MAUDE Adverse Event Report: MEDTRONIC NEUROSURGERY CSF- CARDIAC/PERITONEAL CATHETER, STD, BARIUM IMPR; SHUNT, CENTRAL NERVOUS SYSTEM AND COMPONENTS

Catalog Number	43103
Medical Device Problem Code	Device Operates Differently Than Expected (2913)
Health Effect - Clinical Codes	Therapeutic Response, Decreased (2271); Hydrocephalus (3272)
Date of Event	11/09/2016
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
It was reported to medtronic neurosurgery that the physician performed a ventriculoperitoneal shunt surgery on (b)(6) 2016.According to the report, on (b)(6) 2016, the patient was found "over shunt." reportedly, the device was replaced, and now the patient's cerebrospinal fluid shunt was normal.
Additional Manufacturer Narrative
If information is provided in the future, a supplemental report will be issued.
Additional Manufacturer Narrative
Patient weight updated.If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
Additional information received reported the patient was stable after the device was replaced and the hydrocephalus symptoms were abated.
Additional Manufacturer Narrative
Approximately 8.5 cm of the peritoneal catheter was returned.The returned catheter was patent and met the requirements for leak testing.All catheters are 100% inspected at the time of manufacture.Information is provided in the future, a supplemental report will be issued.

• Brand Name: CSF- CARDIAC/PERITONEAL CATHETER, STD, BARIUM IMPR
• Common Device Name: SHUNT, CENTRAL NERVOUS SYSTEM AND COMPONENTS
• Manufacturer (Section D): MEDTRONIC NEUROSURGERY; 125 cremona drive; goleta CA 93117
• MDR Report Key: 6654015
• Report Number: 2021898-2017-00334
• Device Sequence Number: 1285483
• Product Code: JXG
• UDI-Device Identifier: 00643169466821
• UDI-Public: 00643169466821
• Combination Product (Y/N): N
• Initial Reporter Country: CH
• PMA/510(K) Number: K792005
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2016
• Device Explanted Year: 2016
• Reporter Type: Manufacturer
• Report Source: foreign,health professional
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup,Followup
• Report Date (Section B): 11/15/2017

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?: Yes
• Operator of Device: Health Professional
• Device Expiration Date: 12/31/2019
• Device Catalogue Number: 43103
• Device Lot Number: D73783
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 07/07/2017
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 05/21/2017
• Supplement Date Received by Manufacturer: 05/21/2017; 09/18/2017; 11/02/2017
• Initial Report FDA Received Date: 06/20/2017
• Supplement Report FDA Received Date: 09/07/2017; 10/17/2017; 11/15/2017
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Hospitalization; Required Intervention
• Patient Age: 11 YR
• Patient Weight: 30