MAUDE Adverse Event Report: MEDTRONIC HEART VALVES DIVISION BAND 620BG25 DURAN ANCORE ANNULOPLASTY C; RING, ANNULOPLASTY

Model Number	620BG25
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Tricuspid Regurgitation (2112)
Date of Event	04/18/2018
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 during the implant of this 25 mm annuloplasty band in the tricuspid position, the band was explanted and replaced with a mechanical valve.The reason for explant was reported as persistent regurgitation.The surgeon indicated that the regurgitation was not related to any malfunction of the device.No additional adverse patient effects were reported.

• Brand Name: BAND 620BG25 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: 7518693
• Report Number: 2025587-2018-01150
• Device Sequence Number: 19258405
• Product Code: KRH
• UDI-Device Identifier: 00613994759061
• UDI-Public: 00613994759061
• Combination Product (Y/N): N
• Initial Reporter State: ND
• Initial Reporter Country: US
• PMA/510(K) Number: K032810
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 05/16/2018

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: 09/17/2018
• Device Model Number: 620BG25
• Device Catalogue Number: 620BG25
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 04/25/2018
• Initial Report FDA Received Date: 05/16/2018
• 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: 51 YR