MAUDE Adverse Event Report: MEDTRONIC HEART VALVES DIVISION RING 620RG29 DURAN ANCORE ANNULOPLASTY C; RING, ANNULOPLASTY

Model Number	620RG29
Medical Device Problem Code	Patient Device Interaction Problem (4001)
Health Effect - Clinical Codes	Host-Tissue Reaction (1297); Mitral Valve Stenosis (1965)
Date of Event	12/21/2018
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
No product was returned.Conclusion: 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 11 years and 1 month post implant of this 29mm mitral annuloplasty ring, it was explanted and replaced with a non-medtronic mechanical valve.The reason for replacement was reported as severe mitral stenosis.It was also noted there was pannus overgrowth on the patient's native mitral valve.No additional adverse patient effects were reported.

• Brand Name: RING 620RG29 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: 9192103
• Report Number: 2025587-2019-03143
• Device Sequence Number: 11232537
• Product Code: KRH
• UDI-Device Identifier: 00721902859793
• UDI-Public: 00721902859793
• Combination Product (Y/N): N
• Initial Reporter State: IL
• Initial Reporter Country: US
• PMA/510(K) Number: K032810
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2007
• Device Explanted Year: 2018
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 10/15/2019

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: 07/16/2012
• Device Model Number: 620RG29
• Device Catalogue Number: 620RG29
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 09/30/2019
• Initial Report FDA Received Date: 10/15/2019
• 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: 58 YR
• Patient Weight: 100