BEUDAMED
    FDA Adverse Event Injury Summary report: N

    PATIENT CCO CABLE

    MDR report key: 3656063 · Received March 3, 2014

    Report

    Report Number
    2015691-2014-00501
    Event Type
    Injury
    Date Received
    March 3, 2014
    Date of Event
    February 5, 2014
    Report Date
    February 5, 2014
    Manufacturer
    EDWARDS LIFESCIENCES
    Product Code
    DXG
    PMA / PMN Number
    K043103
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    TX, US
    Reporter Occupation
    BIOMEDICAL ENGINEER

    Narratives

    Additional Manufacturer Narrative · 1

    A 70CC2 CABLE WAS RETURNED FOR EVALUATION. SINCE THE CUSTOMER WAS UNCERTAIN WHICH CABLE WAS USED, 3 CABLES MAINTAINED IN THE OR SUITE WERE RETURNED TO EDWARDS FOR EVALUATION. (RELATED COMPLAINT #S (B)(4)) THE EVALUATION OF THE STATED COMPLAINT CABLE WAS INDEPENDENT OF THE RETURNED MONITOR TO VERIFY FUNCTIONALITY. THE CABLE WAS NOTED UPON VISUAL INSPECTION TO HAVE PHYSICAL DAMAGE WITH ONE OF THE CABLE CONNECTORS OVER-MOLD BROKEN FROM THE CABLE. CONTINUITY TESTING USING A CALIBRATED MULTIMETER SHOWED OPEN WIRE CONNECTIONS. DURING FUNCTIONAL TESTING THE MONITOR DISPLAYED ¿FAIL ¿ REPLACE CABLE¿. THE CABLE WAS FOUND TO BE NONFUNCTIONAL. THE CABLE HAS EXCEEDED ITS USEFUL LIFE. ALTHOUGH IT CANNOT BE CONFIRMED, THE CONDITION OF THE RETURNED CABLE IS CONSISTENT WITH IMPROPER HANDLING AND/OR STORAGE BY THE CUSTOMER, AND NOT A PRODUCT MALFUNCTION OR DEFECT. RELATED COMPLAINT #(B)(4) THE CABLE FROM THE RELATED COMPLAINT (B)(4) SHOWED NO PHYSICAL DAMAGE. CONTINUITY TESTING USING A CALIBRATED MULTIMETER SHOWED OPEN WIRE CONNECTIONS. DURING FUNCTIONAL TESTING THE MONITOR DISPLAYED ¿FAIL ¿ REPLACE CABLE.¿ THE CABLE WAS FOUND TO BE NONFUNCTIONAL. ALTHOUGH IT CANNOT BE CONFIRMED, THE CONDITION OF THE RETURNED CABLE IS CONSISTENT WITH IMPROPER HANDLING AND/OR STORAGE BY THE CUSTOMER, AND NOT A PRODUCT MALFUNCTION OR DEFECT. RELATED COMPLAINT CODE (B)(4) THE CABLE FROM RELATED COMPLAINT (B)(4) SHOWED NO PHYSICAL DAMAGE. CONTINUITY TESTING USING A CALIBRATED MULTIMETER SHOWED OPEN WIRE CONNECTIONS. DURING FUNCTIONAL TESTING THE MONITOR DISPLAYED ¿FAIL ¿ REPLACE CABLE.¿ THE CABLE WAS FOUND TO BE NONFUNCTIONAL. THE CABLE HAS EXCEEDED ITS USEFUL LIFE. ALTHOUGH IT CANNOT BE CONFIRMED, THE CONDITION OF THE RETURNED CABLE IS CONSISTENT WITH IMPROPER HANDLING AND/OR STORAGE BY THE CUSTOMER, AND NOT A PRODUCT MALFUNCTION OR DEFECT. RELATED COMPLAINT CODE (B)(4) THE MONITOR FROM RELATED COMPLAINT (B)(4) WAS VISUALLY INSPECTED. A MANUAL INSPECTION OF THE DEVICE DID NOT NOTE ANY COSMETIC IRREGULARITIES, DAMAGE OR DIFFERENCES NOTICED FROM A NEW UNIT OF THE SAME REVISION AND PART NUMBER. THE MONITOR PERFORMED NORMALLY IN ALL TEST CONDITIONS. FUNCTIONAL TESTING OF THE SYSTEM WAS CONDUCTED IN VARIOUS FLOW CONDITIONS TO CONFIRM FUNCTIONALITY OF THE THERMAL ELEMENT CONTROLS AND SAFETY SYSTEMS. THE SYSTEM WAS AGGRESSIVELY CHALLENGED BY REDUCING FLOW AROUND THE CATHETER WHILE IN CCO MODE AND THE SYSTEM PERFORMED AS DESIGNED IN ALL TEST CONDITIONS. RELATED COMPLAINT CODE (B)(4) THE SWAN GANZ CATHETER FROM RELATED COMPLAINT (B)(4) WAS RECEIVED IN THE EVALUATION LAB FOR VISUAL EXAMINATION, PHOTOS AND X-RAY. VISUAL EXAMINATION DID NOT FIND ANY ABNORMALITIES WITH THE CATHETER BODY, THERMAL FILAMENT, EXTENSION TUBE'S, HUBS OR THERMISTOR AND THERMAL FILAMENT CONNECTORS. THERMAL ELEMENT RESISTANCE VS. TEMPERATURE TEST WAS PERFORMED. THE RESISTANCE OF THE THERMAL ELEMENT OF THE CATHETER AND 5 ADDITIONAL CONTROL UNITS WERE MEASURED IN SPECIFIC FLUID BATH TEMPERATURES. IT WAS CONCLUDED THAT THE RESISTANCE OF THE THERMAL ELEMENT OF THE CATHETER MATCHED THE RESISTANCE THAT WAS INITIALLY PROGRAMMED IN THE CATHETER AS RECORDED IN THE EEPROM VALUES. THERE WERE NO NOTABLE DIFFERENCES BETWEEN THE CATHETER AND THE CONTROL UNITS TESTED. THEREFORE IT WAS CONCLUDED THAT THE RESISTANCE OF THE THERMAL ELEMENT OF THE CATHETER OPERATED WITHIN EXPECTED PARAMETERS. EDWARD¿S PERSONNEL VISITED THE CLINICAL SITE TO GATHER FURTHER INFORMATION REGARDING THE CASE. THE TIMELINES FROM THE ANESTHESIA RECORD AND VIGILANCE II MACHINE WERE REVIEWED. THE ANESTHESIOLOGIST STATED THAT THERE WERE NO PROBLEMS WITH THE INSERTION OF THE CATHETER AND THAT THE PLACEMENT WAS VERIFIED BY ECHO. HE SPOKE ABOUT THE CATHETER BEING PULLED BACK DURING THE REPAIR OF THE PULMONARY ARTERY AND THE REPOSITIONING AFTER COMPLETION OF THE REPAIR. REGARDING THE INJURY, HE STATED THAT THE INJURY WAS ¿VERY SUPERFICIAL¿ AND THERE WAS LITTLE CONCERN ABOUT IT IN THE OR. HE MENTIONED THAT THE INJURY WAS NOT TRANSMURAL AND WAS NOT NOTED UNTIL THE RIGHT ATRIUM WAS OPENED FOR THE TRICUSPID VALVE REPAIR. HE STATED ¿BELIEVE ME, IF THERE WAS ANYTHING OTHER THAN A SUPERFICIAL INJURY, YOU WOULD HAVE GOTTEN A PHONE CALL IMMEDIATELY." HE CONFIRMED THAT THEY CONTINUED TO USE THE CATHETER WITHOUT INCIDENT UNTIL IT WAS REMOVED ON POST OPERATIVE DAY #1. THE PATIENT RECOVERED UNEVENTFULLY. THE PATIENT WAS DISCHARGED ON POST OPERATIVE DAY #6. SEE RELATED MDR SUBMISSIONS: 2015691-2014-00502 (70CC2 CABLE); 2015691-2014-00503 (70CC2 CABLE); 2015691-2014-00500 (VIGILANCE II MONITOR); 2015691-2014-00455 (CCO SWAN GANZ CATHETER).

