BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    ENDOTAK RELIANCE G

    MDR report key: 1042210 · Received May 8, 2008

    Report

    Report Number
    2124215-2008-34432
    Event Type
    Malfunction
    Date Received
    May 8, 2008
    Date of Event
    March 12, 2008
    Report Date
    March 12, 2008
    Manufacturer
    CARDIAC PACEMAKERS, INC
    Product Code
    LWS
    Removal / Correction Number
    NA
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    IT
    Reporter Occupation
    PHYSICIAN

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 ENDOTAK RELIANCE G IMPLANTABLE LEAD LWS CARDIAC PACEMAKERS, INC 0175 NA

    Patients

    Seq Age Sex Outcome Treatment
    1 Other THE DEVICE 4542/123305 WAS IMPLANTED| THE DEVICE 0175/123819 WAS IMPLANTED| THE DEVICE M170/200591 WAS IMPLANTED