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A mitraclip procedure was performed to treat degenerative mitral regurgitation (mr) with a grade of 4+ on a patient with prolapsed posterior leaflet and rotated heart.A steerable guide catheter (sgc) (60317a2077) and a mitraclip xtw clip delivery system (cds) (60429a1098) were prepared for use and inserted.However, upon initial m down steering, the sgc tip and cds moved in the wrong direction upon turning the knob.In the physician¿s opinion, the sgc and the cds were miskeyed due to fluoroscopy deflection.Therefore, a decision was made to retract the cds into the sgc.However, while retracting the cds into the sgc, the clip frictional elements engaged with the soft tip of the sgc and became stuck.Troubleshooting was performed to remove the cds from the sgc but was not successful.Therefore, a decision was made to remove the cds and the sgc together as one system.Once the cds and the sgc were safely in the inferior vena cava (ivc), the clip was able to be dislodged from the tip of the sgc.The entire system was then removed from the patient.A new sgc and a new clip were prepared for the procedure.Two clips were then implanted, reducing mr to a grade of 1.There were no adverse patient effects and no clinically significant delay in the procedure.
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The device was not returned for analysis.A review of the lot history record revealed no manufacturing nonconformities issued to the reported lot that would have contributed to this event.Additionally, a review of the complaint history identified no similar complaints reported from this lot.Based on the available information, the cause of the reported unintended movement (guide steering issues) and difficult to remove cds from sgc could not be determined.There is no indication of a product quality issue with respect to manufacture, design, or labeling.
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