& DEPARTMENT OF HEALTH & HUMAN SERVICES
Food and Drug Administration
Rockville MD 20857
_ The Honorable Richard G. Lugar
United States Senator NOV 05 2009
Washington, D.C. 20510-1401
Dear Senator Lugar:
‘Thank you for your letter of August 4, 2009, regarding a situation brought to your
attention by Dr. Nalini Rajamannan involving the status with the Food and Drug
Administration (FDA or the Agency) of the model 5100 McCarthy Myxo dEtlogix
Annuloplasty Ring, manufactured by Edwards Lifesiences (Edwards) LLC, for use in
heart valve repair. ‘The material you enclosed included a copy of a July 16, 2009, letter
FDA had sent to a patient from Illinois, Ms. Atonista Vlahoulis, who had expressed
concern about the use of the Myxo valve product by a surgeon who implanted this device
inher. Below are responses FDA has made in reply to several follow-up questions the
Agency received to the July 16, 2006, letter addressed to Ms. Vlahoulis.
1. The Agency says that sponsors are “encouraged to contact the Agency if they
have questions regarding the appropriateness of a 510(K).” If there are no
disincentives for making the wrong determination, why would manufacturers
seek advance input from the Agency or submit a new 510(k) rather than wait for
the FDA to request one?
FDA believes that sponsors have disincentives to make the wrong determination.
However, FDA has determined that its guidance to industry entitled “Deciding When to
Submit a 510(K) for a Change to an Existing Device” is not sufficiently clear in
describing when a sponsor must submit a 510(k) to FDA. For example, the changes
Edwards made to its device were not clearly described as requiring the submission of a
510(k).
In recognition of the rapid rate of device evolution, FDA’s regulations provide that
‘manufacturers need to submit a new 510(k) only when a change or modification, or the
sum of incremental changes or modifications, could significantly affect the safety or
effectiveness of the device. ‘This standard is contained in 21 CFR 807.81(a)(3). In our
guidance document entitled “Deciding When to Submit a 510(k) for a Change to an
Existing Device,” the Agency provided guidance on the types of labeling, technology,
performance and material changes that may cross this threshold. We state in the
guidance that if a firm, after consulting the guidance, still has questions on whether or not
anew 510(k) is needed, they should contact our premarket review offices.Page 2 — The Honorable Richard G. Lugar
In that guidance FDA also advised manufacturers that design control requirements
applicable to all Class II and III devices, and to certain Class I devices, are required to
identify, document, validate, review and approve design changes before their
implementations. The device history file must contain or reference the records necessary
to demonstrate that the design was developed in accordance with the approved design
plan and quality system requirements. See 21 CFR 820.30(i), ()). FDA has access to the
device history file upon inspection.
‘A manufacturer has strong incentives to comply with these 510(k) and design control
requirements. Significant consequences flow from noncompliance. Ifa manufacturer
implements a change or modification without submitting a new 510(k), and FDA
subsequently determines the change required clearance of a new 510(k) before device
marketing, FDA considers the unapproved device to be in violation of the Act, may
advise the manufacturer to recall the product or take other measures to correct products
already in distribution, and may take additional compliance action against the
manufacturer and the product. In assessing the appropriate response in a particular
situation, FDA must assess the risks to public health, and determine whether the company
made a good faith effort to determine if the changes could significantly affect the safety
and effectiveness of the device. FDA would consider the significance of the changes
made and possible implications to the patient, whether a manufacturer had appropriate
rationale and/or documentation to support its decision, and whether or not the
manufacturer is taking steps to come into compliance. ‘The manufacturer's interest in
avoiding such compliance actions provides strong incentive for diligence and good faith
in making that initial determination.
There are additional incentives that apply outside the FDA regulatory scheme, such as the
incentive to avoid private lawsuits and other negative interactions with patients and the
health care community.
FDA is planning to update existing guidance in this area. We plan to take the lessons
Jearned from these events and take the opportunity to communicate more clearly on these
issues.
2. Did the FDA review any data on the patients who already had the device
implanted prior to clearance by the FDA for marketing? If not, why not?
‘Yes, an overview of the elinical experience to date was reviewed in the 510(k)
submission, This included a paper entitled “Initial Clinical Experience with Myxo-
ETlogix Mitral Valve Repair Ring,” (J Thorac Cardiovasc Surg 2008:1-9) published by
McCarthy et al., information from Edwards Lifesciences’ in-house registry, and a review
of the Center for Devices and Radiologic Health’s (CDRH or the Center) Manufacturer
and User Facility Device Experience (MAUDE) database.
