MAUDE Adverse Event Report: LSI SOLUTIONS, INC. COR-KNOT®; INSTRUMENT, LIGATURE PASSING AND KNOT TYING

Model Number	030800
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	09/20/2023
Type of Reportable Event	Malfunction
Event or Problem Description
Cor-knot devices not loading into guns correctly and not allowing cor-knot to pull through.

• Brand Name: COR-KNOT®
• Common Device Name: INSTRUMENT, LIGATURE PASSING AND KNOT TYING
• Manufacturer (Section D): LSI SOLUTIONS, INC.; 7796 victor-mendon rd; victor NY 14564
• MDR Report Key: 18613952
• Report Number: 18613952
• Device Sequence Number: 2406158
• Product Code: HCF
• UDI-Device Identifier: 00850200006100
• UDI-Public: (01)00850200006100(17)240531(10)851493
• Combination Product (Y/N): N
• Initial Reporter State: VA
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: User Facility
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 10/12/2023
• Report Date (Section F): 10/12/2023

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: Other
• Device Model Number: 030800
• Device Catalogue Number: 030800
• Device Lot Number: 851493
• Was Device Available for Evaluation?: Yes
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: Yes
• Event Location: Hospital
• Date Report to Manufacturer: 01/31/2024
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 01/31/2024
• 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: Male
• Patient Weight: 112 KG
• Date Report Sent to FDA: 10/12/2023