Contegra® Pulmonary Valved ConduitH020003
Presentation to the Pediatric Advisory Committee September 12, 2017
Dora Vega, MD, PhDDivision of EpidemiologyOffice of Surveillance and BiometricsCenter for Devices & Radiological Health
Device Description
- A glutaraldehyde-crosslinked, heterologous bovine jugular vein with a competent tri-leaflet venous valve
- Indica)ons for Use Correc)on or reconstruc)on of the right ventricular outflow tract (RVOT) in pa)ents aged < 18 years with any of the following congenital heart malformed)ons
- Pulmonary Stenosis (PS)
- Tetralogy of Fallot (TOF)
- Truncus Arteriosus (TA)
- Pulmonary Atresia (PA)
- Transpose)on with Ventricular Septal Defect (VSD) , and– Replacement of previously implanted, but dysfunc)on, pulmonary homografts or valved conduits
Annual Distribution Numbers
- The HDE Annual Distribu)on Number (ADN) is currently defined as the number of devices reasonably needed to treat, diagnose, or cure a popular)on of 8,000 individuals in the United States
- The ADN for Contegra is 4,000 (based on original device approval)
- Since the last PAC review
- 372 sold
- 172 implanted: at least 163 implanted in pediatric (< 22-year-old) pa)ents
Medical Device Report (MDR) Review
- Date: 06/01/16 – 05/31/17
- 109 MDRs: 84 unique events: 1 death (pediatric), 83 injuries
Demographic Data | Value | MDRs containing demographic | |
Country | US: OUS | 89% : 11% | 75: 9(84 Total) |
Patient Gender | Male: Female | 60% : 40% | 50: 34(84 Total) |
Patient Age | Pediatric: Adult | 98% : 2% | 81: 2 (83 Total) |
Pediatric patients: Age Range:1 month – 20 yearsAverage Age: 9.8 ± 5.3 years |
MDR: Primary Reported Eventby Patient Age and TTEO*(MDR Date: 06/01/16 – 05/31/17)
Primary Reported Event |
MDR (n) |
MDR by Patient Age (year) | TTEO (month) | ||
Pediatric (< 22) | Adult (> 22) | Age not reported |
Range |
Mea n | |
Stenosis | 37 | 36 | 1 | 3 — 160 | 73 |
The device replaced (reason not provided) | 35 | 34 | 1 |
3 — 158 |
71 |
Regurgitation | 5 | 4 | 1 | 50 — 136 | 87 |
Arrhythmia | 2 | 2 | 0 — 0.3 | 0.15 | |
Aneurysm | 1 | 1 | 17 | —— | |
Infection/Endocarditis (1 Death) | 2** | 2 | 0.5 — 37 | 19 | |
Increased pressure gradient | 1 | 1 | 133 | —— | |
Thrombus | 1 | 1 | 0.07 | —— | |
Total | 84 | 81 | 2 | 1 |
* Time to Event Occurrence (TTEO)** One MDR involved a potential tracheal compression. A total of 83 MDRs were injuries.
MDR: Poten<al Tracheal Compression
Case Summary (Updated on 9-8-2017)
- Male neonate with a history of Truncus arteriosus type II corrected with a 14 mm Contegra implant and Rastelli procedure
- Conduit replaced with a 12 mm Contegra for unclear reasons 2 weeks aYer first implant– Issues reported included high airway pressure and suspected tracheal compression
- The patient expired 6 days aYer Contegra replacement
- Cause of death: Pneumonia and Sepsis (unrelated to Contegra)
MDR: Primary Reported ProblemComparison of MDRs – 2016 and 2017
Primary Reported Event | 2016 PAC | 2017 PAC |
MDR Count (%) | MDR Count (%) | |
Stenosis | 28 (48 %) | 37 (44 %) |
Device replacement (reason not provided) | 22 (38 %) | 35 (42 %) |
Regurgitation | 2 (3.4 %) | 5 (6 %) |
Arrhythmia | 0 | 2 (2.3 %) |
Aneurysm | 0 | 1 (1.3 %) |
Infection/Endocarditis* | 2 (3.4 %) | 2 (2.3 %) |
Increased pressure gradients | 1 (1.7 %) | 1 (1.2 %) |
Thrombus | 0 | 1 (1.2 %) |
Conduit tear/breakdown | 2 (3.4 %) | 0 |
Device sizing issue | 1 (1.7 %) | 0 |
Total | 58 | 84 |
*. One MDR involved a potential tracheal compression.
