MAUDE Adverse Event Report: MEDTRONIC HEART VALVES DIVISION BAND 620BG27 DURAN ANCORE ANNULOPLASTY C; RING, ANNULOPLASTY

Model Number	620BG27
Medical Device Problem Code	Insufficient Device Problem Information (3190)
Health Effect - Clinical Codes	Zonular Dehiscence (2698); No Information (3190)
Date of Event	09/12/2017
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Without the return of the product, no definitive conclusion can be made regarding the clinical observation.If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
Medtronic received information that 5 years and 6 months post implant of this annuloplasty ring, the ring was explanted for unknown reasons and replaced with a bioprosthetic valve.No adverse patient effects were reported.
Additional Manufacturer Narrative
Medtronic received additional information that the ring was explanted due to the patient's tissue quality which caused a partial dehiscence of the band.The physician reported there was no issue with the band, only with the patient's tissue.If information is provided in the future, a supplemental report will be issued.

• Brand Name: BAND 620BG27 DURAN ANCORE ANNULOPLASTY C
• Common Device Name: RING, ANNULOPLASTY
• Manufacturer (Section D): MEDTRONIC HEART VALVES DIVISION; 1851 e deere ave; santa ana CA 92705
• MDR Report Key: 7022448
• Report Number: 2025587-2017-02087
• Device Sequence Number: 1353627
• Product Code: KRH
• UDI-Device Identifier: 00613994759085
• UDI-Public: 00613994759085
• Combination Product (Y/N): N
• Initial Reporter State: OH
• Initial Reporter Country: US
• PMA/510(K) Number: K960356
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2012
• Device Explanted Year: 2017
• Reporter Type: Manufacturer
• Report Source: health professional,other
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 11/13/2017

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?: No
• Operator of Device: Health Professional
• Device Expiration Date: 10/04/2016
• Device Model Number: 620BG27
• Device Catalogue Number: 620BG27
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 09/21/2017
• Supplement Date Received by Manufacturer: 11/13/2017
• Initial Report FDA Received Date: 11/10/2017
• Supplement Report FDA Received Date: 11/13/2017
• 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: Required Intervention
• Patient Age: 75 YR