BEUDAMED
    FDA Adverse Event Injury Summary report: N

    HEARTWARE VENTRICULAR ASSIST SYSTEM - PUMP

    MDR report key: 11946845 · Received June 7, 2021

    Report

    Report Number
    3007042319-2021-03846
    Event Type
    Injury
    Date Received
    June 7, 2021
    Date of Event
    May 29, 2021
    Report Date
    July 28, 2021
    Manufacturer
    HEARTWARE, INC.
    Product Code
    DSQ
    PMA / PMN Number
    P100047
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    SZ
    Reporter Occupation
    OTHER HEALTH CARE PROFESSIONAL

    Narratives

    Additional Manufacturer Narrative · 0

    A SUPPLEMENTAL REPORT IS BEING SUBMITTED FOR INVESTIGATION SUMMARY. PRODUCT EVENT SUMMARY: THE VENTRICULAR ASSIST DEVICE (VAD) WAS NOT RETURNED FOR EVALUATION. THE REPORTED HIGH POWER EVENT WAS CONFIRMED VIA REVIEW OF THE CONTROLLER LOG FILES WHICH REVEALED AN INCREASE IN POWER CONSUMPTION STARTING ON (B)(6) 2021 WHICH WAS SUBSEQUENTLY FOLLOWED BY A SECOND INCREASE IN POWER CONSUMPTION AND ESTIMATED FLOWS LEADING TO PARAMETERS ABOVE THE NORMAL OPERATING RANGE ON (B)(6) 2021. 52 HIGH WATT ALARMS AND 24 LOW FLOW ALARMS WERE LOGGED SINCE (B)(6)2021. INFORMATION RECEIVED FROM THE SITE INDICATED THAT THREE DAYS AFTER THE IMPLANT PROCEDURE, THE PATIENT EXPERIENCED HEMOLYTIC URINE AND HEMOGLOBINURIA WITH AN INCREASE IN THEIR LACTATE DEHYDROGENASE (LDH) AND HEMOGLOBIN (HGB). A THROMBUS IN THE INFLOW CANNULA OF THE VENTRICULAR ASSIST DEVICE (VAD) WAS CONFIRMED WITH TRANSESOPHAGEAL ECHOCARDIOGRAM (TEE). IT WAS ALSO REPORTED THAT THE VAD EXHIBITED HIGH POWER, HIGH FLOW, AND HIGH WATTS WITH ASSOCIATED HIGH WAT T ALARMS. THE PATIENT RECEIVED ANTICOAGULATION THERAPY, THE VAD WAS TURNED OFF AND THE PATIENT IS ON VENOARTERIAL EXTRACORPOREAL MEMBRANE OXYGENATION (VA ECMO) FROM THE VENA CAVA TO THE AORTA. PER THE HVAD INSTRUCTIONS FOR USE, THROMBUS AND HEMOGLOBINURIA ARE KNOWN POTENTIAL COMPLICATIONS ASSOCIATED WITH THE IMPLANTATION OF A VAD. THERE IS NO EVIDENCE TO SUGGEST THAT A DEVICE MALFUNCTION CAUSED OR CONTRIBUTED TO THE REPORTED EVENT. BASED ON THE AVAILABLE INFORMATION, THE MOST LIKELY ROOT CAUSE OF THE HIGH POWER EVENT CAN BE ATTRIBUTED TO EXTERNAL FACTORS SUCH AS THROMBUS FORMATION/INGESTION. BASED ON THE RISK DOCUMENTATION, POSSIBLE CAUSES OF THE OBSERVED LOW FLOW ALARMS MAY BE ATTRIBUTED TO MULTIPLE FACTORS INCLUDING BUT NOT LIMITED TO THROMBUS AT THE INFLOW CANNULA/OUTFLOW GRAFT, CONSTRICTION AT THE OUTFLOW GRAFT, POOR VAD FILLING, AND/OR INAPPROPRIATE PUMP ROTATIONAL SPEED. POSSIBLE CLINICAL FACTORS THAT MAY HAVE CONTRIBUTED TO THIS EVENT INCLUDE THE PATIENT¿S PRE-EXISTING HISTORY AND RELATED COMORBIDITIES, THE PROGRESSION OF THEIR UNDERLYING DISEASE, ISSUES RELATED TO THE THERAPEUTIC USE OF ANTICOAGULANT AND ANTIPLATELET MEDICATIONS AND THE PATIENT'S COMPLEX POST-OPERATIVE COURSE. THERE ARE POSSIBLE PATIENT, PHARMACOLOGICAL AND PROCEDURAL FACTORS THAT MAY HAVE CONTRIBUTED TO THIS EVENT. INVESTIGATION OF THIS EVENT IS COMPLETED AND THE FILE WILL BE CLOSED. IF NEW INFORMATION IS RECEIVED, THE FILE WILL BE RE-OPENED AND A SUPPLEMENTAL WILL BE SUBMITTED.### MEDTRONIC IS SUBMITTING THIS REPORT TO COMPLY WITH FDA REPORTING REGULATIONS UNDER 21 CFR PARTS 4 AND 803. THIS REPORT IS BASED UPON INFORMATION OBTAINED BY MEDTRONIC, WHICH THE COMPANY MAY NOT HAVE BEEN ABLE TO FULLY INVESTIGATE OR VERIFY PRIOR TO THE DATE THE REPORT WAS REQUIRED BY THE FDA. MEDTRONIC HAS MADE REASONABLE EFFORTS TO OBTAIN MORE COMPLETE INFORMATION AND HAS PROVIDED AS MUCH RELEVANT INFORMATION AS IS AVAILABLE TO THE COMPANY AS OF THE SUBMISSION DATE OF THIS REPORT. THIS REPORT DOES NOT CONSTITUTE AN ADMISSION OR A CONCLUSION BY FDA, MEDTRONIC, OR ITS EMPLOYEES THAT THE DEVICE, MEDTRONIC, OR ITS EMPLOYEE CAUSED OR CONTRIBUTED TO THE EVENT DESCRIBED IN THE REPORT. IN PARTICULAR, THIS REPORT DOES NOT CONSTITUTE AN ADMISSION BY ANYONE THAT THE PRODUCT DESCRIBED IN THIS REPORT HAS ANY ¿DEFECTS¿ OR HAS ¿MALFUNCTIONED¿. THESE WORDS ARE INCLUDED IN THE FDA 3500A FORM AND ARE FIXED ITEMS FOR SELECTION CREATED BY THE FDA TO CATEGORIZE THE TYPE OF EVENT SOLELY FOR THE PURPOSE OF REGULATORY REPORTING. MEDTRONIC OBJECTS TO THE USE OF THESE WORDS AND OTHERS LIKE THEM BECAUSE OF THE LACK OF DEFINITION AND THE CONNOTATIONS IMPLIED BY THESE TERMS. THIS STATEMENT SHOULD BE INCLUDED WITH ANY INFORMATION OR REPORT DISCLOSED TO THE PUBLIC UNDER THE FREEDOM OF INFORMATION ACT. ANY REQUIRED FIELDS THAT ARE UNPOPULATED ARE BLANK BECAUSE THE INFORMATION IS CURRENTLY UNKNOWN OR UNAVAILABLE. A GOOD FAITH EFFORT WILL BE MADE TO OBTAIN THE APPLICABLE INFORMATION RELEVANT TO THE REPORT. IF INFORMATION IS PROVIDED IN THE FUTURE, A SUPPLEMENTAL REPORT WILL BE ISSUED.

