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It was reported device embolization occurred.A left atrial appendage closure (laac) procedure was being performed.A watchman access system (was) and a 31mm watchman flx pro laa closure device and delivery system (wds) was selected for use.The wds was advanced, deployed and the closure device was implanted in the laa.As the patient was being moved over to the bed, they complained of arm pain and their blood pressure dropped.It was found that the 31mm closure device had embolized out of the appendage into the mitral valve.A non-boston scientific (bsc) grasping device was used to retrieve the device, and a new 27mm closure device was implanted.There were no further complications, and the patient has been discharged home.
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With all the available information, boston scientific (bsc) concludes:
device technical analysis
the watchman flx? pro was not returned; therefore, device analysis could not be completed.Device history record review
a review was completed of the device history records (dhr) for the watchman flx? pro, part # m635wu60310 batch # 0039099517.The dhr review confirmed that the device met all material, assembly, and performance specifications prior to distribution.Labeling review
there was no evidence to suggest that the device was used in a manner inconsistent with the labeling.Watchman flx? pro instructions for use (ifu) lists potential complications, risks and adverse events that may be associated with the use of this device which include implant embolization, pain, and hypotension.Risk review
a risk review was completed and confirmed that the events of implant embolization, pain, and hypotension were defined in the risk documentation.These event types have been accounted for during product risk analysis to support acceptable risk benefit for the product.Investigation conclusion
based on a thorough review of the reported complaint, boston scientific has assigned an investigation conclusion code of cause not established.
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