Medical Device
Manufacturing
THE TRADE PAPER OF THE FACTORY FLOOR
Z-1498-2020Class II

LivaNova Heater-Cooler System 3T -

LivaNova USA, Inc. / initiated 2020-02-24 / Terminated / root cause: design

LivaNova USA Inc. began a recall of LivaNova Heater-Cooler System 3T - Product Usage: The Heater-Cooler 3T System is used to circulate water through heat exchangers to warm or cool a patient... on . FDA classified it as Class II and gives the reason as "The firm is providing validated cleaning and disinfection instructions in their revised operating instructions to reduce the risk of NTM contamination". As of , the recall status on record is Terminated, and MDM tags the root cause as design.

Recall record

Recall number
Z-1498-2020
Classification
Class II
Status
Terminated
Initiated
Posted
Terminated
Recalling firm
LivaNova USA, Inc.
Product
LivaNova Heater-Cooler System 3T - Product Usage: The Heater-Cooler 3T System is used to circulate water through heat exchangers to warm or cool a patient during cardiopulmonary bypass procedures lasting 6 hours or less.
Product code
DWC Controller, Temperature, Cardiopulmonary Bypass
Reason for recall
The firm is providing validated cleaning and disinfection instructions in their revised operating instructions to reduce the risk of NTM contamination.
Root cause tag
design
FDA root cause
Device Design
Action
On 02/24/2020, the firm sent an "URGENT MEDICAL DEVICE CORRECTION" Letter to customers informing them that the firm is executing a voluntary correction for their Heater-Cooler Systems and providing customers with a recently cleared operating instructions that includes a validated instructions for cleaning and disinfecting the external surfaces, connectors, fittings, and water circuits. The firm is instructing customers to discard or destroy older versions of the operating instruction and advising that all Heater-Cooler Systems in use at their facility should be upgraded with the 3T Aerosol Collection Set (vacuum canister and internal seal) to further reduce the risk of potential aerosol emission form the 3T system. These corrections apply to all 3T Systems currently in distribution, which includes upgrading any loaners that were previously distributed or that are pending distribution. Actions to be Taken by the Customer/User Use the Validated Operating Instructions Provided with this Customer Letter " The FDA cleared Operating Instructions are found in Attachment 1 as well as at Product Resources on www.livanova.com. - Please read and follow the instructions carefully. - Section 2.1.5 Integrating the HC3T into your facility provides guidance on the use of the 3T System in your facility, highlighting critical tasks that users had the most difficulty with during human factors testing. - Section 6 Maintaining the heater-cooler provides guidance on the maintenance of the 3T System including the validated cleaning and disinfection instructions. - Section 7.1.4 General performance data describes performance testing results that emphasize the importance of following the cleaning and disinfection instructions and consistently using the 3T Aerosol Collection Set during surgeries. Specifically, these results describe how (1) the disinfection and water maintenance process maintains water quality and (2) the 3T Aerosol Collection Set design change reduces the
Quantity in commerce
Total Worldwide=9309 systems (2713 system in U.S.)
Distribution
U.S. Nationwide distribution including Puerto Rico. This matter was triggered by the clearance of K191402, thus only the United States, including Puerto Rico, is affected. O.U.S. - none
Product codes and lots
Device Listing: E572259  Product Code Product Description Affected Serial Number range 16-02-80 Heater-Cooler 3T, 230V 16S10027 16S16874 16-02-81 Heater-Cooler 3T, 240V 16S10743 16S11708 16-02-82 Heater-Cooler 3T, 208V 16S10772 16S16840 16-02-83 Heater-Cooler 3T, 127V 16S11455 16S16509 16-02-85 Heater-Cooler 3T, 120V 16S10958 16S16847 16-02-95 Heater-Cooler 3T, 200V 16S12004 16S16818

Enforcement reports

One row per recalled product line
FDA enforcement reports joined to recall event Z-1498-2020
Recall numberClassStatusVoluntary or mandatedReport dateClassified
Z-1498-2020Class IITerminatedVoluntary: Firm initiated