| Model Number |
NVRO-27 |
| Medical Device Problem Codes |
Perivalvular Leak (1457); Adverse Event Without Identified Device or Use Problem (2993)
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| Health Effect - Clinical Code |
Insufficient Information (4580)
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| Date of Event |
08/19/2026
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Type of Reportable Event
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Death
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Event or Problem Description
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It was reported on (b)(6) 2026 a 27mm navitor vision valve was selected for implant using a large flexnav delivery system.The patient was in sinus rhythm.Blood pressure was between 70mmhg and 100mmhg prior to the procedure.During the procedure it was noted that there was difficulty keeping the delivery system coaxial to the aorta due to the delivery system's inner curvature coming from the right subclavian access.The device was partially re-sheathed twice.The device was implanted.The final implant depth was 3mm from the non-coronary cusp (ncc) and 8mm from the left coronary cusp (lcc).A moderate perivalvular leak (pvl) was noted on the left side.The decision was made to implant a second device to address the pvl.A second 27mm navitor vision valve was implanted at an implant depth of 0mm from the ncc and 5mm from the lcc.Pvl improved to mild; however, the patient remained hypotensive.On the same day the patient passed away.
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Event or Problem Description
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It was reported on (b)(6) 2026 a 27mm navitor vision valve was selected for implant using a large flexnav delivery system.The patient was in sinus rhythm.Blood pressure was between 70mmhg and 100mmhg prior to the procedure.During the procedure it was noted that there was difficulty keeping the delivery system coaxial to the aorta due to the delivery system's inner curvature coming from the right subclavian access.The device was partially re-sheathed twice.The device was implanted.The final implant depth was 3mm from the non-coronary cusp (ncc) and 8mm from the left coronary cusp (lcc).A moderate perivalvular leak (pvl) was noted on the left side.The decision was made to implant a second device to address the pvl.A second 27mm navitor vision valve was implanted at an implant depth of 0mm from the ncc and 5mm from the lcc.Pvl improved to mild; however the patient remained hypotensive.On the same day the patient passed away.
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Additional Manufacturer Narrative
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The device remains implanted in patient.The device will not be returned for evaluation.Investigation is not yet complete.A follow-up report will be submitted with all additional relevant information.
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Additional Manufacturer Narrative
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An event of perivalvular leak and death was reported.A returned device assessment could not be performed as the device was not returned for analysis.The device history record was reviewed to ensure that each manufacturing and inspection operation was performed, and the product met all specifications.Based on the available information, the cause of the reported perivalvular leak and patient death could not be conclusively determined.The reported surgical intervention was a result of case-specific circumstances as another valve was implanted.There is no indication of a product quality issue with respect to labeling design or manufacturing of the device.
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Search Alerts/Recalls
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