not indicated that it is the product problem, and also not indicates a manufacturing defect caused or contributed to the reported failure during the investigation.The most probable root cause of the knob difficult/ unable to tighten-arm could be the misalignment of acme nut and acme screw when using with extreme strength pulling flexlink arm forward or rotating the knob rapidly or leaner with too much strength.
Event or Problem Description
N/a.

• Brand Name: ACROBAT-I STABILIZER Z
• Common Device Name: STABILIZER, HEART
• Manufacturer (Section D): MAQUET CARDIOVASCULAR LLC; 45 barbour pond drive; wayne NJ
• Manufacturer (Section G): MAQUET CARDIOVASCULAR LLC; 45 barbour pond drive; wayne NJ
• Manufacturer Contact: arelean guzman ; 45 barbour pond drive; wayne, NJ
• MDR Report Key: 13674027
• Report Number: 2242352-2022-00200
• Device Sequence Number: 20022429
• Product Code: MWS
• UDI-Device Identifier: 00607567500006
• UDI-Public: 00607567500006
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Foreign,User Facility,Company Representative
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 08/13/2022

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Expiration Date: 09/06/2023
• Device Model Number: ACROBAT-I STABILIZER Z
• Device Catalogue Number: XP-5000Z
• Device Lot Number: 3000190786
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 02/07/2022
• Supplement Date Received by Manufacturer: 06/21/2022; 09/02/2022
• Initial Report FDA Received Date: 03/04/2022
• Supplement Report FDA Received Date: 07/11/2022; 09/02/2022
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 09/06/2021
• Is the Device Labeled for Single Use? (Y/N): Yes
• Usage of Device: Unknown
• Patient Sequence Number: 1
• Patient Sex: Unknown