MAUDE Adverse Event Report: DAVOL INC., SUB. C.R. BARD, INC. -1213643 XENMATRIX; PORCINE SURGICAL MESH

Catalog Number	1161935
Medical Device Problem Code	Patient Device Interaction Problem (4001)
Health Effect - Clinical Code	Hernia (2240)
Date of Event	01/22/2015
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
As reported, about 10 months post-implant of the two xenmatrix devices implanted on (b)(6) 2014 (device #1 and device #2), the patient was diagnosed with recurrent incisional hernia and underwent reoperation to repair the hernia.The clinician has assessed the patient¿s postoperative course as definitely related to the study device and possibly related to the procedure.However, based on the information provided, no conclusion can be made.Hernia recurrence is a known inherent risk of surgery and listed as a possible complication in the instructions-for-use (ifu) supplied with the device.Review of manufacturing records confirms product was manufactured to specification.This mdr represents the ae of hernia recurrence associated with device #2.Additional mdrs have been submitted to represent the aes of hernia recurrence associated with device #1 and abscess & fistula (device #3).Not returned - remains implanted.
Event or Problem Description
Alleged per clinical trial dvl-he-020: on (b)(6) 2014, the subject patient underwent a multiple-recurrent open incisional transverse hernia (25 cm x 20 cm) repair procedure, during which two xenmatrix surgical grafts (device #1 & device #2) were trimmed and placed in underlay fashion intra-peritoneally using sutures.Fascia was completely closed with vicryl suture in interrupted stitch technique and full closure was achieved with sutures.Concomitant procedure included lysis of adhesion(s).The patient was discharged from the hospital on (b)(6) 2014.On (b)(6) 2015, the patient was diagnosed with recurrent incisional hernia.On (b)(6) 2015, the patient underwent reoperation to repair the hernia, during which another xenmatrix surgical graft (device #3) was implanted.The patient was discharged from the hospital on (b)(6) 2015.The ae (hernia recurrence) is clinically assessed to be of moderate severity, definitely related to the study device #1 & device #2, possibly related to the procedure and recovered/resolved.The reported adverse event met the definition of an sae (serious adverse event) and does not meet the definition of uade (unlisted adverse device event).On (b)(6) 2015, the patient was diagnosed with an abscess and was admitted into the hospital.The patient was discharged on (b)(6) 2015 and the abscess resolved on (b)(6) 2015.On (b)(6) 2015, the patient was diagnosed with an enterocutaneous fistula and was admitted into the hospital on (b)(6) 2015 and underwent a surgical procedure.Both the abscess and fistula were noted to be associated with the xenmatrix implanted on (b)(6) 2015 (device 3).

• Brand Name: XENMATRIX
• Common Device Name: PORCINE SURGICAL MESH
• Manufacturer (Section D): DAVOL INC., SUB. C.R. BARD, INC. -1213643; 100 crossings blvd.; warwick RI 02886
• Manufacturer (Section G): BARD SHANNON LIMITED -3005636544; san geronimo industrial park; lot #1, road #3, km 79.7; humacao PR 00791
• Manufacturer Contact: andrew topoulos ; 100 crossings blvd.; warwick, RI 02886 ; 8005566756
• MDR Report Key: 15209232
• Report Number: 1213643-2022-00580
• Device Sequence Number: 2123094
• Product Code: FTM
• UDI-Device Identifier: 00801741031441
• UDI-Public: (01)00801741031441
• Combination Product (Y/N): N
• Initial Reporter State: PA
• Initial Reporter Country: US
• PMA/510(K) Number: K140501
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2014
• Reporter Type: Manufacturer
• Report Source: Other,Study,Health Professional,User Facility
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 08/10/2022

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?: No
• Operator of Device: Health Professional
• Device Expiration Date: 10/28/2015
• Device Catalogue Number: 1161935
• Device Lot Number: HUXI1698
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 07/14/2022
• Initial Report FDA Received Date: 08/11/2022
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 11/08/2013
• 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: Initial
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Hospitalization; Required Intervention
• Patient Age: 57 YR
• Patient Sex: Female
• Patient Weight: 84 KG