MAUDE Adverse Event Report: SORIN GROUP ITALIA S.R.L. CARBOMEDICS TOP HAT PROSTHETIC HEART VALVE; MECHANICAL HEART VALVE PROSTHESIS

Model Number	S5-023
Medical Device Problem Code	Insufficient Device Problem Information (3190)
Health Effect - Clinical Code	No Information (3190)
Date of Event	12/10/2019
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Device disposition presently unknown.
Event or Problem Description
On (b)(6) 2011 a patient received a carbomedics top hat s5-023 mechanical heart valve as part of an mvr.The manufacturer was notified that on (b)(6) 2019 the device was removed and replaced with another mitral valve.No further information was received.
Additional Manufacturer Narrative
The manufacturer made several attempts to follow-up for further information however no further event details were received.A complete manufacturing and material records review for the device has been performed.The results confirmed that the device satisfied all material, visual and performance standards required at the time of manufacture and release.Based on the available information, it is not possible to draw a definitive conclusion regarding the reported event.However, based on the document review performed, no manufacturing deficits were identified.The manufacturer attempted to follow up further on this event, but no additional information been received to date.However, should additional information be provided, the manufacturer will re-assess the event and take further investigative action as applicable.Fields changed: b4, g4, g7, h2, h6.

• Brand Name: CARBOMEDICS TOP HAT PROSTHETIC HEART VALVE
• Common Device Name: MECHANICAL HEART VALVE PROSTHESIS
• Manufacturer (Section D): SORIN GROUP ITALIA S.R.L.; strada crescentino snc; saluggia, vc
• MDR Report Key: 9896225
• Report Number: 3005687633-2020-00110
• Device Sequence Number: 11322349
• Product Code: LWQ
• UDI-Device Identifier: 08022057012913
• UDI-Public: (01)08022057012913(240)S5-023(17)150903
• Combination Product (Y/N): N
• Initial Reporter State: NE
• Initial Reporter Country: US
• PMA/510(K) Number: P900060
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2011
• Device Explanted Year: 2019
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 05/26/2020

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: 09/03/2015
• Device Model Number: S5-023
• Device Catalogue Number: S5-023
• Was the Report Sent to FDA?: No
• Initial Date Received by Manufacturer: 02/28/2020
• Supplement Date Received by Manufacturer: 05/26/2020
• Initial Report FDA Received Date: 03/29/2020
• Supplement Report FDA Received Date: 05/26/2020
• 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: 18 YR