PERFUSION REPORTS

REPORT
093
DATE
1/11/2021
TITLE
Detached bullet tip of sump-updated response Sep 2022
DETAILS OF INCIDENT

During mini-access MVR, surgeon became aware the bullet tip of the weighted sump had become detached and was in the LV cavity.

DETAILS OF INJURY TO PATIENT

None

TYPE OF DEVICE/MANUFACTURER

Liva Nova 20Fr weighted sump sucker "AtraSump"

Product code: SU-29602

Date of manufacture: July 2020

ACTION TAKEN

Surgeon removed bullet tip from ventricle with no issues. The sump was replaced without further problems and the faulty unit saved for inspection by Liva Nova.

RESPONSE FROM MANUFACTURER

Received response: Investigation summary

Liva Nova received a report stating that, during the procedure, the tip of the SU-29602 cannula came off. No defects were noted before starting the procedure, however the cannula detached during use but having recovered it immediately, no patient was affected.

A photo was provided as evidence of the defect, in particular the disconnected part was between: spring, inner tubing (PN 20742)and connector (PN 20741). The DHR review highlighted that the lot whose claimed product belong to was released as conform according to specifications. Up until April 2022, other similar complaints were recorded from different customers but on different cannula lots. The factors that could contribute to the reported issues are: (i) a failure during the manufacturing steps to apply the proximal connector on the tip assembly, performed by the operators, so that an adequate bonding was not guaranteed and / or (ii) a defective supplier component due to out of specs. The unit has been requested for investigation, and received in Arvada. Per MOP 6003-032, the connection site between the connector and the tubing should have a feature that did not appear to be present on returned unit, the seam between the tubing and the connector should have a visible bead of extra UV adhesive. While there is a thin layer of adhesive, it would appearthat this layer is flat and would hardly provide additional support to thisconnection. Moreover, the critical dimensions for this connection site were evaluated and the results revealed that the components used in this assembly appear to have been in specification. Therefore, no supplier issue occurred. Based on all facts mentioned, it cannot be ruled out that the root cause of th etip detachment is related to a manufacturing deviation during the assembly phase. The issue was addressed within CAPA-ARV-2022-0005. Further corrective action will be implemented through the CAPA process. Liva Nova maintains and document periodic customer events monitoring process in order to evaluate actions for products improvement.

ADDTIONAL INFORMATION
SUPPORTING VISUALS/VIDEO
SUPPORTING DOCUMENT

OTHER PERFUSION
 REPORTS

London Core Review Cardiothoracic Surgery Course - Touch icon
London Core Review Cardiothoracic Surgery Course - Help Guide
Select and scroll to view chosen report
REPORT NO
002
1/1/10
Luer Cap Found In Venous Inlet Port
REPORT NO
001
1/1/09
Oxygenator Water To Blood Leak
Perfusion Report cards are shown in batches of 30 at any one time where available.
123
122
121
120
119
118
117
116
115
114
112
111
110
109
108
107
106
105
104
103
102
101
100
099
098
097
096
095
094
093
092
091
090
089
088
087
086
085
084
083
082
081
080
079
078
077
076
075
074
073
072
071
070
069
068
067
066
065
064
063
062
061
060
059
058
057
056
055
054
053
052
051
050
049
048
047
046
045
044
043
042
041
040
039
038
037
036
035
034
033
032
031
030
029
028
027
026
025
024
023
London Core Review Cardiothoracic Surgery Course - Touch icon
London Core Review Cardiothoracic Surgery Course - Help Guide
Know the report number? Scroll horizontally through the circle icons and select to view the appropriate report.