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The manufacturing and material records for the device involved in this event, as they pertain to the reported issue, were retrieved and reviewed by the manufacturer¿s quality engineering.The results confirmed that this prosthesis satisfied all required material, visual, and performance standards at the time of manufacture and release.Since the valve was not returned to the manufacturer, no further investigation on the device could be performed.However, the document review did not reveal any anomalies concerning either the device size or the stent structure.Based on the available information, a 23mm inspiris valve was implanted following the explant of the pvf-l.This size corresponds to the upper limit for a perceval size m and the lower limit for a size l.Given that the annulus diameter appears to lie at the borderline between these two sizes, it cannot be ruled out that the reported valve movement may have resulted from unintended oversizing.As the sizing procedure is a critical step of the perceval plus valve implant, several recommendations are provided in the perceval plus valve¿s ifu, to prevent mis-sizing.In particular, the sizing procedure can lead to erroneous results in case the obturators of the sizers supplied with the prosthesis are inadvertently passed through the annulus in a direction not perpendicular to the annulus plane as this may alter the perceived resistance.Also, an inadvertent deformation of the annulus while using the white obturators could lead to erroneous results.In addition, care should be taken to perform the measurement precisely at the annular level, avoiding inadvertent advancement of the sizer int the lvot.To allow for an early detection of possible inadvertent mispositioning or mis-sizing of the perceval plus prosthesis prior to implant site closure, it is ultimately recommended to confirm valve integrity, correct positioning and valve functionality under beating heart conditions with transesophageal echocardiography (tee) prior to surgical access closure.However, since the surgeon declined further follow ups, no additional details about the event are available, and a definitive root cause cannot be determined.
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The manufacturer was informed of the intraoperative explant of a perceval plus, pvf-l, which occurred on (b)(6) 2025.Reportedly, the annulus was initially sized for a large valve.However, the surgeon indicated that the valve had moved so it was explanted and a size 23mm inspiris valve was implanted instead.Additional bypass time was required, though the exact duration could not be confirmed.The explanted valve will not be returned.Attempts to obtain further details were unsuccessful, as the surgeon declined additional follow up, and no further information is available regarding the event.
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