MAUDE Adverse Event Report: PERFUSION SYSTEMS CARDIOBLATE LP ABLATION BIPOLAR DEVICE; ELECTROSURGICAL, CUTTING & COAGULATION & ACCES

Model Number	60841
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Hemorrhage/Blood Loss/Bleeding (1888); Blood Loss (2597)
Date of Event	05/15/2019
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The relationship with this device was deemed as possibly related by the cec.If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
The patient had a concomitant surgical procedure of cabg through sternotomy.During the same procedure ((b)(6) 2019) a cyroflex probe powered by a cryoconsole, and a cardioblate lp clamp powered by a cardioblate generator were used.The left atrial appendage was successfully amputated/excised.Left pulmonary vein (pv) and right pulmonary vein (pv) conduction block was successfully achieved.On the same day as the procedure ((b)(6) 2019) the patient experienced pericardial artery bleeding which was treated with a blood transfusion and surgical procedure of clipping the bleeding artery.The adverse event was deemed by the site as related to the concomitant procedure but not related to the study devices and study procedure.The clinical events committee (cec) deemed a causal relationship between the concomitant procedure and study procedure to the adverse event and possibly related to cryoflex probe and cryo console, and the cardioblate clamp and cardioblate generator.
Additional Manufacturer Narrative
Medtronic received additional information that the adverse event was deemed by the site as causally related to the concomitant procedure and study procedure but not related to the study devices.The adverse event was deemed by the sponsor as related to the concomitant procedure, study procedure and not related to the study de vices.The clinical events committee (cec) deemed a causal relationship between the concomitant procedure and study procedure to the adverse event.The comments from cec state: pericardial artery tear.Correction b2: hospitalization and intervention were required.Medtronic is submitting this report to comply with fda reporting regulations under 21 cfr parts 4 and 803.This report is based upon information obtained by medtronic, which the company may not have been able to fully investigate or verify prior to the date the report was required by the fda.Medtronic has made reasonable efforts to obtain more complete information and has provided as much relevant information as is available to the company as of the submission date of this report.This report does not constitute an admission or a conclusion by fda, medtronic, or its employees that the device, medtronic, or its employee caused or contributed to the event described in the report.In particular, this report does not constitute an admission by anyone that the product described in this report has any ¿defects¿ or has ¿malfunctioned¿.These words are included in the fda 3500a form and are fixed items for selection created by the fda to categorize the type of event solely for the purpose of regulatory reporting.Medtronic objects to the use of these words and others like them because of the lack of definition and the connotations implied by these terms.This statement should be included with any information or report disclosed to the public under the freedom of information act.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.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.

• Brand Name: CARDIOBLATE LP ABLATION BIPOLAR DEVICE
• Common Device Name: ELECTROSURGICAL, CUTTING & COAGULATION & ACCES
• Manufacturer (Section D): PERFUSION SYSTEMS; 7611 northland dr; brooklyn park MN 55428
• Manufacturer (Section G): PERFUSION SYSTEMS; 7611 northland dr; brooklyn park MN 55428
• Manufacturer Contact: alison sweeney ; parkmore business park west; galway, MN ; EI ; 7635055378
• MDR Report Key: 8974488
• Report Number: 2184009-2019-00057
• Device Sequence Number: 3011702
• Product Code: GEI
• UDI-Device Identifier: 00885074359618
• UDI-Public: 00885074359618
• Combination Product (Y/N): N
• Initial Reporter State: VA
• Initial Reporter Country: US
• PMA/510(K) Number: K093203
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Study
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 08/23/2023
• 2 Devices were Involved in the Event: 1 2

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: 12/17/2021
• Device Model Number: 60841
• Device Catalogue Number: 60841
• Device Lot Number: 647B
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 08/12/2019
• Supplement Date Received by Manufacturer: 07/24/2023
• Initial Report FDA Received Date: 09/09/2019
• Supplement Report FDA Received Date: 08/23/2023
• Date Device Manufactured: 01/02/2019
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention; Hospitalization
• Patient Age: 79 YR
• Patient Sex: Male
• Patient Ethnicity: Non Hispanic
• Patient Race: White