MAUDE Adverse Event Report: Edwards Lifesciences Edwards SAPIEN 3 Ultra RESILIA Transcatheter Heart Valve; Aortic valve, prosthesis, percutaneously delivered

Model Number	9755RSL29A
Medical Device Problem Code	Perivalvular Leak (1457)
Health Effect - Clinical Code	Heart Failure/Congestive Heart Failure (4446)
Date of Event	08/13/2026
Type of Reportable Event	Serious Injury
Event or Problem Description
As reported by the field clinical specialist (fcs), during off label implant of a 29 mm sapien 3 ultra resilia valve in the mac position, the team started with a 16f esheath+ in the right femoral vein.There was a problem crossing the septum when the 29mm commander delivery system (ds) with the valve were inserted.The team decided to pull the ds and 16f esheath+ as one unit.The first valve was wasted.Another 29mm ds and 29mm sapien 3 ultra resilia were prepped.This time though, the team decided to use a 26f gore dry seal sheath to deliver the valve.It was able to successfully cross the septum with valve.The valve was deployed with nominal volume.Post dilatation was performed with +3cc.The team decided to do another post dilation but the ds was not able to go through the gore dry seal sheath, so another 29mm ds was prepped for post dilatation with +5cc.The operator also asked to attach an atrion inflation device to the system for pressure monitoring.The post dilatation was successful with mild-moderate pvl remaining.The 29mm ds was removed from the patient and they were stable after the case.An update from the fcs noted that 2 days post implant, the patient had a valve in valve procedure using another 29mm sapien 3 ultra resilia valve due to hemolysis and heart failure from to the paravalvular leak (pvl).
Additional Manufacturer Narrative
Per the instructions for use (ifu), paravalvular leak (pvl) is a known potential adverse event associated with bioprosthetic heart valves and the transcatheter valve replacement (tvr) procedure.Paravalvular leak refers to blood flowing through a channel between the structure of the implanted valve and the landing zone, as a result of a lack of appropriate sealing of the valve to the target site.Some pvl is not uncommon post-deployment.Many cases are mild to moderate, and either resolve over time or do not cause symptoms.Others may be more clinically significant and require intervention.The patient screening manual and the procedure didactic identify several procedural and anatomical factors which could contribute to pvl, including device malposition, inaccurate measurement of the landing zone, uneven distribution of calcium on the landing zone, bulky or severe calcification, an elliptical annulus shape, and valve under-sizing.The mechanism behind worsening or late pvl is not well understood but may be related to cardiac remodeling.Hemolysis is the destruction of red blood cells.There are multiple extrinsic and intrinsic factors including use of extracorporeal circulation, transfusion, infection, tumors, autoimmune disorders, medication side effects, a metabolic abnormality, and red blood cell membrane instability.Normal red blood cells (erythrocytes) have a lifespan of about 120 days.After the lifespan is over the red blood cells break down and are removed from the circulation by the spleen.In some medical conditions, or because of taking certain medications, this breakdown of red blood cells is increased.Medications that have been associated with hemolysis include acetaminophen, penicillin, and other pain medications.Red cells may be destroyed due to defects in the cells themselves.Another cause of hemolytic anemia is break down due to mechanical damage, such as from artificial heart valves or heart-lung bypass; or they as a result of turbulent blood flow pattern and erythrocyte destruction caused by pvl or central regurgitation.Edwards extensively trains physicians before they are qualified to use the sapien transcatheter heart valves (all models).The device training manuals instructs the operator on proper imaging screening requirements, including the use of good quality echocardiography and/or computed tomography (ct) to appropriately measure the landing zone, assess the content and distribution of calcium, and other patient anatomical factors.Multiple imaging modalities should be considered during valve size selection.Contraindications, important considerations when assessing the valve, and choosing the proper transcatheter heart valve are also discussed.The device was used in off-label implantation in the mac position.As there are no specific ifu or training materials related to mac procedures, the available training materials were reviewed only for information potentially relevant to the device use.The device training manuals also instruct the operator on proper positioning and deployment of the valve, including patients screening and procedural considerations.Device preparation, approach, deployment, imaging, procedure-specific training manuals, and proctored procedures are also included.In this case, there was no allegation or indication a product malfunction contributed to this adverse event.Investigation results suggest/indicate being implanted in the mac position could have caused or contributed to this event.A review of edwards lifesciences risk management documentation was performed for this case.The reported event is an anticipated risk of the transcatheter heart valve procedure, additional assessment of this adverse event is not required at this time.The ifu and training manuals have been reviewed and no inadequacies have been identified with regards to warnings, contraindications, and the directions/conditions for the successful use of the device.Complaint histories for all reported events are reviewed against trending control limits monthly, and any excursions above the control limits are assessed and documented as part of this monthly review.As such, neither a product risk assessment, nor corrective or preventative actions are required at this time.

• Brand Name: Edwards SAPIEN 3 Ultra RESILIA Transcatheter Heart Valve
• Common Device Name: Aortic valve, prosthesis, percutaneously delivered
• Manufacturer (Section D): Edwards Lifesciences; 1 edwards way; irvine CA 92614
• Manufacturer (Section G): Edwards Lifesciences; 1 edwards way; irvine CA 92614
• Manufacturer Contact: renee van dorne ; 1 edwards way; irvine, CA 92614 ; +1(949)250-6385
• MDR Report Key: 50590787
• Report Number: 2015691-2026-18283
• Device Sequence Number: 10104042
• Product Code: NPT
• UDI-Device Identifier: 00690103215823
• UDI-Public: (01)00690103215823(17)290225
• Combination Product (Y/N): N
• Initial Reporter State: NY
• Initial Reporter Country: US
• PMA/510(K) Number: P140031
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2026
• Device Explanted Year: 2026
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Health Professional,User Facility
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 09/03/2026

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: Health Professional
• Device Model Number: 9755RSL29A
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 09/03/2026
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 02/26/2026
• 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
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 85 YR
• Patient Sex: Female