MAUDE Adverse Event Report: INTEGRA LIFESCIENCES SWITZERLAND SAR STD CHPV W PRECHAMBER UNITIZED

Model Number	82-3111
Medical Device Problem Code	Obstruction of Flow (2423)
Health Effect - Clinical Code	Meningitis (2389)
Date of Event	02/18/2022
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
An investigation has been initiated based on the reported information.Upon completion of the investigation, a follow-up report will be submitted.
Event or Problem Description
A physician reported a hakim valve (id 823111) was implanted via v-p shunt on unknown date with unknown setting, the patient developed meningitis and shunt obstruction was suspected.The valve was removed on (b)(6) 2022.It was unknown if the valve was replaced.The patient current condition is unknown.
Additional Manufacturer Narrative
The hakim valve (id 823111) was returned for evaluation: device history record (dhr) - the product code 82-3111 with lot cpgbvp, conformed to the specifications when released to stock.Failure analysis - the valve was visually inspected; a needle hole over the needle guard was noted.The position of the cam when valve was received was 110mmh2o.The valve was hydrated.The valve was leak tested and only leaked from the needle hole in over the needle guard.The valve passed the test for programming, occlusion, reflux and pressure.Root cause - no root cause could be determined as the technician could not confirm any occlusions with the valve at the time of investigation.The possible root cause for the issue reported by the customer, could be due to biological debris and protein build up interfering with the valve mechanism, at the time of investigation no occlusion issues were noted.
Event or Problem Description
N/a.

• Brand Name: STD CHPV W PRECHAMBER UNITIZED
• Common Device Name: CHPV
• Manufacturer (Section D): INTEGRA LIFESCIENCES SWITZERLAND SAR; rue girardet 29; rue girardet 29; le locle ; SZ
• Manufacturer (Section G): INTEGRA LIFESCIENCES SWITZERLAND SAR; rue girardet 29; ch-2400; le locle ; SZ
• Manufacturer Contact: vivian nelson ; 1100 campus drive; princeton, NJ ; 6099362319
• MDR Report Key: 14015392
• Report Number: 3013886523-2022-00129
• Device Sequence Number: 15021376
• Product Code: JXG
• UDI-Device Identifier: 10886704041467
• UDI-Public: (01)10886704041467(17)180430(10)CPGBVP
• Combination Product (Y/N): N
• PMA/510(K) Number: K122118
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Explanted Year: 2022
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional,User Facility
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 05/06/2022

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?: No
• Operator of Device: Health Professional
• Device Expiration Date: 04/30/2018
• Device Model Number: 82-3111
• Device Catalogue Number: 823111
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 03/17/2022
• Supplement Date Received by Manufacturer: 04/28/2022
• Initial Report FDA Received Date: 04/05/2022
• Supplement Report FDA Received Date: 05/07/2022
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 05/31/2013
• 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: Unknown
• Patient Sequence Number: 1
• Patient Sex: Unknown