MAUDE Adverse Event Report: PERFUSION SYSTEMS OCTOPUS EVOLUTION AS TISSUE STABILIZER; STABILIZER, HEART

Model Number	TS2500
Medical Device Problem Code	Delivered as Unsterile Product (1421)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	06/19/2024
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Device evaluation summary: visual inspection shows evidence of damage to the medtronic package and there is evidence of a tear in the tyvek lid.Reason for return was confirmed.Note on g4 pma / 510(k) #: device is class i exempt.This regulatory report is being submitted as part of a retrospective review and remediation as part of a capa action.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.
Event or Problem Description
Medtronic received information that prior to use of an octopus tissue stabilizer, it was reported that when receiving goods from the carrier's forwarder from medtronic to an pha.The customer observed that 01 box had damaged packaging, the product inside had black stains due to damaged outer shell.The device was replaced.There was no patient involvement, so no adverse effect occurred.Medtronic received additional information that the package is intact, customer kept the defective package as it was received.

• Brand Name: OCTOPUS EVOLUTION AS TISSUE STABILIZER
• Common Device Name: STABILIZER, HEART
• Manufacturer (Section D): PERFUSION SYSTEMS; 7611 northland dr; brooklyn park MN 55428
• Manufacturer (Section G): PERFUSION SYSTEMS; 7611 northland dr; brooklyn park MN 55428
• Manufacturer Contact: alison sweeney ; parkmore business park west; galway ; EI ; 091708096
• MDR Report Key: 24108300
• Report Number: 2184009-2026-00102
• Device Sequence Number: 17618593
• Product Code: MWS
• UDI-Device Identifier: 00643169668904
• UDI-Public: (01)00643169668904(17)260920(10)2023090821
• Combination Product (Y/N): N
• Initial Reporter Country: VM
• PMA/510(K) Number: N/A
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional,Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 01/19/2026

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 Expiration Date: 09/20/2026
• Device Model Number: TS2500
• Device Catalogue Number: TS2500
• Device Lot Number: 2023090821
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 07/08/2024
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 06/20/2024
• Initial Report FDA Received Date: 01/19/2026
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 09/20/2023
• 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
• Patient Sex: Unknown