| Model Number |
9-VSD-MUSC-010 |
| Medical Device Problem Code |
Device Damaged by Another Device (2915)
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| Health Effect - Clinical Code |
No Clinical Signs, Symptoms or Conditions (4582)
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| Date of Event |
08/05/2025
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Type of Reportable Event
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Malfunction
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Additional Manufacturer Narrative
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Investigation is not yet complete.A follow-up report will be submitted with all additional relevant information.
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Event or Problem Description
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It was reported that on (b)(6) 2025, a 12mm amplatzer septal occluder (aso) was chosen for implantation into a pseudoaneurysm neck present on the outside wall of the left ventricle.A greater than 80cm delivery sheath was required to reach the defect, so a delivery cable from an amplatzer trevisio was used with a non-abbott terumo sheath.The sheath was advanced to the defect.Once the aso exited the tip of the sheath, it deformed into a cobra shape.The aso was removed and the deformation was massaged out.The aso was re-loaded with tension and attempted to be deployed again but deformed into cobra shape once more.It was thought papillary strands may have prevented a normal deployment or interaction with the non-abbott sheath.A 12mm amplatzer ventricular septal defect occluder (vsd) was then chosen for implantation utilizing the same non-abbott 7f delivery sheath.The vsd was hard to advance through the sheath, so the sheath was exchanged for a non-abbott 7f shuttle sheath.The 12mm vsd was deployed but was deformed (elongated and bulbous) possibly due to papillary muscle again.12mm vsd removed and exchanged for 10mm vsd with the same delivery system.The 10mm vsd was deployed but insufficiently closed the defect as it was too small so it was removed.When removing, it pulled a shred of the delivery sheath inner lumen.Finally, a 11mm aso was implanted successfully.The patient remained hemodynamically stable throughout the procedure.There were no reported patient consequences.
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Additional Manufacturer Narrative
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It was reported that when removing the vsd device, it pulled a shred of the delivery sheath inner lumen.The investigation confirmed the returned device met specifications when analyzed at abbott under non-physiological conditions.The returned loader was noted to be kinked.The device history record was reviewed to ensure that each manufacturing and inspection operation was performed and the product met all defined manufacturing specifications.The cause of the reported event could not be conclusively determined.There were no complaints associated with any other devices from the lot.There is no indication of a product quality issue with respect to labeling design or manufacturing of the device.
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Search Alerts/Recalls
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