MAUDE Adverse Event Report: PERFUSION SYSTEMS BP2 ABLATION DEVICE BIOPOLAR DEVICE; ELECTROSURGICAL, CUTTING & COAGULATION & ACCESSORIES

Model Number	60831
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Complete Heart Block (2627); Heart Block (4444)
Date of Event	09/10/2019
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
The patient had the following concomitant surgical procedures mitral valve repair, tricuspid valve repair and coronary artery bypass grafting (four anastomoses) through sternotomy.During the same procedure ((b)(6) 2019) a cryoflex probe powered by a cryoconsole and a cardioblate bp2 clamp and a cardioblate maps powered by a cardioblate generator were used.The left atrial appendage was successfully closed.Left pulmonary vein (pv) and right pulmonary vein (pv) conduction block were achieved.On (b)(6) 2019 the patient experienced right bundle branch block.The patient status is not recovered/not resolved.The adverse event was deemed by the site as possibly related to the concomitant procedure, study procedure and cryoflex probe.The adverse event was deemed by the site as unlikely related to the cardioblate bp2 clamp.
Additional Manufacturer Narrative
Additional information: a.Patient information.Weight in kgs.2.6.Patient codes (ime/annex e): this field has been updated.Medtronic submits this report to comply with fda regulations 21 cfr parts 4 and 803.Medtronic has made reasonable efforts to provide 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.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.Medtronic will submit a supplemental report if additional relevant information becomes known.

• Brand Name: BP2 ABLATION DEVICE BIOPOLAR DEVICE
• Common Device Name: ELECTROSURGICAL, CUTTING & COAGULATION & ACCESSORIES
• 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: 9265644
• Report Number: 2184009-2019-00061
• Device Sequence Number: 14014099
• Product Code: GEI
• UDI-Device Identifier: 00885074266022
• UDI-Public: 00885074266022
• Combination Product (Y/N): N
• Initial Reporter State: UT
• 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 Assistant
• Type of Report: Initial,Followup
• Report Date (Section B): 11/21/2024

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: 03/13/2022
• Device Model Number: 60831
• Device Catalogue Number: 60831
• Device Lot Number: 115C
• 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: 10/17/2019
• Supplement Date Received by Manufacturer: 11/20/2024
• Initial Report FDA Received Date: 11/01/2019
• Supplement Report FDA Received Date: 11/21/2024
• Date Device Manufactured: 03/29/2019
• 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: Hospitalization
• Patient Age: 74 YR
• Patient Sex: Male
• Patient Weight: 77 KG
• Patient Ethnicity: Non Hispanic
• Patient Race: White