MAUDE Adverse Event Report: MEDTRONIC DOMINICANA CSF-FLOW CONTROL SHUNT; SHUNT, CENTRAL NERVOUS SYSTEM AND COMPONENTS

Model Number	9040 B
Medical Device Problem Code	Complete Blockage (1094)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	01/09/2026
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
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 regarding a shunt.It was reported that the doctor used the shunt, however, they mentioned that there was an issue with it as the fluid could not flow through when they used the valve.When they switched back to the patient's old valve, the fluid was able to flow.The patient's status at the time of the report was alive-no injury.Additional information received reported that after speaking with the doctor, the patient's currently implanted catheter (connected to the old shunt) was blocked so the procedure was to change out the old catheter and the old shunt to the new catheter and the new shunt.It was stated that there was nothing wrong with the patient's old shunt.The issue was that the cerebrospinal fluid (csf) was not draining through the new shunt.However, the doctor mentioned that the reservoir was filling with fluid during testing.As such, the doctor decided not to replace the old shunt with the new faulty shunt.The doctor did not share any details regarding the old shunt as the old shunt was not the problem, therefore, the manufacturer of the old shunt including the currently implanted catheter remained unknown.

• Brand Name: CSF-FLOW CONTROL SHUNT
• Common Device Name: SHUNT, CENTRAL NERVOUS SYSTEM AND COMPONENTS
• Manufacturer (Section D): MEDTRONIC DOMINICANA; zona franca de san isidro; carretera san isidro, km 17; santo domingo 11500 ; DR 11500
• Manufacturer (Section G): MEDTRONIC DOMINICANA; zona franca de san isidro; carretera san isidro, km 17; santo domingo 11500 ; DR 11500
• Manufacturer Contact: justin ellis ; 4620 n. beach st.; fort worth, TX 76137 ; 7635265677
• MDR Report Key: 24133270
• Report Number: 9612501-2026-00151
• Device Sequence Number: 10387703
• Product Code: JXG
• UDI-Device Identifier: 00763000027889
• UDI-Public: (01)00763000027889(17)280915(10)0227531401
• Combination Product (Y/N): N
• Initial Reporter Country: SN
• PMA/510(K) Number: K831678
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (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): 01/21/2026

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 Model Number: 9040 B
• Device Catalogue Number: 9040 B
• Device Lot Number: 0227531401
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 01/09/2026
• Initial Report FDA Received Date: 01/21/2026
• Date Device Manufactured: 10/12/2023
• 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