Safety Alert Or Field Safety Notices for Mitral Valve Repair System, MitraClip Clip Delivery System

According to Medicines and Healthcare products Regulatory Agency, this safety alert or field safety notices involved a device in United Kingdom that was produced by Abbott Vascular.

What is this?

Field safety notices are communications sent out by medical device manufacturers or their representatives in relation to actions that they may be taking in relation to their product that is on the market. These are mainly for health workers, but also for users. They can include recalls and alerts.

Learn more about the data here
  • Type of Event
    Safety alert / Field Safety Notice
  • Event ID
  • Event Number
  • Date
  • Event Date Posted
  • Event Country
  • Event Source
  • Event Source URL
  • Notes / Alerts
    Data from the United Kingdom is current through April 2019. All of the data comes from the Medicines and Healthcare products Regulatory Agency, except for the categories Manufacturer Parent Company and Product Classification.
    The Parent Company and the Product Classification were added by ICIJ.
    The parent company information is based on 2017 public records. The device classification information comes from FDA’s Product Classification by Review Panel, based on matches of recall data from the U.S. and the United Kingdom.
  • Extra notes in the data
  • Reason
    Risk of death or serious harm to the patient. if the actuator knob on the clip delivery system (cds) is turned in the wrong direction, this can prevent successful deployment of the clip, leading to the need for open surgical repair. the mhra has been notified by the manufacturer that there have been four reports (including one uk report), of the actuator knob of the clip delivery system (cds) being turned in the wrong direction (i.E. clockwise instead of anti-clockwise) when attempting to disengage and deploy the clip from the cds. turning the actuator knob incorrectly could lead to a fracture of the cds internal assembly, leading to an inability to control the release of the clip from the cds. since the clip may already have a firm grasp on the mitral valve at this point, open surgery may be required to disengage the clip from the cds. the uk incident led to the need for emergency open surgical repair. the bulk of the cds could only be removed from the clip using surgical bolt cutters and the remaining shaft of the cds unscrewed from the clip using forceps. unfortunately, the patient died one week later, following renal complications. in order to help prevent further incidents of this type, the manufacturer issued a fsn on 27 february 2013 providing advice. in addition, new devices will have a blue directional arrow on the actuator knob to help operators visualise the correct direction of turn. the manufacturer has also confirmed to the mhra that they intend to make a number of design changes which should ultimately make it impossible to turn the actuator knob in the wrong direction. the implementation of the final stages of the design changes will not, however, be completed for up to two years.
  • Action
    Follow the manufacturer’s guidance given in the device’s Instructions for Use (IFU) and in their recent Field Safety Notice (FSN) with regards to the correct operation of the CDS Actuator Knob. Observe the blue arrow on the Actuator Knob, which is present on newer devices, indicating the direction in which it should be turned. Interventional Cardiologists Cardiothoracic Surgeons


  • Model / Serial
  • Product Description
    Mitral Valve Repair System. MitraClip Clip Delivery System.
  • Manufacturer


  • Manufacturer Parent Company (2017)
  • Manufacturer comment
    “We are in constant communication with regulatory agencies and competent authorities worldwide which allows us to implement global recalls or in-country communication quickly and effectively,” Abbott, which now owns St. Jude Medical told ICIJ in a statement. In addition to sending global notices to physicians worldwide, we also make sure that product advisories are available online and classification of product recalls and product advisories are determined by global regulatory bodies which can impact the timing in any given country. MD companies follow varying regulations in different countries. In come countries software is not regulated so a recall in one country related to software would not be classified as a recall or field action in another. In addition, review cycles within the regulatory process can be different in each country which can impact communication and recall timing.
  • Source