BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    CAPSUREFIX NOVUS

    MDR report key: 1863138 · Received October 9, 2010

    Report

    Report Number
    2649622-2010-10412
    Event Type
    Malfunction
    Date Received
    October 9, 2010
    Date of Event
    July 13, 2010
    Manufacturer
    MEDTRONIC PUERTO RICO, INC.
    Product Code
    DTB
    PMA / PMN Number
    P930039/S009
    Removal / Correction Number
    ASKU
    Report Source
    Manufacturer report
    Reporter Location
    US
    Reporter Occupation
    PHYSICIAN

    Narratives

    Additional Manufacturer Narrative · 1

    THE INFORMATION SUBMITTED REFLECTS ALL RELEVANT DATA RECEIVED. IF ADDITIONAL RELEVANT INFORMATION IS RECEIVED, A SUPPLEMENTAL REPORT WILL BE SUBMITTED. EVALUATION SUMMARY: (B)(4) HELIX/LOBE DISTORTED/BENT; FULL LEAD WAS RETURNED AND ANALYZED. BLOOD IN/ON HELIX/LOBE MECHANISM (SLEEVE HEAD).

    Description of Event or Problem · 1

    IT WAS REPORTED THAT "SCREW DIDN'T WORK PROPERLY UPON INSERTION" AND LOOKED TO BE UNCOILED UNDER FLUOROSCOPY. THE LEAD WAS NOT IMPLANTED. NO PATIENT COMPLICATIONS HAVE BEEN REPORTED AS A RESULT OF THIS EVENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 CAPSUREFIX NOVUS IMPLANTABLE PACING LEAD DTB MEDTRONIC PUERTO RICO, INC. 5076 ASKU

    Patients

    Seq Age Sex Outcome Treatment
    1 85 YR Required Intervention