BEUDAMED
    FDA Adverse Event Injury Summary report: N

    UNKNOWN EDWARDS TRANSFEMORAL SHEATH

    MDR report key: 10862439 · Received November 18, 2020

    Report

    Report Number
    2015691-2020-14473
    Event Type
    Injury
    Date Received
    November 18, 2020
    Date of Event
    May 6, 2020
    Report Date
    October 28, 2020
    Manufacturer
    EDWARDS LIFESCIENCES
    Product Code
    NPT
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    GM
    Reporter Occupation
    PHYSICIAN

    Narratives

    Additional Manufacturer Narrative · 0

    THIS IS ONE OF THREE MANUFACTURER REPORTS BEING SUBMITTED FOR THIS CASE.  PLEASE REFERENCE RELATED MANUFACTURER REPORT NO: 2015691-2020-14472,  2015691-2020-14473,  2015691-2020-14474.

    Additional Manufacturer Narrative · 1

    THIS IS TWO OF THREE MANUFACTURER REPORTS BEING SUBMITTED FOR THIS CASE.   THE DATES OF THE EVENTS ARE UNKNOWN; HOWEVER, THE ARTICLE WAS SUBMITTED FOR PUBLICATION ON MAY 46, 2020. THEREFORE, THE 'SUBMISSION FOR PUBLICATION DATE' WAS USED AS THE OCCURRENCE DATE.   IN THIS CASE, THE EXACT  SHEATH MODEL NUMBER IS NOT AVAILABLE. THEREFORE, THIS REPORT WILL REFLECT AN UNKNOWN EDWARDS TRANSFEMORAL SHEATH. THE POSSIBLE PMA NUMBERS ASSOCIATED WITH AN EDWARDS TRANSFEMORAL SHEATH:  K093877- RETROFLEX 3TM INTRODUCER SHEATH SET; P130009 - EDWARDS EXPANDABLE INTRODUCER SHEATH SET; P140031- EDWARDS ESHEATH INTRODUCER SET. REFERENCE ARTICLE: PATSALIS, POLYKARPOS C., ET AL. "UNDERSIZING BUT OVERFILLING ELIMINATES THE GRAY ZONES OF SIZING FOR TRANSCATHETER AORTIC VALVE REPLACEMENT WITH THE BALLOON-EXPANDABLE BIOPROSTHESIS." IJC HEART & VASCULATURE 30 (2020): 100593. ACCORDING TO THE INSTRUCTIONS FOR USE (IFU), CARDIOVASCULAR COMPLICATIONS, INCLUDING PERFORATION OR DISSECTION OF VESSELS WHICH MAY REQUIRE INTERVENTION, ARE POTENTIAL ADVERSE EVENTS ASSOCIATED WITH THE TRANSFEMORAL TRANSCATHETER AORTIC VALVE REPLACEMENT PROCEDURE.   ACCORDING TO LITERATURE REVIEW, AND AS DOCUMENTED IN A TECHNICAL SUMMARY WRITTEN BY EDWARDS LIFESCIENCES, VASCULAR COMPLICATIONS ARE A WELL-RECOGNIZED COMPLICATION OF THE TRANSFEMORAL TAVR PROCEDURE IN THIS ELDERLY POPULATION WITH MULTIPLE CO-MORBIDITIES. EDWARDS HAS REVIEWED MANY REPORTS, INCLUDING SCREENING DATA RECORDS AND SOURCE DOCUMENTATION OF VASCULAR COMPLICATIONS AND HAS FOUND THAT THE ROOT CAUSE IS TYPICALLY RELATED TO A COMBINATION OF VESSEL SIZE, TORTUOSITY AND CALCIFICATIONS. ALTHOUGH THE INCIDENCE IS DECREASING WITH SMALLER SHEATH/DELIVERY SYSTEM SIZES AND PHYSICIAN EXPERIENCE, THERE WILL CONTINUE TO BE CASES IN WHICH VASCULAR COMPLICATIONS WILL OCCUR. THE THV PHYSICIAN TRAINING MANUALS INSTRUCT ON PROCEDURAL CONSIDERATIONS FOR SHEATH INSERTION WITH REGARDS TO PROPER SCREENING CRITICAL TO REDUCING VASCULAR COMPLICATIONS. THE TRAINING MANUAL INSTRUCTS THE OPERATOR ON PROPER SHEATH INSERTION AND WITHDRAWAL TECHNIQUES, INCLUDING PRE-DILATING THE VESSEL WITH THE EDWARDS DILATORS, AS NEEDED. IT ALSO NOTES THAT CALCIFICATION MAY REDUCE LUMEN DIAMETER AND LIMIT OR PREVENT TRANSFEMORAL PASSAGE OF THE DEVICES. THE IFU CONTRAINDICATES PATIENTS WITH ILIO-FEMORAL VESSEL CHARACTERISTICS THAT WOULD PRECLUDE SAFE PLACEMENT OF SHEATHS SUCH AS SEVERE OBSTRUCTIVE CALCIFICATION OR SEVERE TORTUOSITY. PRE-PROCEDURE SCREENING AND ASSESSMENT OF THE FEMORAL/ILIAC ARTERY INTERNAL DIAMETERS WILL ENABLE THE CLINICIAN TO DETERMINE IF THE SAPIEN VALVE CAN BE DELIVERED TRANSFEMORALLY. ASSESSMENT OF LOCATION AND AMOUNT OF CIRCUMFERENTIAL CALCIUM WILL AID IN DETERMINING AREAS OF REDUCED VESSEL DIAMETERS. THE OPERATORS ARE TRAINED TO MEASURE MINIMUM VESSEL DIAMETER TAKING CALCIUM INTO ACCOUNT. THE PHYSICIAN TRAINING MANUAL ALSO LISTS THE MINIMUM RECOMMENDED VESSEL SIZE FOR EACH SIZE DEVICE. DESPITE THE BEST SCREENING TOOLS, A SMALL PERCENTAGE OF PATIENTS WILL HAVE FEMORAL/ILIAC VESSELS THAT ARE NOT AMENABLE TO THE TRANS-FEMORAL APPROACH OR WHERE INCREASED RESISTANCE IS ENCOUNTERED DURING INSERTION OF DEVICES. IN MANY CASES, THE VESSEL MINIMUM LUMINAL DIAMETER (MLD) MAY BE BORDERLINE OR BELOW THE INDICATED SIZE. IN ADDITION, SIGNIFICANT CALCIFICATION AND/OR TORTUOSITY, NOT ALWAYS APPRECIABLE ON IMAGING, COULD BE CONTRIBUTING FACTORS TO THE EVENT. IN THIS CASE, THERE WAS NO ALLEGATION OR INDICATION A DEVICE MALFUNCTION CONTRIBUTED TO THIS ADVERSE EVENT.  INVESTIGATION RESULTS SUGGEST/INDICATE THE CAUSE OF THE TWENTY-SEVEN REPORTED VASCULAR COMPLICATIONS IS UNKNOWN. DETAILS OF THE EVENTS WERE NOT PROVIDED. HOWEVER, IN ADDITION TO THE MECHANISMS DESCRIBED ABOVE PATIENT AND PROCEDURE FACTORS NOT REPORTED MAY HAVE 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.

