MAUDE Adverse Event Report: EDWARDS LIFESCIENCES EDWARDS COMMANDER DELIVERY SYSTEM; PROSTHESIS, MITRAL VALVE, PERCUTANEOUSLY DELIVERED

Model Number COMMANDER DELIVERY SYSTEM UNKNOWN

Device Problem Adverse Event Without Identified Device or Use Problem (2993)

Patient Problems Death (1802); Perforation (2001); Cardiac Tamponade (2226)

Event Date 03/25/2020

Event Type  Death  

Manufacturer Narrative

Exemption number e2016006, this report summarizes 2 death events of perforation with or w/o tamponade for the sapien 3 in the mitral position.The ¿time to event¿ (tte, in days) for this event was 0.Per the instructions for use, cardiovascular injuries, including perforation or dissection of vessels, ventricle, myocardium or valvular structures, are potential adverse events associated with standard cardiac catheterization, balloon valvuloplasty and the transcatheter aortic valve replacement (tavr) procedure.There are several potential etiologies for ventricular perforation during a tavr procedure, including perforation by the guidewire, the delivery system, or the transvenous pacer (tvp) lead.Physicians are extensively trained by edwards before they are qualified to use the transcatheter heart valve (thv).Training includes proper guidewire positioning, fixation of the tvp to prevent ventricle perforation, and careful manipulation of devices.Per the procedure didactic, patients with small ventricles are at particularly high risk for ventricular perforation.In this case, specific procedural details are not available to determine potential contributing factors 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.The device identification (di) numbers for edwards commander delivery system are: (b)(4).

Event Description

(b)(6) registry alternative summary reporting (asr) adverse event submission for february 2020 data extract for mitral deaths for the sapien 3.February 2020 data extract includes data provided by acc for q3 2019 (july 1 - september 30).  this report summarizes 2 death events of perforation with or w/o tamponade for the sapien 3 for (b)(6) february 2020.The age range for these events are from 78 to 89.The breakdown for gender is as follows: 1 male and 1 female.

Event Description

This report summarizes 2 death events of perforation with or w/o tamponade for the sapien 3 for (b)(6) 2020.

Manufacturer Narrative

Supplemental report to add noe statement in b5 section.

Manufacturer Narrative

Supplemental report to resubmit h6 codes.

• Brand Name: EDWARDS COMMANDER DELIVERY SYSTEM
• Type of Device: PROSTHESIS, MITRAL VALVE, PERCUTANEOUSLY DELIVERED
• Manufacturer (Section D): EDWARDS LIFESCIENCES; 1 edwards way; irvine CA 92614
• MDR Report Key: 9988980
• MDR Text Key: 188645160
• Report Number: 2015691-2020-11577
• Device Sequence Number: 1
• Product Code: NPU
• Combination Product (y/n): N
• PMA/PMN Number: P140031
• Number of Events Reported: 2
• Summary Report (Y/N): Y
• Report Source: Manufacturer
• Source Type: health professional,user faci
• Type of Report: Initial,Followup,Followup
• Report Date: 03/25/2020

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
• Device Operator: Health Professional
• Device Model Number: COMMANDER DELIVERY SYSTEM UNKNOWN
• Device Catalogue Number: N/A
• Device Lot Number: N/A
• Was Device Available for Evaluation?: No
• Initial Date Manufacturer Received: 03/25/2020
• Initial Date FDA Received: 04/22/2020
• Supplement Dates Manufacturer Received: 03/25/2020; 07/16/2020
• Supplement Dates FDA Received: 04/24/2020; 07/21/2020
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1
• Patient Outcome(s): Death
• Patient Age: 84 YR