Records identified through PubMed and Embase (06/01/16- 05/31/17) (n = 58) | Duplicates Excluded (n=7 |
Titles and abstracts reviewed (n=51) | Records Excluded (n= 26)
|
Full text articles assessed for eligibility(n = 25) | Reviewed and excluded articles (n=24)
|
The article included in the final review (n =1) 1 Case report |
Case Report – 1 pa<entFalchettiet al. 2016Contegra 12 mm: How Long Can It Last? World Jfor Pediatric and Congenital Heart Surgery. 2016Belgium
16 years freedom from failure -12 mm Contegra Background -Pre-implanta<on
- Pa<ent: 4 mo. old female (wt. 3kg) referred from another country with Type 1 TA, large VSD, RVH, right-sided or)c arch, grade 2/4 valve regurgitate)on, and well developed PA branches
- Implanta<on and Hospital Course:
- RVOT reconstruc)on with 12 mm Contegra
- The Main PA diameter measured 9 mm
- PA diameter mismatch results in a Z-score of + 2.5
- Pa)ent discharged POD16 for follow-up at referring country
TA= truncus arteriosus, VSD= ventricular septal defect, RVH= right ventricular hypertrophy, PA = pulmonary artery, PH = pulmonary hypertension, POD= post opera)on date
16 years -Post-implantation
- Referred for reopera)on due to conduit failure
- Healthy female : wt. 33kg/73 lbs; ht.156 cm/5’2”
- TTE: competent truncal valves, conduit stenosis, 110 mm Hg RVOT gradient, no regurgita)on, and normal RV and LV function
- CT scan: conduit diameter shrinkage to 9 mm and calcifica)on
- Replaced with a 22 mm pulmonary homography Poten<al factors contribu<ng to 16 years of freedom from failure
- Moderate oversizing: Z score of +2.5
- Suturing technique: Distal every suture, potentially contributing to avoidance of distal stenosis
RH= right heart, RVOT= right ventricular ouRlow tract, RV= right ventricle, LV= leY ventricle, TTE= Transthoracic Echocardiography, CT= computed tomography
FDA Conclusions
- MDR data review idetified a case of conduit replacement for an unclear reason(s). The FDA believes that currently there is insufficient information to determine if this was a case of tracheal compression due to the device
- Other Adverse Events reported in MDRs are known events addressed in the device IFU
- No new concerns were reported in the literature
FDA Recommendations
- FDA will con)nue the conversa)on with the manufacturer for additional information regarding the suspected case of tracheal compression
- FDA will continue device surveillance and reportthe following to the PAC in 2018:
- Device Annual Distribu)on Numbers
- MDR Data
- Literature Review
Questions to the PAC
- Does the Commi4ee agree with CDRH’s conclusions and recommendations about surveillance and report of ADN, MDRs, and literature review?
- Does the Commi4ee have any additional comment(s)?
Office of Device EvaluationJonathan ReichChangfu Wu | Office of the Center DirectorNia Benjamin*Vasum PeirisVictoria Wagman |
Office of Surveillance and BiometricsGeorge Aggrey*Kelly BauerJiping ChenJose Delgado DonayreBenjamin EloffChih-Hsin “Jenny” Liu*Greg O’ConnellNadezda RadojaErika TangDora Vega*Aron yustin | Office on Pediatrics and TherapeuticsJudith Cope,Robert “Skip” NelsonAmy OdegaardKenneth QuintoPam Weinel |
(*) Slides prepared by
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