MAUDE Adverse Event Report: BERLIN HEART GMBH EXCOR®; VENTRICULAR (ASSIST) BYPASS

Model Number	P10P-001
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Hemolysis (1886)
Date of Event	04/29/2025
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The excor blood pump pu valves; 10 ml in/out; ø 6 mm; sn (b)(6) was in use on the patient from (b)(6) 2025 until the time of the event on (b)(6) 2025.The pump continued to remain on the patient for a further 7 days until the patient was escalated to continuous flow on (b)(6) 2025.We have reviewed the production records of the excor blood pump and the pump was produced according to our specification.
Event or Problem Description
The site contacted berlin heart inc.(bhi) clinical affairs on (b)(6) 2025 to report that the patient being supported with an excor pediatric vad system experienced hemolysis.The patient's ldh levels increased to 2148 u/l and pfhgb 77.6 mg/dl on (b)(6) 2025.The rate on the excor active driving unit was decreased at the time of the event.Repeated lab values showed continued hemolysis and the patient was transitioned to continuous flow on (b)(6) 2025.According to the site, the excor blood pump maintained complete fill and ejection.

• Brand Name: EXCOR®
• Common Device Name: VENTRICULAR (ASSIST) BYPASS
• Manufacturer (Section D): BERLIN HEART GMBH; wiesenweg 10; berlin, 12247 ; GM 12247
• MDR Report Key: 22071139
• Report Number: 3008454189-2025-00012
• Device Sequence Number: 21008147
• Product Code: DSQ
• UDI-Device Identifier: 04260090040102
• UDI-Public: (01)04260090040102(17)270131
• Combination Product (Y/N): N
• Initial Reporter State: IL
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Importer
• Initial Reporter Occupation: Nurse
• Type of Report: Initial
• Report Date (Section B): 05/22/2025
• Report Date (Section F): 05/22/2025

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: P10P-001
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: Yes
• Distributor Facility Aware Date: 05/12/2025
• Device Age: 14 MO
• Event Location: Hospital
• Date Report to Manufacturer: 05/12/2025
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 05/22/2025
• 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: Other
• Patient Age: 4 MO
• Patient Sex: Female
• Patient Weight: 5 KG
• Date Report Sent to FDA: 05/22/2025