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

Model Number	P15P-001
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Ischemia Stroke (4418)
Date of Event	05/09/2025
Type of Reportable Event	Serious Injury
Event or Problem Description
The site contacted berlin heart inc (bhi) clinical affairs (ca) on (b)(6) 2025 to report that the patient supported with excor blood pump pu valves; 15 ml in/out; ø 9 mm; was noted to have left facial drooping, left upper and lower extremity weakness on (b)(6) 2025.On the same day, a ct scan, with and without contrast as well as perfusion scan were performed, and the results showed no acute abnormality.There was a chronic right parietal infarct.This was new from the previous ct, which showed a perfusion abnormality in the region.According to the site, the excor blood pump performed as intended with complete filling and ejection.The pump was noted to have deposits before and after the event.
Additional Manufacturer Narrative
The excor blood pump pu valves; 15 ml in/out; ø 9 mm; sn (b)(6) was in use on the patient from (b)(6) 2025 up to date.The event occurred on (b)(6) 2025, which is (34 days) after the pump was placed on the patient.The pump continues to remain on the patient.We have reviewed the production records of the excor blood pump and concluded that the pump was produced according to our specification.

• Brand Name: EXCOR®
• Common Device Name: VENTRICULAR (ASSIST) BYPASS
• Manufacturer (Section D): BERLIN HEART GMBH; wiesenweg 10; berlin, 12247 ; GM 12247
• MDR Report Key: 22176666
• Report Number: 3008454189-2025-00013
• Device Sequence Number: 9200065
• Product Code: DSQ
• UDI-Device Identifier: 04260090040157
• UDI-Public: (01)04260090040157(17)270518
• Combination Product (Y/N): N
• Initial Reporter State: TX
• 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: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 06/10/2025
• Report Date (Section F): 06/10/2025

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: P15P-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: 05/13/2025
• Device Age: 12 MO
• Event Location: Hospital
• Date Report to Manufacturer: 05/13/2025
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 06/10/2025
• 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: 9 MO
• Patient Sex: Female
• Patient Weight: 8 KG
• Date Report Sent to FDA: 06/10/2025