MAUDE Adverse Event Report: DATASCOPE CORP. LINEAR 7.5FR. 40CC IAB; SYSTEM, BALLOON, INTRA-AORTIC AND CONTROL

Model Number	0684-00-0480-01
Medical Device Problem Code	Appropriate Device Problem Term/Code Not Available (3191)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	06/15/2025
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Due to character limit in e1 initial reporter name is (b)(6) event site name is (b)(6).The device has not been returned to the manufacturer so we are unable to complete an evaluation.If provided we will send a supplemental report with our additional findings.Complaint record id # (b)(4).
Event or Problem Description
The nurse called to inform that a 40 cc linear intra-aortic balloon had been used on the patient.While the doctor had inserted the balloon and was trying to draw blood from, they position, the balloon could not draw blood.The doctor moved the position of the balloon and tried to draw blood again but found that blood could not be drawn.
Event or Problem Description
The nurse called to inform that a 40 cc linear intra-aortic balloon had been used on the patient.While the doctor had inserted the balloon and was trying to draw blood from the y position, the balloon could not draw blood.The doctor moved the position of the balloon and tried to draw blood again, but found that blood could not be drawn.There was no harm or injury reported.
Additional Manufacturer Narrative
Due to characterization limit e1: initial reported: (b)(6).Updated fields: patient demographics, b4, b5, b7, d4 lot number, expiry date, serial number, d8, d9, e1 (initial reporter name, event site email, event site telephone), g1 (contact person ¿ mfg site), g3, g6, h2, h3, h6 (type of investigation, investigation findings, component codes, health effect ¿ impact codes, investigation conclusions).Corrected filed: d4 (udi number).No decon or visual inspection performed since product was not returned and could not be evaluated.Therefore, we were unable to confirm or determine a root cause for the reported failure.The failure mode is addressed in the risk file and is operating within its risk profile.The ifu addresses the reported failure.There were no ncmrs identified which could cause or contribute to the reported failure.The investigation does not indicate that the device was inadvertently released as non-conforming or an adulterated product or was a counterfeit.The complaint history review did not identify an adverse trend (increase in number of complaints over past three (3) months).Based on the rational provided above, no escalation to the capa process is required.
Event or Problem Description
N/a.
Additional Manufacturer Narrative
Updated fields: b4, g3, g6, h2.A1 (sex).Corrected fields: d1, e2.

• Brand Name: LINEAR 7.5FR. 40CC IAB
• Common Device Name: SYSTEM, BALLOON, INTRA-AORTIC AND CONTROL
• Manufacturer (Section D): DATASCOPE CORP.; 15 law drive; fairfield NJ 07004
• Manufacturer (Section G): DATASCOPE CORP.; 15 law drive; fairfield NJ 07004
• Manufacturer Contact: ewelina chorlowska ; 15 law drive; fairfield, NJ 07004
• MDR Report Key: 22356002
• Report Number: 2248146-2025-0000333
• Device Sequence Number: 8621996
• Product Code: DSP
• UDI-Device Identifier: 10607567106564
• UDI-Public: (01)10607567106564(10)3000388403(17)270513(11)240513
• Combination Product (Y/N): N
• Initial Reporter Country: TH
• PMA/510(K) Number: K041281
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional,User Facility,Company Representative
• Initial Reporter Occupation: Nurse
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 08/08/2025

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: Health Professional
• Device Model Number: 0684-00-0480-01
• Device Catalogue Number: 0684-00-0480-01
• Device Lot Number: 3000388403
• 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: 06/16/2025
• Supplement Date Received by Manufacturer: 07/24/2025; 07/31/2025
• Initial Report FDA Received Date: 06/30/2025
• Supplement Report FDA Received Date: 07/29/2025; 08/08/2025
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 05/13/2024
• Is the Device Labeled for Single Use? (Y/N): Yes
• Usage of Device: Initial
• Patient Sequence Number: 1
• Patient Age: 59 YR
• Patient Sex: Male
• Patient Weight: 96 KG