BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    VITALITY AVT

    MDR report key: 1041602 · Received May 8, 2008

    Report

    Report Number
    2124215-2008-31935
    Event Type
    Malfunction
    Date Received
    May 8, 2008
    Date of Event
    July 18, 2006
    Report Date
    January 22, 2008
    Manufacturer
    CARDIAC PACEMAKERS, INC
    Product Code
    LWS
    Removal / Correction Number
    Z47/53-08
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    MN, US
    Reporter Occupation
    LAY USER/PATIENT

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 VITALITY AVT IMPLANTABLE CARDIOVERTER DEFIBRILLATOR LWS CARDIAC PACEMAKERS, INC A135 NA

    Patients

    Seq Age Sex Outcome Treatment
    1 78 YR Other THE DEVICE T180/211399 WAS IMPLANTED 23-JAN-2008| THE DEVICE 4054/432338 WAS IMPLANTED 09-MAY-2003| THE DEVICE 4055/409052 WAS IMPLANTED 09-MAY-2003| THE DEVICE 0158/116123 WAS IMPLANTED 09-MAY-2003