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| Model Number |
GWBC30 |
| Medical Device Problem Code |
Patient Device Interaction Problem (4001)
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| Health Effect - Clinical Codes |
Bradycardia (1751); Low Blood Pressure/ Hypotension (1914); Cardiac Tamponade (2226); Cardiac Perforation (2513); Pericardial Effusion (3271)
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| Date of Event |
01/06/2026
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Type of Reportable Event
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Death
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Event or Problem Description
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It was reported that following the implant of a transcatheter, the valve was successfully implanted.Upon withdrawing the wire, the valve was pulled and dislodged.A snare was used to stabilize the dislodged valve in the ascending aorta, and a second valve was implanted.Immediately after the implant of the second valve, hypotension and bradycardia were observed.An echocardiogram was performed that revealed a large pericardial effusion.Subsequently, resuscitation was performed, including cardiac massage, temporary pacing, and pericardial drainage.Emergency surgery was performed via left anterior thoracotomy in the apical area.At the end of the procedure, bleeding had ceased and the patient was hemodynamically stable.Approximately 5 hours following the implant procedure, the patient died.The physician assessed that during the implant of the second valve, the medtronic guidewire caused a left ventricle perforation that resulted in tamponade and subsequent death.Per the physician, the event was a procedure related complication, with no claims against the valve or delivery catheter system (dcs).
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Additional Manufacturer Narrative
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Select patient information cannot be included in regulatory report due to regional privacy regulations.Continuation of d10: product id: evfxplus-26 (serial: (b)(6)); product type: 0195-heart valves; implant date: (b)(6) 2026.Product id: d-evolutfx-2329 (lot: 0012454239); product type: 0195-heart valves.Medtronic submits this report to comply with fda regulations 21 cfr parts 4 and 803.Medtronic has made reasonable efforts to provide as much relevant information as is available to the company as of the submission date of this report.This report does not constitute an admission or a conclusion by fda, medtronic, or its employees that the device, medtronic, or its employee caused or contributed to the event described in the report.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.Medtronic will submit a supplemental report if additional relevant information becomes known.
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Additional Manufacturer Narrative
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Updated: b5, d4, h4, h6, h8.Medtronic submits this report to comply with fda regulations 21 cfr parts 4 and 803.Medtronic has made reasonable efforts to provide as much relevant information as is available to the company as of the submission date of this report.This report does not constitute an admission or a conclusion by fda, medtronic, or its employees that the device, medtronic, or its employee caused or contributed to the event described in the report.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.Medtronic will submit a supplemental report if additional relevant information becomes known.
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Event or Problem Description
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It was reported that following the successful implant of a transcatheter valve, upon withdrawing the wire, the valve was pulled and dislodged.A snare was used to stabilize the dislodged valve in the ascending aorta, and a second valve was implanted.Immediately after the implant of the second valve, hypotension and bradycardia were observed.An echocardiogram was performed that revealed a large pericardial effusion.Subsequently, resuscitation was performed, including cardiac massage, temporary pacing, and pericardial drainage.Emergency surgery was performed via left anterior thoracotomy in the apical area.At the end of the procedure, bleeding had ceased and the patient was hemodynamically stable.Approximately 5 hours following the implant procedure, the patient died.The physician assessed that during the implant of the second valve, the medtronic (confida) guidewire caused a left ventricle perforation that resulted in tamponade and subsequent death.Per the physician, the event was a procedure related complication, with no claims against the valve or delivery catheter system (dcs).Additional information was received that a pre-implant balloon dilation was not performed and a medtronic (confida) guidewire was used for the procedure.The guidewire was introduced and placed into the apex of the left ventricle through a catheter that was already positioned in the ventricle.The guidewire position was monitored throughout the procedure.The direction of dislodgement was aortic.The physician reported that the patient's frail, elderly condition and underlying pulmonary edema were contributing factors to the event.The physician excluded both the first and second valve and dcs used as contributing causes to the death.
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Search Alerts/Recalls
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