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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 dock and anatomy was confirmed based on empirical evidence.Available information in the complaint file suggests patient factors likely contributed to the event due to anatomical reasons, commissure to commissure distance and a perforation in the posterior leaflet.Therefore, the most likely cause of this event is due to patient factors.Based on the available information from the event description and engineering investigation, the root cause is likely due to patient factors.Potential patient factors such as large commissure to commissure distance and/or pre-existing commissural health conditions, such as leaflet cleft, perforation, prolapse, flail, and/or mac, may have influenced pvl outcome.This issue is not related to a device malfunction that is related to 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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