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The following sections were updated/corrected/added: b4, g3, g6, h2, h6 and h11 the complaint for intraprocedural paravalvular leak between the dock and anatomy was confirmed based on empirical evidence.Available information suggests that procedural factors likely contributed to the event due to a low dock.Therefore, the most likely cause of this event is procedural factors.Based on the available information from the event description and engineering investigation, the root cause is likely due to procedural factors.Procedural factors affecting pvl include low dock deployment, incorrect or canted dock position, and/or a crisscrossed dock.This issue is not related to a device malfunction that is associated with a manufacturing deficiency, labeling issue, or device-related infection.Therefore, a dhr is not required.Since there are no confirmed product or labeling/ifu/training material non-conformances affecting distributed product, and no other triggers have been met, no preventative or corrective actions are required.
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