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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: BERLIN HEART GMBH EXCOR BLOOD PUMP PU VALVES,30 ML IN/OUT Ø9 MM VENTRICULAR ASSIST DEVICE

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BERLIN HEART GMBH EXCOR BLOOD PUMP PU VALVES,30 ML IN/OUT Ø9 MM VENTRICULAR ASSIST DEVICE Back to Search Results
Model Number P30P-001X01
Device Problem Output Problem (3005)
Patient Problem No Consequences Or Impact To Patient (2199)
Event Date 12/09/2019
Event Type  malfunction  
Manufacturer Narrative
The excor blood pump,s/n (b)(4), was in use by the patient from (b)(6) 2019 to (b)(6) 2019 (160 days). 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. Initial visual inspection of the returned blood pump is indicative of a membrane defect. A detailed investigation report will be provided as soon as available.
 
Event Description
We were informed by the clinic about a suspected membrane defect of an excor blood pump of a patient support in the lvad configuration. The clinic provided a video at the time of the incident. Upon evaluation, berlin heart recommended to exchange the blood pump. The affected blood pump was exchanged in the clinic by trained personnel. The exchange was performed without complications and the patient is doing well.
 
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Brand NameEXCOR BLOOD PUMP PU VALVES,30 ML IN/OUT Ø9 MM
Type of DeviceVENTRICULAR ASSIST DEVICE
Manufacturer (Section D)
BERLIN HEART GMBH
wiesenweg 10
berlin, 12247
GM 12247
Manufacturer (Section G)
BERLIN HEART GMBH
wiesenweg 10
berlin, 12247
GM 12247
Manufacturer Contact
dudley rajapaksa
9391 grogan's mill road
suite a-6
the woodlands, TX 77380
2818639706
MDR Report Key9555289
MDR Text Key203831557
Report Number3004582654-2020-00001
Device Sequence Number1
Product Code DSQ
UDI-Device Identifier04260090040126
UDI-Public04260090040126
Combination Product (y/n)N
Reporter Country CodeGM
PMA/PMN Number
P160035
Number of Events Reported1
Summary Report (Y/N)N
Report Source Manufacturer
Source Type foreign,user facility
Reporter Occupation
Remedial Action Replace
Type of Report Initial,Followup
Report Date 01/06/2020
1 Device was Involved in the Event
0 Patients were Involved in the Event:
Date FDA Received01/06/2020
Is this an Adverse Event Report? No
Is this a Product Problem Report? Yes
Device Operator
Device Expiration Date04/30/2021
Device Model NumberP30P-001X01
Device Catalogue NumberP30P-001X01
Was Device Available for Evaluation? Device Returned to Manufacturer
Date Returned to Manufacturer12/11/2019
Is the Reporter a Health Professional? Yes
Was the Report Sent to FDA?
Event Location No Information
Date Manufacturer Received12/09/2019
Was Device Evaluated by Manufacturer? No
Date Device Manufactured06/06/2018
Is the Device Single Use? Yes
Is This a Reprocessed and Reused Single-Use Device? No
Type of Device Usage Initial

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