MAUDE Adverse Event Report: COOK INC COOK FLEXIBLE MYOCARDIAL BIOPSY FORCEPS

Catalog Number	FBF-5.2-120
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	01/12/2017
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Common name: device, biopsy, endomyocardial.Product code: dwz.This mdr is being filed after the associated complaint was reviewed under remediation protocol (b)(4), complaint/mdr retrospective review and remediation and reassessed as reportable.Additional complaint investigation and record remediation was not performed.
Event or Problem Description
It was reported that during the biopsy of left ventricle, the flexible myocardial biopsy forceps would not open inside the patient when advanced through the guiding catheter.After the procedure, the user checked if the device shaft of the device was bent.It was further noted that the handle would not actuate the forceps due to a missing rivet and internal corrosion.The procedure was completed with another device, and there were no injuries or additional procedures reported.

• Brand Name: COOK FLEXIBLE MYOCARDIAL BIOPSY FORCEPS
• Manufacturer (Section D): COOK INC; 750 daniels way; bloomington IN 47404
• MDR Report Key: 8173808
• Report Number: 1820334-2018-03842
• Device Sequence Number: 1902684
• Product Code: DWZ
• UDI-Device Identifier: 00827002053892
• UDI-Public: (01)00827002053892(17)210113(10)6515681
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: foreign,health professional,o
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 12/18/2018

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: Health Professional
• Device Expiration Date: 01/13/2021
• Device Catalogue Number: FBF-5.2-120
• Device Lot Number: 6515681
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 01/26/2017
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 12/13/2018
• Initial Report FDA Received Date: 12/18/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1