BEUDAMED
    FDA Adverse Event Death Summary report: N

    ZEPHYR ENDOBRONCHIAL VALVE (EBV)

    MDR report key: 11807955 · Received May 11, 2021

    Report

    Report Number
    3007797756-2021-00090
    Event Type
    Death
    Date Received
    May 11, 2021
    Date of Event
    April 8, 2021
    Report Date
    May 11, 2021
    Manufacturer
    PULMONX CORPORATION
    Product Code
    NJK
    UDI-DI
    00811907030324
    PMA / PMN Number
    P180002
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    CA, US
    Reporter Occupation
    003

    Narratives

    Additional Manufacturer Narrative · 1

    PNEUMOTHORAX IS THE MOST COMMON SIDE EFFECT ASSOCIATED WITH THE ZEPHYR VALVE TREATMENT (CRINER ET AL. A MULTICENTER RANDOMIZED CONTROLLED TRIAL OF ZEPHYR ENDOBRONCHIAL VALVE TREATMENT IN HETEROGENEOUS EMPHYSEMA (LIBERATE). AM J RESPIR CRIT CARE MED. 2018; 198 (9): 1151-1164). TARGETED LOBAR DEFLATION LIKELY CAUSES INFLATION OF THE IPSILATERAL LOBE, WHICH CAN RESULT IN A TEAR OF THE ALREADY COMPROMISED PARENCHYMAL TISSUE OF THE EMPHYSEMATOUS IPSILATERAL LOBE, RESULTING IN A PNEUMOTHORAX (CRINER ET AL. A MULTICENTER RANDOMIZED CONTROLLED TRIAL OF ZEPHYR ENDOBRONCHIAL VALVE TREATMENT IN HETEROGENEOUS EMPHYSEMA (LIBERATE). AM J RESPIR CRIT CARE MED. 2018; 198 (9): 1151-1164). IN THE LIBERATE STUDY (IDE CLINICAL STUDY USED TO SUPPORT PMA P180002'S APPROVAL), 26.6% OF THE ZEPHYR VALVE SUBJECTS EXPERIENCED A PNEUMOTHORAX IN THE TREATMENT PERIOD ([LESS THAN OR EQUAL TO 45 DAYS). THESE WERE MANAGED USING STANDARD OF CARE PROCEDURES AS PER PREVIOUSLY PUBLISHED GUIDELINES (VALIPOUR, ARSCHANG, ET AL. RESPIRATION 87.6 (2014): 513-521). IN 17.4% OF THE EVENTS, THE PNEUMOTHORAX RESOLVED WITHOUT ANY ADDITIONAL INTERVENTION WITH SUBJECTS UNDER CAREFUL OBSERVATION. IN OVER HALF THE EVENTS (56.5%), THE PNEUMOTHORAX WAS MANAGED WITH A CHEST-TUBE ONLY. AN ADDITIONAL 13% OF THE EVENTS WERE MANAGED WITH A CHEST-TUBE AND THE TEMPORARY REMOVAL OF ONE OR MORE VALVES, WHILE ANOTHER 13% OF THE EVENTS WERE MANAGED WITH A CHEST-TUBE AND REMOVAL OF ALL THE IMPLANTED VALVES. UPON SUCCESSFUL RESOLUTION OF THE PNEUMOTHORAX, REMOVED VALVES CAN BE REPLACED. PATIENTS THAT EXPERIENCED A PNEUMOTHORAX EXPERIENCED CLINICAL BENEFITS OF THE ZEPHYR VALVE TREATMENT THAT WERE SIMILAR TO THE BENEFITS EXPERIENCED BY PATIENTS WHO DID NOT HAVE A PNEUMOTHORAX. THE ZEPHYR EBV SYSTEM IFU AND PULMONX TRAINING PROGRAM BOTH SPECIFICALLY REFERENCE PNEUMOTHORAX AS A KNOWN SIDE EFFECT OF THIS PROCEDURE AND THE PUBLISHED GUIDELINES (VALIPOUR, ARSCHANG, ET AL. "EXPERT STATEMENT: PNEUMOTHORAX ASSOCIATED WITH ENDOSCOPIC VALVE THERAPY FOR EMPHYSEMA-POTENTIAL MECHANISMS, TREATMENT ALGORITHM, AND CASE EXAMPLES." RESPIRATION 87.6 (2014): 513-521). THE REPORTED EVENT ALIGNS WITH THE EXPERIENCE OBSERVED IN THE LIBERATE CLINICAL STUDY AND IS AN EXPECTED SIDE EFFECT TO THE ZEPHYR VALVE TREATMENT.

    Description of Event or Problem · 1

    PATIENT HAD THREE ZEPHYR VALVES IMPLANTED IN THE LEFT UPPER LUNG AND LINGULA ON (B)(6) 2021 AT UF HEALTH. ON (B)(6) 2021, THE PATIENT DEVELOPED AN ASYMPTOMATIC PNEUMOTHORAX VISIBLE ON CHEST X-RAY. THE PATIENT WAS DISCHARGED THAT DAY DUE TO THE SMALL SIZE OF THE PNEUMOTHORAX. THE PATIENT WENT TO THE ER AT (B)(6) HOSPITAL ON (B)(6) 2013, WAS DIAGNOSED WITH A LARGE PNEUMOTHORAX ON THE LEFT SIDE, AND A CHEST TUBE WAS PLACED. ON (B)(6) 2021, THE PATIENT WAS TRANSFERRED TO UF HEALTH. THE PNEUMOTHORAX RESOLVED ON (B)(6) 2021 BUT A THE PATIENT HAD A PERSISTENT AIR LEAK. THE TREATING PHYSICIAN WAS PLANNING TO REMOVE THE VALVE FROM THE LINGULA ON (B)(6) 2021, BUT THE PATIENT UNEXPECTEDLY PASSED AWAY THAT MORNING. NO AUTOPSY WAS PERFORMED. THE PATIENT HAD SEVERE COPD WITH SEVERE CAD WHO SUDDENLY PASSED AWAY 11 DAYS AFTER THE VALVE PROCEDURE. THE EXACT CAUSE OF DEATH IS UNKNOWN, BUT IN THE PHYSICIAN'S OPINION THE DEATH WAS NOT CAUSED OR RELATED TO THE DEVICE OR PROCEDURE, BUT MORE LIKELY TO THE CAD.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    702055 ZEPHYR ENDOBRONCHIAL VALVE (EBV) ENDOBRONCHIAL VALVE NJK PULMONX CORPORATION ZEPHYR 5.5 EBV 504810-V7.0 00811907030324

    Patients

    Seq Age Sex Outcome Treatment
    1 Death| H| R