    Additional Manufacturer Narrative · 1

    INVESTIGATION OF THIS EVENT IS PENDING AND A SUPPLEMENTAL REPORT WILL BE SENT UPON ITS COMPLETION. IF INFORMATION IS PROVIDED IN THE FUTURE, A SUPPLEMENTAL REPORT WILL BE ISSUED.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT, THREE DAYS AFTER THE IMPLANT PROCEDURE, THE PATIENT EXPERIENCED HEMOLYTIC URINE AND HEMOGLOBINURIA WITH AN INCREASE IN THEIR LACTATE DEHYDROGENASE (LDH) AND HEMOGLOBIN (HGB). A THROMBUS IN THE INFLOW CANNULA OF THE VENTRICULAR ASSIST DEVICE (VAD) WAS CONFIRMED WITH TRANSESOPHAGEAL ECHOCARDIOGRAM (TEE). IT WAS ALSO REPORTED THAT THE VAD EXHIBITED HIGH POWER, HIGH FLOW, AND HIGH WATTS WITH ASSOCIATED HIGH WATT ALARMS. THE PATIENT RECEIVED ANTICOAGULATION THERAPY, THE VAD WAS TURNED OFF AND THE PATIENT IS ON VENOARTERIAL EXTRACORPOREAL MEMBRANE OXYGENATION (VA ECMO) FROM THE VENA CAVA TO THE AORTA. THE PLAN IS TO EXCHANGE THE VENTRICULAR ASSIST DEVICE (VAD). NO FURTHER PATIENT COMPLICATIONS HAVE BEEN REPORTED AS A RESULT OF THIS EVENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    845811 HEARTWARE VENTRICULAR ASSIST SYSTEM - PUMP VENTRICULAR (ASSISST) BYPASS DSQ HEARTWARE, INC. 1104

    Patients

    Seq Age Sex Outcome Treatment
    1 Life Threatening| R