‘The MeCarthy paper describes a two-surgeon, single-institution experience with 100
Myxo ETlogix (dETlogix) implants for repair of myxomatous mitral regurgitation over
18 months. ‘The authors reported no postoperative mortality, infection, myocardialPage 3 ~The Honorable Richard G. Lugar
infarction, or renal failure. There was one reoperation for bleeding and one stroke.
Ninety-ight percent of patients showed no residual regurgitation on intraoperative
echocardiogram, with a mean transvalvular gradient of 3.0 mmHg. At hospital discharge
(average 5.6 days later), 93.9 percent of patients had no regurgitation and 6.1 percent had
+ regurgitation.
Follow-up was reported for an unknown number of patients with a total of 338
echocardiograms over an average time of 6.1 months (range unknown), Mitral
regurgitation (MR) of 1+ was found in 18 percent of the Myxo ETlogix patients; itis
stated that there was no statistical difference between discharge MR and follow-up MR,
and that no patient had MR >2+. Persistent, obstructive systolic anterior motion was not
seen. The safety and effectiveness outcomes reported in this manuscript are similar to
what one would expect for mitral valve repair operations involving an annuloplasty ring.
In the 510(k) the sponsor provided a summary of the data included in their in-house
registry. The sponsor reported that a total of 667 units had been distributed with 10
observations. Four were complaints, including two cases of suture pull-out, one case of a
systemic rash responding to steroids, and the fourth, a possible cause of “inflammatory
response.” The sponsor reported that there were six device explants, Four devices were
explanted during the procedure, but without report on whether the device was replaced
with a different ring or by valve replacement. Details for the remaining two explants
were not available.
‘The Agency also reviewed medical device reports (MDRs) submitted to the MAUDE
database during our review of the 510(k). This database search returned five entries for
four events (it appeared that the first two entries were for the same event). ‘Three of the
four events occurred on the date of implant for suture pulling through the annulus or for
“unknown reasons.” The fourth event was patient death and took place approximately six
months after implant. The cause of death was not reported.
Regarding our review of Edwards’ in-house registry data and the MDRs submitted for the
dETlogix device, the Agency felt that the frequency and type of complaints and adverse
events reports were consistent with the expected outcomes in this patient population,
After reviewing all of the data described above, the Agency concluded that the clinical
experience with the dETlogix device was similar to legally marketed annuloplasty rings.
3. Has the FDA required the company to take specific actions to prevent wrong
determinations from occurring again in the future? If so, please describe what
actions are being required of the company.
Yes, FDA held a meeting with the firm to explain our decisionmaking process and
expectations for determining when a new 510(k) is required. The firm must implement a
corrective and preventive action to ensure that they have an appropriate process in place
to correctly determine when a modification to a device requires a new 510(k). A.
corrective and preventive action is an action to correct and prevent distribution ofPage 4 - The Honorable Richard G. Lugar
products that do not meet specifications or have other quality problems. This is required
by the Quality System regulation for medical devices. On a follow-up inspection FDA
verified that Edwards had implemented an appropriate corrective and preventive action
by changing its procedures for determining when a 510(K) must be submitted to FDA.
4, Has the FDA requested the company notify all patients implanted with the
dETlogix ring before it was cleared by the FDA that they had received an
experimental device? If not, why not?
No, FDA has not requested that the company notify all patients who received the device
prior to clearance. The Agency takes very seriously its responsibility for human subject
protection. However, in this case FDA has determined that the device meets the
standards for safety and effectiveness applicable to this class II device and that Edwards
did not believe it was testing an investigational device. Therefore, in this case, we do not
believe that notification would provide a benefit to patients, and instead may
‘unnecessarily alarm patients and raise unwarranted concerns. However, in cases where
the evidence shows that patients may be at greater risk from the device or where we have
identified steps that can be taken to ameliorate the risks to patients, we would generally
request sponsors notify patients who received an unapproved or uncleared device.
5. According to FDA’s guidance, manufacturers are only required to maintain
documentation of their analysis on whether or not a modification to their device
requires the filing of a new 510(k) and to make that documentation available to
the FDA during an inspection. Why are manufacturers not required to submit
that documentation to the Ageney at the time that the determination is made so
that the Agency is on notice and has a file of all modifications made to a device?
One of the cardinal features distinguishing the medical device industry from the
pharmaceutical industry is that design and manufacture of medical devices change and
evolve at a much faster rate than for most pharmaceutical products. Modifications to a
device can occur relatively frequently, and their impact can range from very minor to
significant in terms of safety or effectiveness. Currently, approximately 3500 510(k)
notifications are received every year, with over 120,000 cleared since the device
amendments were passed in 1976. A requirement that manufacturers submit
documentation every time a minor change is made to a marketed device would result in a
Jarge number of paper filings. Handling and reviewing these paper filings would entail
the redirection of limited resources to an activity with likely a small public health benefit.