    Description of Event or Problem · 1

    AS REPORTED BY AN EDWARDS LIFESCIENCES AFFILIATE FOR (B)(6) THROUGH THE REVIEW OF THE MEDICAL ARTICLE: "UNDERSIZING BUT OVERFILLING ELIMINATES THE GRAY ZONES OF SIZING FOR TRANSCATHETER AORTIC VALVE REPLACEMENT WITH THE BALLOON-EXPANDABLE BIOPROSTHESIS". CORRESPONDING AUTHOR POLYKARPOS C. PATSALIS. DATA FROM 246 CONSECUTIVE HIGH-RISK PATIENTS WITH SYMPTOMATIC AORTIC VALVE STENOSIS WHO UNDERWENT TRANSFEMORAL (TF) TAVR USING THE EDWARDS SAPIEN 3 BIOPROSTHESIS WERE ANALYZED RETROSPECTIVELY. THE FOLLOWING EVENT OCCURRED: TWENTY-SEVEN PATIENTS HAD VASCULAR COMPLICATIONS. DETAILS OF THE EVENTS WERE NOT PROVIDED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1325428 UNKNOWN EDWARDS TRANSFEMORAL SHEATH AORTIC VALVE, PROSTHESIS, PERCUTANEOUSLY DELIVERED NPT EDWARDS LIFESCIENCES UNKNOWN EDWARDS TRANSFEMORAL SHEATH N/A

    Patients

    Seq Age Sex Outcome Treatment
    1 Other