MAUDE Adverse Event Report: HEARTWARE, INC HEARTWARE® VENTRICULAR ASSIST SYSTEM - CONTROLLER AC ADAPTER; CIRCULATORY ASSIST SYSTEM

Catalog Number	1425US
Medical Device Problem Code	Connection Problem (2900)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	08/25/2015
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The cac adapter was returned for evaluation.Various analyses were conducted and reviewed in order to evaluate the performance of the device in relation to the reported event.Failure analysis of the returned device revealed that the controller ac adapter failed visual examination due to a broken internal wire on the output cable.Additionally, the device failed functional testing due to the inability to adequately provide dc voltage.This was most likely perceived as the reported controller ac adapter not staying connected.As a result, the most likely root cause of the reported event can be attributed to a broken wire due to the handling of the device.Per the instructions for use (ifu): the hvad controller requires two power sources for safe operation: either two batteries, or one battery and an ac adapter or dc adapter.The cac adapter has cables that connect to the controller and into an electrical outlet.The instructions for use (ifu) and patient manual instruct the user that a green indicator light on the adapter will indicate proper connection.The redundant power source will continue to supply power to the pump.Users are instructed to return any damaged components to heartware.Any observed damage would be mitigated by the exchange of this component for another one.This device is used for treatment not diagnosis.The ventricular assist system is indicated for use as a bridge to cardiac transplantation in patients who are at risk of death from refractory end-stage left ventricular heart failure.The system is designed for in-hospital and out-of-hospital settings.Heartware will submit a supplemental report when new facts arises which materially alters information submitted in a previous mdr report.This event was assessed and is being reported as part of a retrospective review of events, which was in response to an update to the mdr decision criteria.
Event or Problem Description
It was reported that the patient complained that his ac adapter would not stay connected to his controller.The vad coordinator confirmed the incident.There were no reported consequences associated with the event.No further information was provided. .

• Brand Name: HEARTWARE® VENTRICULAR ASSIST SYSTEM - CONTROLLER AC ADAPTER
• Common Device Name: CIRCULATORY ASSIST SYSTEM
• Manufacturer (Section D): HEARTWARE, INC; 14400 nw 60th avenue; miami lakes FL 33014 3105
• MDR Report Key: 6915164
• Report Number: 3007042319-2017-03544
• Device Sequence Number: 1181662
• Product Code: DSQ
• UDI-Device Identifier: 00888707000093
• UDI-Public: 00888707000093
• Combination Product (Y/N): N
• Initial Reporter State: IL
• Initial Reporter Country: US
• PMA/510(K) Number: P100047
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 08/25/2015

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Lay User/Patient
• Device Expiration Date: 12/31/2014
• Device Catalogue Number: 1425US
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 09/16/2015
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 02/27/2017
• Initial Report FDA Received Date: 10/05/2017
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 47 YR
• Patient Weight: 70