BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    ESSENZ

    MDR report key: 20470252 · Received October 17, 2024

    Report

    Report Number
    9611109-2024-00479
    Event Type
    Malfunction
    Date Received
    October 17, 2024
    Date of Event
    September 26, 2024
    Report Date
    November 28, 2024
    Manufacturer
    LIVANOVA DEUTSCHLAND
    Product Code
    DTQ
    UDI-DI
    04033817903062
    PMA / PMN Number
    K232291
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    US
    Reporter Occupation
    OTHER HEALTH CARE PROFESSIONAL
    Health Professional
    Yes

    Narratives

    Additional Manufacturer Narrative · 0

    H 11:THE COCKPIT LOG FILES HAVE BEEN REQUESTED AND ANALYSED. A TSCP FIALURE HAS BEEN LOGGED IN THE DATE OF EVENT. ANALYSIS OF THE COMPLAINT DATABASE REVEALED SIMILAR REPORTS FROM OTHER CUSTOMERS USING SW HLM.1.5. A SOFTWARE ANOMALY HAS BEEN LOGGED TO ADDRESS THE REPORTED ISSUE. THE INVESTIGATION CONFIRMED THE PROBLEM, HIGHLIGHTING THAT THE BACKUP CONTROL UNIT MAINTAINS CONTROL DURING THE RESET. ONCE THE COCKPIT USER INTERFACE IS RESTORED, THE ¿LAST CASE¿ BUTTON ENABLES USERS TO RETRIEVE ALL PRIOR SETTINGS AND PROCEED WITHOUT ANY DATA LOSS. DURING THE RESET, THE HEART-LUNG MACHINE'S CRITICAL FUNCTIONS, INCLUDING PUMPS, ALARMS, SENSORS, AND SAFETY SYSTEMS, CONTINUED TO PERFORM AS DESIGNED. IN CERTAIN SCENARIOS, THE GAS BLENDER MIGHT SWITCH TO STANDBY MODE, REQUIRING THE OPERATOR TO REACTIVATE IT VIA THE USER INTERFACE ON THE GAS BLENDER UNIT TO ENSURE CONTINUOUS OPERATION. AFTER A SECOND RESET, A NEW CASE MUST BE INITIATED FROM THE HOME SCREEN. THE ROOT CAUSE OF THIS ISSUE WAS IDENTIFIED AS A SOFTWARE ANOMALY RELATED TO A MEMORY VIOLATION. THE ISSUE HAS BEEN FIXED UNDER SW HLM.1.5.1. LIVANOVA HAS TAKEN ACTION BY IMPLEMENTING A DEDICATED CAPA AND A FIELD ACTION (FA-CP-MUN-2024-004) TO PROVIDE CUSTOMERS WITH INSTRUCTIONS ON IMMEDIATE MEASURES AND TO OUTLINE THE CORRECTIVE ACTIONS BEING IMPLEMENTED TO ADDRESS THIS ISSUE.

    Additional Manufacturer Narrative · 0

    A.1.-A.5. PATIENT INFORMATION WAS NOT PROVIDED. H11: LIVANOVA DEUTSCHLAND MANUFACTURES THE ESSENZ CONSOLE. THE INCIDENT OCCURRED IN OULU, FINLAND. THIS EVENT HAS BEEN CONSERVATIVELY REPORTED TO FDA, DESPITE LIVANOVA'S RISK ANALYSIS ASSESSING THE OVERALL RISK AS LOW AND WITHIN ACCEPTABLE LIMITS. LIVANOVA INITIATED AN INVESTIGATION. IF ANY ADDITIONAL INFORMATION PERTINENT TO THE REPORTED EVENT IS RECEIVED, IT WILL BE PROVIDED IN A SUPPLEMENTAL REPORT.

    Description of Event or Problem · 0

    SEE INITIAL REPORT.

    Description of Event or Problem · 0

    LIVANOVA DEUTSCHLAND RECEIVED A REPORT THAT A COCKPIT RESET OF AN ESSENZ CONSOLE EQUIPPED WITH SOFTWARE VERSION 1.5 OCCURRED DURING PROCEDURE. THE COCKPIT SCREEN WENT BACK TO THE INITIAL PAGE, WHILE ACTUATOR AREA CONTINUED TO DISPLAY FLOWS AND ROLES AND THE PUMPS CONTINUED TO RUN. THE USER THEN SELECTED THE OPTION "LAST CASE" AND THE PROCEDURE ENDED WITHOUT ANY FURTHER INCIDENT. THERE WAS NO PATIENT INJURY.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1249937 ESSENZ CONSOLE, HEART-LUNG MACHINE, CARDIOPULMONARY BYPASS DTQ LIVANOVA DEUTSCHLAND HLM 04033817903062

    Patients

    Seq Age Sex Outcome Treatment
    1 NA Unknown