BEUDAMED
    FDA Adverse Event Injury Summary report: N

    BRAVO

    MDR report key: 18383349 · Received December 22, 2023

    Report

    Report Number
    9710107-2023-00255
    Event Type
    Injury
    Date Received
    December 22, 2023
    Date of Event
    November 14, 2023
    Report Date
    February 15, 2024
    Manufacturer
    GIVEN IMAGING LTD., YOQNEAM
    Product Code
    FFT
    UDI-DI
    07290101369714
    PMA / PMN Number
    K102543
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    HK
    Reporter Occupation
    PHYSICIAN
    Health Professional
    Yes

    Narratives

    Additional Manufacturer Narrative · 0

    ADDITIONAL INFORMATION: B5, D9, G3, H3, H6 H3 EVALUATION SUMMARY: MEDTRONIC CONDUCTED AN INVESTIGATION BASED UPON ALL INFORMATION RECEIVED. THE CAPSULE AND DELIVERY SYSTEM WERE RETURNED FOR EVALUATION. THE EVALUATION FOUND NO POTENTIALLY CONTRIBUTING FACTORS, AND THE SAMPLE MET ALL RELATED SPECIFICATIONS. IT WAS REPORTED THAT THE CAPSULE FAILED TO ATTACH. THE REPORTED ISSUE COULD NOT BE CONFIRMED. THE MOST LIKELY CAUSE COULD NOT BE IDENTIFIED BECAUSE NO RELATED PROBLEM WAS DETECTED WITH THE DEVICE. THE MANUFACTURING RECORDS FOR EACH DEVICE ARE THOROUGHLY REVIEWED PRIOR TO RELEASE TO ENSURE THAT IT MEETS ALL MEDTRONIC QUALITY SPECIFICATIONS. A SECONDARY REVIEW OF THE DEVICE HISTORY RECORDS FOUND NO POTENTIALLY CONTRIBUTING FACTORS. 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 · 0

    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.

    Description of Event or Problem · 0

    ACCORDING TO THE REPORTER, THE CAPSULE FAILED TO ATTACH AND WAS FOUND IN THE PATIENT'S ESOPHAGUS. THE DOCTOR PERFORMED OESOPHAGOGAST RODUODENOSCOPY (OGD) BEFORE CAPSULE PLACEMENT AND FOUND OESOPHAGO-GASTRIC JUNCTION (OGJ) AT 36 CENTIMETER. THE DOCTOR DECIDED TO PLACE THE CAPSULE AT 30 CENTIMETER FROM MOUTH. THE SUCTION WAS TURNED ON THE WHEN CAPSULE REACHED 30 CENTIMETER LOCATION AND THEN THE SUCTION PRESSURE REACHED 600MMHG. 60 SECONDS WAS COUNTED BEFORE THE PHYSICIAN FIRED THE DELIVERY DEVICE. AFTER FIRING, THE HANDLE WAS ROTATED AND RELEASED THE CAPSULE FROM THE DELIVERY KIT. HOWEVER, THE CAPSULE WAS FOUND NOT ATTACHED TO THE ESOPHAGUS WALL UNDER OES OPHAGOGASTRODUODENOSCOPY IMAGE. THE CAPSULE WAS RETRIEVED FROM THE PATIENT WITH AN UNKNOWN DEVICE. THE PATIENT WAS PREPPED FOR THE PROCEDURE.

    Description of Event or Problem · 0

    ACCORDING TO THE REPORTER, THE CAPSULE FAILED TO ATTACH AND WAS FOUND IN THE PATIENT'S ESOPHAGUS. THE DOCTOR PERFORMED OESOPHAGOGAST RODUODENOSCOPY (OGD) BEFORE CAPSULE PLACEMENT AND FOUND OESOPHAGO-GASTRIC JUNCTION (OGJ) AT 36 CENTIMETER. THE DOCTOR DECIDED TO PLACE THE CAPSULE AT 30 CENTIMETER FROM MOUTH. THE SUCTION WAS TURNED ON THE WHEN CAPSULE REACHED 30 CENTIMETER LOCATION AND THEN THE SUCTION PRESSURE REACHED 600MG. 60 SECONDS WAS COUNTED BEFORE THE PHYSICIAN FIRED THE DELIVERY DEVICE. AFTER FIRING, THE HANDLE WAS ROTATED AND RELEASED THE CAPSULE FROM THE DELIVERY KIT. HOWEVER, THE CAPSULE WAS FOUND NOT ATTACHED TO THE ESOPHAGUS WALL UNDER OESOP HAGOGASTRODUODENOSCOPY IMAGE. THE CAPSULE WAS RETRIEVED FROM THE PATIENT WITH AN UNKNOWN DEVICE. THE PATIENT WAS PREPPED FOR THE PROCEDURE.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    2153657 BRAVO ELECTRODE, PH, STOMACH FFT GIVEN IMAGING LTD., YOQNEAM FGS-0636 59843F 07290101369714

    Patients

    Seq Age Sex Outcome Treatment
    1 NA Female Required Intervention