BERLIN HEART GMBH EXCOR BLOOD PUMP PU VALVES, 30 ML IN/OUT Ø9 MM; VENTRICULAR ASSIST DEVICE
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Model Number P30P-001X01 |
Device Problem
Output Problem (3005)
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Patient Problem
No Consequences Or Impact To Patient (2199)
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Event Date 10/11/2019 |
Event Type
malfunction
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Manufacturer Narrative
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The excor blood pump,s/n (b)(4), was in use by the patient from (b)(6) 2019 until (b)(6) 2019 ((b)(6)).We have reviewed the production records of the excor blood pump, s/n (b)(4).This pump was produced according to our specification.The blood pump is designed with a triple layer membrane separating the air chamber from blood chamber for safety reasons.The entire membrane consists of an air-side layer, a middle layer and a blood-side layer.In case of disruption in one of the triple layers, there are two more layers that will maintain the integrity of the air and blood chambers.Investigation of the returned pump is currently ongoing and a detailed report will be provided as soon as available.
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Event Description
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Berlin heart was informed by the clinic about an incomplete filling and emptying the excor blood pump of a patient supported in the lvad configuration.The patient became tachycardiac.The affected blood pump was exchanged by trained personnel at the clinic and the patient is doing well.
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Manufacturer Narrative
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During initial visual examination of the returned blood pump, an air cushion could be detected between the membrane layers.For further analysis the pump was disassembled and the membrane layers were individually examined.A leakage was detected in the air-side layer along the rolling radius of the stabilization ring.Furthermore, graphite agglomerates were found between the membranes.The middle layer and the blood-side layer of the triple layer membrane were found to be intact.The thickness of the defect membrane layer and the adjacent layer of the returned blood pump was re-measured at fixed points.The thickness of the individual layers at all the fixed locations in the air-side and middle layer was found to be within specification.The cause of the failure was most likely the graphite particles that formed due to an abrasion between the layers.This caused increased friction at points, which finally led to the defect in the air-side layer.As a result of this defect, air got in and formed an air cushion, causing the reduced pump performance (incomplete filling and emptying).
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