This is, however, an issue the Agency is revisiting. As noted in our response to question
#1, we believe our current policy for what constitutes a minor change is not sufficiently
clear. To address this deficiency we are in the process of revising our current guidance
document. In addition, as CDRH moves towards the electronic submission of
applications through rulemaking and investments in information technology, the Center
will be in a better position to handle and analyze the larger volume of information that
‘would come from manufacturers submitting documentation of minor changes made to a
devicePage 5 ~ The Honorable Richard G, Lugar
6. According to the Heartwire article, Edwards maintained in-house documentation
ofits determination that the dETlogix ring did not require a new 510(k), and did
not submit the documentation until FDA asked for that documentation last year
during FDA’s investigation of the matter.
. If allegations regarding the dE Tlogix ring had not been brought to the FDA’s
attention, at what point in time might the FDA have discovered that a wrong
determination had been made during a routine inspection of the manufacturer?
In the above-mentioned guidance, we request that a firm, when submitting a 510(k) for a
change or modification, identify previous modifications to the device for which they did
not submit 2 510(k). If, during the review of the new 510(k), we find that one of the
previous modifications did meet the criteria for a 510(k), we address that finding with the
firm. In addition, FDA may become aware of changes made to a device by receiving a
complaint, through our own investigation of adverse event reports or other reports to
EDA, or during an inspection. Based on past experience, we would most likely have
detected this kind of change/modification during our inspection.
b. How comprehensive is FDA’s review of a manvfacturer’s analysis during a
routine inspection?
‘The level of review varies. FDA may perform routine inspections at two levels of
coverage: Level I or II. A Level I inspection covers corrective and preventive actions
plus either design controls or production and process controls. A Level II inspection
covers management controls, design controls, corrective and preventive actions, and
production and process controls. During an inspection, if design controls are reviewed,
the investigator will review one preproduction and one postproduction design change
This review may lead to the collection of documentation of the design changes and the
firm's documented rationale for determining whether these changes require a new 510(k).
In addition, the investigator may review complaints or corrective and preventive action
records,
c. Does the FDA always request such documentation for review during each
inspection? If not, how frequently does the FDA review such documentation?
No, FDA does not always request such documentation for review during each inspection
and we do not track how frequently we review such documentation. Instead FDA
requests and reviews records using a risk-based approach, tailoring its review to the
purpose of the inspection for that particular facility. As stated above, during an
inspection, if design controls are reviewed, the investigator will review one preproduction
and one postproduction design change. This review may lead to the collection of
documentation of the design changes and the firm's documented rationale for determining
whether these changes require a new 510(k). In addition, the investigator may review
complaints or corrective and preventive action records.Page 6 ~The Honorable Richard G. Lugar
4d. Does the Agency maintain any database of all modifications made to devices
cleared and/or approved by the Agency even if the Agency does not conduct a
comprehensive review of all of the modifications? If not, why not? And how does
FDA track what modifications have been made to each device?
‘The Agency does not maintain a database of 510(k) modifications. We do, however,
track these changes through the review of the submission, For example, each time a new
feature is added the FDA reviewer will typically describe the significance/evolution of
the design history. As previously noted, in our above referenced guidance, we request
that a firm, when submitting a 510(k) for a change or modification, identify previous
modifications to the device for which they did not submit a 510(K). If, during the review
of the new 510(k), we find that one of the previous modifications did meet the criteria for
2 510(K), we address that finding with the firm, For many of the same reasons described
in our response to question #5, however, FDA does not maintain a database related to
modifications not addressed or submitted as part of a 510(k) review.
7. Please describe in detail any steps the FDA plans or is planning to take to
improve its oversight of manufacturer determinations on when to submit a $10(k)
for a modification to an existing device.
As noted, in our responses to questions #1 and #5, FDA is currently reviewing and
revising the guidance document entitled “Deciding When to Submit a 510(k) for a
Change to an Existing Device.” Furthermore, we have commissioned the Institute of
‘Medicine to conduct a comprehensive study of the 510(k) process and to make
recommendations on appropriate administrative, regulatory, and legislative changes.
FDA will also explore requiring the submission of documentation when minor changes
are made to a device once electronic submissions are required and the necessary
information technology system to handle these submissions is established.
Thank you for your continued interest in this important matter. If we can be of further
assistance, please let us know.
Sincerely,
b Abies
Jeanne Ireland
Assistant Commissioner
for Legislation
Enolosure