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Model Number NVTR-25 |
Device Problems
Migration or Expulsion of Device (1395); Improper or Incorrect Procedure or Method (2017)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 12/01/2022 |
Event Type
Injury
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Event Description
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It was reported that on (b)(6) 2022, a 25mm navitor valve was chosen for implant using a small flexnav delivery system ((b)(4)).The perimeter was measured as 72.8mm.The device size was chosen based on the calcification of the valve annulus.There was tortuosity encountered when attempting to access the blood vessel to implant the valve.A prebav was performed using an 18mm non-abbott balloon.It was seen via echocardiogram that there was some valve movement after the prebav and atrial regurgitation remained mild.The device was then placed at 5mm.After it was released, the valve could not expand.The device was removed from the patient with the delivery system, and both were discarded.Another prebav was completed using a 20mm balloon.A new delivery system ((b)(4)) and 25mm navitor valve ((b)(4)) were chosen for implant.The valve was deployed at 5mm again.After 5-7 minutes the valve expanded to 80% and the device was released from the delivery cable.As the delivery system was being removed, the stent on the non-coronary cusp side came off and the valve popped out of the patient's annulus.A snare was opened and intended to snare the valve away from the coronary artery ostium.However, the device was difficult to ensnare so the snare procedure was aborted.It was observed that the valve traveled between 15-20mm and stopped moving at the sinotubular junction (stj).It was determined that there was no risk of coronary artery occlusion.A non-abbott valve was then chosen to implant in a valve in valve procedure.This valve also did not expand well, and it was suspected that the size of the implantation site was insufficient.The valve was recaptured three times, but the result did not change.The user was concerned that the valve would be displaced again when attempting to remove the nosecone, so the second valve was not implanted.The patient remained hemodynamically stable throughout the procedure.There was no clinically significant delay.The patient was reported as stable.
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Manufacturer Narrative
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Investigation is not yet complete.A follow-up report will be submitted with all additional relevant information.
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Manufacturer Narrative
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An event of migration of valve out of patient's annulus was reported.A returned device assessment could not be performed as the device remains implanted and was not returned for analysis.The device history record was reviewed to ensure that each manufacturing and inspection operation was performed and the product met all defined manufacturing specifications.Based on the information received, the cause of the reported incident could not be conclusively determined.Please note that per the instructions for use,, "once the valve is fully deployed, repositioning and retrieval of the valve is not possible.Attempted retrieval (e.G., use of a guidewire, snare, or forceps) may cause aortic root, coronary artery, and/or myocardial damage." and "prior to release, use appropriate imaging to ensure the struts at the inflow (lvot) portion of the valve are aligned and confirm the depth of the implant is approximately 3 mm (0.12 in.).".
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Event Description
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N/a.
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Search Alerts/Recalls
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