    Additional Manufacturer Narrative · 1

    THE DEVICE EVALUATION IS ANTICIPATED. HOWEVER THE COMPLIANT COULD NOT BE CONFIRMED WITHOUT THE COMPLETION OF THE PRODUCT EVALUATION. A SUPPLEMENTAL REPORT WILL BE SENT WHEN THE INVESTIGATION IS COMPLETE.

    Additional Manufacturer Narrative · 1

    EVALUATION SUMMARY: EXAMINATION FOUND THAT A CONTINUITY TEST WAS PERFORMED USING A MULTI-METER WHICH RESULTED IN AN OPEN WIRE CONNECTION AT S1-3 TO P1-13, S1-2 TO P1-12 AND S1-1 TO P1-14. THEY ALSO TESTED THE CABLE ON A KNOWN GOOD, CALIBRATED VIGILANCE II MONITOR, RESULTING IN TEST FAILURE WITH ¿FAIL REPLACE CABLE¿ ERROR MESSAGE. THE CABLE CONNECTOR OVER MOLD OF THIS CABLE IS ALSO BROKEN. THE DEVICE HISTORY RECORD REVIEW WAS NOT PERFORMED BECAUSE THE LOT NUMBER IS UNKNOWN.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT A PATIENT INCURRED A 3CM LINEAR FULL THICKNESS BURN IN THE RIGHT ATRIUM DURING AN AORTIC ROOT REPLACEMENT AND TRICUSPID VALVE REPAIR. THE BURN WAS ON THE LATERAL ATRIAL WALL ADJACENT TO A THERMAL FILAMENT OF A CCO SWAN GANZ CATHETER. THE SURGEON STATED THAT IT ¿LOOKED LIKE AN ABLATION BURN.¿ THE SURGEON STATED THAT SHE WAS ABLE TO ¿EASILY SUTURE REPAIR THE INJURY.¿ SHE ALSO STATED THAT THE CCO FEATURE OF THE SWAN GANZ CATHETER WAS TURNED OFF WHEN THE PATIENT WENT ON BYPASS AND WORKED WELL AFTER THE CASE. NO PATIENT COMPLICATIONS WERE NOTED. THE PATIENT WAS DISCHARGED ON POD #6.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    126179 PATIENT CCO CABLE COMPUTER, DIAGNOSTIC, PRE-PROGRAMMED, SINGLE-FUNCTION DXG EDWARDS LIFESCIENCES 70CC2

    Patients

    Seq Age Sex Outcome Treatment
    1 Required Intervention