BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    HEARTWARE VENTRICULAR ASSIST SYSTEM - BATTERY

    MDR report key: 7642245 · Received June 27, 2018

    Report

    Report Number
    3007042319-2018-02744
    Event Type
    Malfunction
    Date Received
    June 27, 2018
    Date of Event
    June 1, 2018
    Report Date
    January 11, 2019
    Manufacturer
    HEARTWARE, INC.
    Product Code
    DSQ
    UDI-DI
    00888707000376
    PMA / PMN Number
    P100047
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    MA, US
    Reporter Occupation
    HEALTH PROFESSIONAL

    Narratives

    Additional Manufacturer Narrative · 0

    PRODUCT EVENT SUMMARY: THE BATTERY WAS RETURNED FOR EVALUATION. FUNCTIONAL TESTING REVEALED THAT THE BATTERY TRIGGERED A CELL-UNDER- VOLTAGE AND PACK-UNDER-VOLTAGE FLAG, WHICH RENDERED THE BATTERY INOPERABLE. A CELL-UNDER-VOLTAGE FLAG IS TRIGGERED WHEN A CELL PAIR FALLS BELOW A VOLTAGE THRESHOLD. LIKEWISE, A PACK-UNDER-VOLTAGE FLAG IS TRIGGERED WHEN THE BATTERY PACK FALLS BELOW A VOLTAGE THRESHOLD. THE BATTERY WAS UNABLE TO CHARGE OR PROVIDE POWER. INTERNAL INSPECTION OF THE BATTERY REVEALED A LIFTED CELL WELD BETWEEN CELL PAIRS, WHICH CONTRIBUTED TO THE FLAGS. AS A RESULT, THE REPORTED NOT CHARGING AND INABILITY TO PROVIDE POWER WAS CONFIRMED. THE MOST LIKELY ROOT CAUSE OF THE REPORTED EVENTS CAN BE ATTRIBUTED TO A LIFTED CELL WELD. BASED ON AN INTERNAL INVESTIGATION, THE ROOT CAUSE OF THE LIFTED CELL WELD CAN BE ATTRIBUTED TO TERMINAL WELDS EXPERIENCING ADDED STRESS AS A RESULT OF THE UNCONTROLLED BENDING OF THE TABS AND RESISTANCE WELDS OCCURRING ON WELD FREE ZONES. MEDTRONIC, INC. (MEDTRONIC) IS SUBMITTING THIS REPORT TO COMPLY WITH 21 C.F.R. PART 803, THE MEDICAL DEVICE REPORTING REGULATION. 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 IN THE TIME ALLOTTED AND HAS PROVIDED AS MUCH INFORMATION AS IS AVAILABLE TO THE COMPANY AS OF THE SUBMISSION DATE THIS REPORT. THIS REPORT DOES NOT CONSTITUTE AN ADMISSION OR A CONCLUSION BY FDA, MEDTRONIC, OR ITS EMPLOYEES THAT THE DEVICE, MEDTRONIC OR ITS EMPLOYEES 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 REPORTING PURSUANT TO PART 803. MEDTRONIC OBJECTS TO THE USE OF THESE WORDS AND OTHERS LIKE IT 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

    THIS DEVICE IS USED FOR TREATMENT NOT DIAGNOSIS. THE VENTRICULAR ASSIST SYSTEM IS INDICATED FOR USE AS A BRIDGE TO CARDIAC TRANSPLANTATION AND DESTINATION THERAPY IN PATIENTS WHO ARE AT RISK OF DEATH FROM REFRACTORY END-STAGE LEFT VENTRICULAR HEART FAILURE. THE SYSTEM IS DESIGNED FOR IN-HOSPITAL AND OUT-OF-HOSPITAL SETTINGS. IF INFORMATION IS PROVIDED IN THE FUTURE, A SUPPLEMENTAL REPORT WILL BE ISSUED.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT THE BATTERY WAS UNABLE TO HOLD A CHARGE APPROPRIATELY AND DID NOT PROVIDE POWER WHEN TESTED ON THE CONTROLLER PORT. THE PATIENT REPORTED HEARING AN AUDIBLE WHEN THE BATTERY WAS COMPLETELY DRAINED EVEN THOUGH THE SECOND BATTERY STILL HAD A FULL CHARGE. THE BATTERY WAS REPLACED. NO PATIENT COMPLICATIONS HAVE BEEN REPORTED AS A RESULT OF THIS EVENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    485182 HEARTWARE VENTRICULAR ASSIST SYSTEM - BATTERY VENTRICULAR (ASSISST) BYPASS DSQ HEARTWARE, INC. 1650 00888707000376

    Patients

    Seq Age Sex Outcome Treatment
    1 50 YR 1103 VAD