BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    CAPSUREFIX NOVUS

    MDR report key: 1923095 · Received December 13, 2010

    Report

    Report Number
    2649622-2010-13232
    Event Type
    Malfunction
    Date Received
    December 13, 2010
    Date of Event
    September 21, 2010
    Manufacturer
    MEDTRONIC PUERTO RICO, INC.
    Product Code
    DTB
    PMA / PMN Number
    P930039/S017
    Removal / Correction Number
    ASKU
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    CA, 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) NO ANOMALIES WERE FOUND. THE FULL LEAD WAS RETURNED AND ANALYZED. THERE WAS BLOOD IN/ON THE HELIX MECHANISM AND SLEEVEHEAD.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT THE PHYSICIAN ATTEMPTED TO POSITION THE LEAD IN SEVERAL DIFFERENT LOCATIONS AND THAT THE LEAD'S FIXATION HELIX EVENTUALLY BECAME IMPINGED WITH TISSUE AND HE WAS UNABLE TO CLEAN IT OUT. THE LEAD WAS REMOVED AND RETURNED AND A NEW LEAD WAS IMPLANTED. THERE WERE NO PATIENT COMPLICATIONS 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. 4076 ASKU

    Patients

    Seq Age Sex Outcome Treatment
    1 79 YR Other