MAUDE Adverse Event Report: MEDTRONIC NEUROSURGERY INNERVISION SNAP SHUNT VENTRICULAR CATHETER, STANDARD, 6CM; CATHETER, VENTRICULAR

Catalog Number	27065 C
Medical Device Problem Code	Device Operates Differently Than Expected (2913)
Health Effect - Clinical Code	Therapeutic Response, Decreased (2271)
Date of Event	06/02/2017
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The product was unavailable for return.Therefore an evaluation of the device performance was not possible.A review of the manufacturing records showed no anomalies.All catheters are 100% inspected at the time of manufacture.Please refer to the manufacturer report 2021898-2017-00385 for previous valve issues.A good faith effort will be made to obtain the applicable information relevant to the report.If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
It was reported to medtronic neurosurgery that on (b)(6) 2017, the physician's notes showed they left the new valve at the prior setting, but the patient was noted to have hydrocephalus.Reportedly, the patient went to surgery on (b)(6) 2017 and had a ventriculoperitoneal (vp) shunt revision.The physician's operative note stated they decided to replace the valve and change the setting as well as replace the proximal catheter with another catheter.

• Brand Name: INNERVISION SNAP SHUNT VENTRICULAR CATHETER, STANDARD, 6CM
• Common Device Name: CATHETER, VENTRICULAR
• Manufacturer (Section D): MEDTRONIC NEUROSURGERY; 125 cremona drive; goleta CA 93117
• MDR Report Key: 6725983
• Report Number: 2021898-2017-00387
• Device Sequence Number: 1267602
• Product Code: HCA
• UDI-Device Identifier: 00643169483880
• UDI-Public: 00643169483880
• Combination Product (Y/N): N
• Initial Reporter State: FL
• Initial Reporter Country: US
• PMA/510(K) Number: K983331
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Explanted Year: 2017
• Reporter Type: Manufacturer
• Report Source: health professional,other
• Initial Reporter Occupation: Nurse
• Type of Report: Initial
• Report Date (Section B): 06/19/2017

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: 09/30/2021
• Device Catalogue Number: 27065 C
• Device Lot Number: E18646
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 06/19/2017
• Initial Report FDA Received Date: 07/19/2017
• 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: 19 YR
• Patient Weight: 80