MAUDE Adverse Event Report: MEDTRONIC MEXICO TRI-AD RING; RING, ANNULOPLASTY

Model Number	900SFC230
Medical Device Problem Code	Patient Device Interaction Problem (4001)
Health Effect - Clinical Code	Atrial Fibrillation (1729)
Date of Event	12/11/2024
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Medtronic submits this report to comply with fda regulations 21 cfr parts 4 and 803.Medtronic has made reasonable efforts to provide as much relevant information as is available to the company as of the submission date of this report.This report does not constitute an admission or a conclusion by fda, medtronic, or its employees that the device, medtronic, or its employee caused or contributed to the event described in the report.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.Medtronic will submit a supplemental report if additional relevant information becomes known.
Event or Problem Description
Medtronic received information that 1 day post implant of this 30mm tricuspid annuloplasty band, it was reported that the patient re converted to atrial fibrillation and was treated with a bolus of antiarrhythmic medication and later converted to normal sinus rhythm. it was stated that the patient developed atrial fibrillation with rapid ventricular rate during the induction period of the impla nt procedure, but prior to implant of the band.The patient was then treated with a bolus of antiarrhythmic medication and cardioverted twice, returning to sinus rhythm.It was noted that the surgeon decided to perform a maze procedure during the operation.It was stated that due to the worsening of the patients atrial fibrillation post-operatively, the patient required medical intervention, qualifying this event as device-related. no additional adverse patient effects were reported.

• Brand Name: TRI-AD RING
• Common Device Name: RING, ANNULOPLASTY
• Manufacturer (Section D): MEDTRONIC MEXICO; av. paseo del cucapah #10510; tijuana,bc 22570 ; MX 22570
• Manufacturer (Section G): MEDTRONIC MEXICO; av. paseo del cucapah #10510; tijuana,bc 22570 ; MX 22570
• Manufacturer Contact: alison sweeney ; parkmore business park west; galway ; EI ; 091708096
• MDR Report Key: 21195965
• Report Number: 9612164-2025-00351
• Device Sequence Number: 15587023
• Product Code: KRH
• UDI-Device Identifier: 00763000102326
• UDI-Public: 00763000102326
• Combination Product (Y/N): N
• Initial Reporter State: MI
• Initial Reporter Country: US
• PMA/510(K) Number: K093903
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2024
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Study,Health Professional,Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 01/21/2025

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 Model Number: 900SFC230
• Device Catalogue Number: 900SFC230
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 12/24/2024
• Initial Report FDA Received Date: 01/21/2025
• Date Device Manufactured: 07/11/2024
• 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
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 61 YR
• Patient Sex: Male
• Patient Weight: 94 KG
• Patient Ethnicity: Non Hispanic
• Patient Race: White