MAUDE Adverse Event Report: EDWARDS LIFESCIENCES EVOQUE TRICUSPID VALVE REPLACEMENT SYSTEM; PERCUTANEOUSLY DELIVERED PROSTHESES AND TRICUSPID VALVES

Model Number	9850EV48US
Medical Device Problem Code	Patient Device Interaction Problem (4001)
Health Effect - Clinical Code	Heart Block (4444)
Date of Event	06/20/2025
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The manufacturer's investigation is ongoing and a follow-up report will be submitted when the investigation is complete.
Event or Problem Description
Edwards received notification of a transcatheter tricuspid valve replacement (ttvr) procedure involving the evoque system.Upon deployment/full release of the evoque valve, patient went into complete heart block with an underlying junctional rhythm about 40bpm which converted to 2:1 2nd degree av block after about a minute.The final valve deployment position was stable at annular level.Due to the stable rhythm, it was decided to remove the evoque delivery system and wire and place a temporary pacing wire through the femoral vein access site.Ep was consulted.Once ep arrived, patient had converted to a sinus tachycardia about 115bpm.It was decided to place a temp-perm pacemaker via right internal jugular access in case high grade av block returns.The patient did end up needing the permanent pacemaker (ppm).The temp-perm was removed, and a leadless ppm was successfully placed.The patient is doing well.
Additional Manufacturer Narrative
The following sections were updated/corrected/added: b4, g3, g6, h2, h6 and h11.Additional type of investigation codes that were unable to be added in h6: labeling review.The complaint for "valve interacts with conduction system" was confirmed with other empirical evidence via information reported by edwards clinical specialist.The device history record review was completed.There were no non-conformances related to the issue observed or identified, and this device passed all manufacturing and sterilization inspections.Per the instructions for use (ifu), conduction system disturbance and/or heart block which may require treatment (including permanent pacemaker) are potential adverse events.Heart block and other conduction disturbances are common in patients with underlying cardiovascular disease and can be exacerbated or aggravated with standard intra-operative medications or anesthesia.Such events are related to the patient's underlying condition.Other mechanisms for conduction abnormalities could be related to coronary obstruction due to air embolism, coronary spasm and/or local edema affecting the av node.Conduction disturbances have also been documented during transcatheter cardiac procedures as a result of direct interaction with cardiac anatomy, especially in patients with underlying conduction abnormalities.Other potential causes include trauma by a guidewire or delivery system.Additionally, cardiac conduction system complications are known risks with tricuspid valve interventions due to the proximity of the atrioventricular node (av node) to the septal leaflet of the tricuspid valve.These conduction disturbances can lead to post-operative heart block, requiring pacemaker implantation.Nevertheless, a definitive root cause cannot be determined.Since no manufacturing non-conformances were confirmed and no ifu/training deficiencies were identified, no corrective/preventative actions are required.

• Brand Name: EVOQUE TRICUSPID VALVE REPLACEMENT SYSTEM
• Common Device Name: PERCUTANEOUSLY DELIVERED PROSTHESES AND TRICUSPID VALVES
• Manufacturer (Section D): EDWARDS LIFESCIENCES; 1 edwards way; irvine CA 92614
• Manufacturer (Section G): EDWARDS LIFESCIENCES; 1 edwards way; irvine CA 92614
• Manufacturer Contact: cassandra cook ; 1 edwards way; irvine, CA 92614 ; 5743778277
• MDR Report Key: 22472378
• Report Number: 2015691-2025-05606
• Device Sequence Number: 7853670
• Product Code: NPW
• UDI-Device Identifier: 00690103217452
• UDI-Public: (01)00690103217452(17)261119(11)241119
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: P230013
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2025
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 08/12/2025

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: 9850EV48US
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 06/20/2025
• Supplement Date Received by Manufacturer: 08/08/2025
• Initial Report FDA Received Date: 07/10/2025
• Supplement Report FDA Received Date: 08/12/2025
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 11/19/2024
• 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
• Usage of Device: Initial
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Sex: Female