inforMED
DeathJAF

THD EVOLUTION US

Received Mar 1, 2014 · Event occurred Feb 26, 2014

Report 3006680097-2014-00001 · MDR key 3680040

Device

Generic name

Evolution Us And Slide One Kit

Manufacturer

Thd Spa

Model number

700016A

Catalog number

NA

Lot number

NA

Product problems

  • Adverse Event Without Identified Device or Use Problem

Patient

Not reported

  • Death

Narrative

Additional Manufacturer Narrative

BASED ON A CONVERSATION BETWEEN (B)(6) SALES REP AND THE ANESTHESIOLOGIST OF THE SECOND THD CASE, THE PT WAS KNOWN TO HAVE HEART PROBLEMS. (B)(6). THD SPA MADE THREE ATTEMPTS TO DIRECTLY CONTACT THE DOCTOR AND GATHER FIRST HAND RELATED INFO: FIRST ATTEMPT - (B)(4) 2014 4:35PM (CET), (B)(4), AT THE PRESENCE OF (B)(4)). DR. (B)(6) WAS BUSY WITH PTS AT THE (B)(6). SECOND ATTEMPT - (B)(4) 2014 5:15PM (CET),(B)(4), AT THE PRESENCE OF (B)(4). DR. (B)(6) WAS BUSY WITH PTS AT THE (B)(6). THIRD ATTEMPT -(B)(4) 2014 (EST), (B)(4), DR. (B)(6) WAS NOT AVAILABLE.

Description of Event or Problem

DURING A SCHEDULED THD CASE, REGULARLY PROCEEDING, THE SURGEON WAS WARNED BY THE ANESTHESIOLOGIST ABOUT A HEART PROBLEM RELATED TO THE PT. THE THD CASE WAS SUSPENDED SINCE CHEST COMPRESSION PROCEDURE WAS INITIATED TO SUPPORT THE PT. NEVERTHELESS, THE PT DIED. THE SURGEON REFERRED THAT THE DEATH WAS NOT CAUSED BY THE THD CASE. FIFTY MINUTES LATER, A SECOND SCHEDULED THD CASE STARTED AT THE SAME FACILITY WITH ANOTHER SURGEON. THIS SECOND CASE WAS SUCCESSFULLY TERMINATED.