Per the instructions for use (ifu), conduction system defects (heart block) which may require a permanent pacemaker are potential adverse events associated with balloon aortic valvuloplasty, deployment of the prosthetic valve, and the overall tavr procedure.According to the valve academic research consortium (varc) guidelines, the close anatomical relationship between the aortic valve complex and the branching atrioventricular bundle may provide an explanation for these complications of the tavr procedure.According to literature review, and as documented in a clinical technical summary written by edwards lifesciences, atrioventricular conduction disturbances after tavr are associated with many patient related and procedural related factors, including pre-operative co-morbid status, the degree and bulkiness of aortic valve and annular calcification, inter-ventricular septal thickness, pre-existing electrocardiogram abnormalities, the depth of prosthesis implantation, and the profile of the implanted prosthesis.Unlike conventional avr, where there may be localized trauma due to decalcification of the annulus and/or suture placement in the proximity of the av node or the bundles, tavr may cause conduction abnormalities through mechanical impingement of the conduction system by the prosthesis.The mechanisms of the development of heart block after tavr are well documented and described in the literature.It is also documented that pre-existing heart block is common in patients undergoing tavr or surgical avr and another 4-6 % will develop postoperative heart block, potentially requiring a permanent pacemaker.In this case, there was no allegation or indication a device malfunction contributed to this adverse event.Investigation results suggest/indicate in addition to procedural factors (pressure from the implanted valve on cardiac structures), patient factors (valvular calcification, pre-existing rbbb) likely contributed to the event.The ifu and training manuals have been reviewed and no inadequacies have been identified with regards to warnings, contraindications, and the directions/conditions for the successful use of the device.Complaint histories for all reported events are reviewed against trending control limits on a monthly basis, and any excursions above the control limits are assessed and documented as part of this monthly review.No corrective or preventative actions are required at this time.
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As reported by our affiliate in (b)(6) and through the (b)(6) registry, complete av block developed after the transfemoral tavr procedure for a 23mm sapien xt valve.A temporary pacer was introduced.A ddd permanent pacemaker implant was placed.The patient outcome was judged to be ¿recovering¿.The native annular diameter measured 20.3mm x 23.1mm by computed tomography (ct) with an annular area of 408.7 mm2.The diameter of sinotubular junction (stj) measured 27.3mm, and the diameter of the sinus of valsalva (sov) measured 30.1 mm.Aortic valve calcification (degree unknown) was reported.The device remains deployed in the patient body and will not be returned for evaluation.
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