BEUDAMED
    FDA Adverse Event Death Summary report: N

    EPIC MAX VALVE (AORTIC)

    MDR report key: 18801100 · Received February 28, 2024

    Report

    Report Number
    2135147-2024-00919
    Event Type
    Death
    Date Received
    February 28, 2024
    Date of Event
    February 7, 2024
    Report Date
    June 10, 2024
    Manufacturer
    ABBOTT MEDICAL
    Product Code
    LWR
    UDI-DI
    05415067045447
    PMA / PMN Number
    P040021
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    LA, US
    Reporter Occupation
    PHYSICIAN
    Health Professional
    Yes

    Narratives

    Additional Manufacturer Narrative · 0

    AN EVENT OF EXPLANT DUE TO BLEEDING FROM THE AORTIC ROOT WAS REPORTED. INFORMATION FROM THE FIELD INDICATED THAT POST-OPERATIVELY THE PATIENT DEVELOPED AN ISCHEMIC LOWER EXTREMITY LIMB AS A COMPLICATION FROM A IABP THAT LED TO SEPSIS AND END-ORGAN INJURY AND ULTIMATELY A FATALITY. THE DEVICE WAS RETURNED TO ABBOTT FOR INVESTIGATION WHICH REVEALED THAT THE SEWING CUFF WAS INTACT AND CONTAINED BLOOD/BODILY FLUID. THERE WERE NO PERFORATIONS OR TEARS OBSERVED AND THE CUSPS WERE MOBILE. THE DEVICE HISTORY RECORD WAS REVIEWED TO ENSURE THAT EACH MANUFACTURING AND INSPECTION OPERATION WAS PERFORMED, AND THE PRODUCT MET ALL SPECIFICATIONS. THE CAUSE OF THE REPORTED EVENT COULD NOT BE CONCLUSIVELY DETERMINED.

    Additional Manufacturer Narrative · 0

    INVESTIGATION IS NOT YET COMPLETE. A FOLLOW-UP REPORT WILL BE SUBMITTED WITH ALL ADDITIONAL RELEVANT INFORMATION.

    Description of Event or Problem · 0

    IT WAS REPORTED THAT ON (B)(6) 2024, A 21MM EPIC MAX VALVE WAS CHOSEN FOR IMPLANT IN A 64-YEAR-OLD FEMALE PATIENT) WITH A HISTORY OF AORTIC INSUFFICIENCY, CORONARY ARTERY DISEASE AND HYPERTENSION. THE PATIENT UNDERWENT AN AORTIC VALVE REPLACEMENT (AVR) WITH A CONCOMITANT CORONARY ARTERY BYPASS GRAFTING (CABG) TO THE LEFT ANTERIOR DESCENDING CORONARY ARTERY (LAD) USING THE LEFT INTERNAL MAMMARY ARTERY (LIMA). THE PATIENT HAD A SMALL AORTIC ROOT WITH THIN AORTIC TISSUE AND AN AORTIC ENLARGEMENT WAS REQUIRED. THE AORTIC VALVE WAS SIZED FOR A 21 MM EPIC MAX VALVE USING THE REPLICA SIZER END OF THE EPIC MAX SIZER SET. THE 21 MM SIZER FIT WAS GOOD, AND A DECISION WAS MADE TO IMPLANT THE 21MM EPIC MAX VALVE. THE EPIC MAX 21MM WAS IMPLANTED WITHOUT DIFFICULTY WITH THE SUTURES SECURED USING COR-KNOTS. AFTER COMING OFF CARDIOPULMONARY BYPASS IT WAS NOTED THAT THERE WAS BLEEDING FROM THE BASE OF THE AORTA IN THE NON-CORONARY SINUS WITH VISIBLE PLEDGETS CONSISTENT WITH AN AORTIC-VENTRICULAR SEPARATION. THE PATIENT WAS PLACED BACK ON CARDIOPULMONARY BYPASS AND THE EPIC MAX 21MM VALVE WAS REMOVED TO EXPOSE THE AREA OF BLEEDING. THE AORTIC BLEEDING SITE WAS REPAIRED WITH AUTOLOGOUS PERICARDIAL TISSUE AND THE VALVE WAS RESIZED. ALTHOUGH AN EPIC MAX 21MM VALVE WAS ABLE TO BE FITTED A DECISION WAS MADE TO IMPLANT INSTEAD AN EPIC MAX 19MM VALVE. THE PATIENT HAD DIFFICULTY COMING OFF CARDIOPULMONARY BYPASS DUE TO THE PROLONGED PROCEDURE AND ULTIMATELY AN INTRA-AORTIC BALLOON PUMP (IABP) WAS PLACED AND THE PATIENT SUCCESSFULLY CAME OFF CARDIOPULMONARY BYPASS. OVER THE NEXT FEW DAYS THE MYOCARDIAL FUNCTION RECOVERED. HOWEVER, THE PATIENT DEVELOPED AN ISCHEMIC LOWER LIMB AS A COMPLICATION FROM THE IABP AND NEEDED TO UNDERGO A LOWER EXTREMITY AMPUTATION. HOWEVER, A DECISION WAS MADE NOT TO AMPUTATE THE LOWER EXTREMITY AND THE PATIENT DEVELOPED SEPSIS WITH END-ORGAN FAILURE DUE TO THE ISCHEMIC LOWER EXTREMITY. THE PATIENT SUBSEQUENTLY PASSED AWAY. THIS ISSUE REPORTEDLY CAUSED A CLINICALLY SIGNIFICANT DELAY DUE TO HAVING TO REMOVE, REPAIR, AND REPLACE VALVE.

    Description of Event or Problem · 0

    IT WAS REPORTED THAT ON (B)(6) 2024, A 21MM EPIC MAX VALVE WAS CHOSEN FOR IMPLANT. THE PATIENT WAS PRESENTED WITH SMALL AORTIC ROOT, REQUIRING ENLARGEMENT. THE 21MM EPIC MAX VALVE WAS IMPLANTED. HOWEVER, THE PATIENT STARTED BLEEDING AND ATRIOVENTRICULAR DISSECTION WAS NOTICED. THE VALVE WAS EXPLANTED, AND PERICARDIAL PATCH REPAIR WAS PERFORMED. A REPLACEMENT 19MM EPIC MAX VALVE WAS IMPLANTED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1224352 EPIC MAX VALVE (AORTIC) HEART-VALVE, NON-ALLOGRAFT TISSUE LWR ABBOTT MEDICAL BR00038722 05415067045447

    Patients

    Seq Age Sex Outcome Treatment
    1 64 YR Female Other| R