BEUDAMED
    FDA Adverse Event Injury Summary report: N

    CAPSUREFIX NOVUS

    MDR report key: 1924431 · Received December 14, 2010

    Report

    Report Number
    2649622-2010-13561
    Event Type
    Injury
    Date Received
    December 14, 2010
    Date of Event
    September 21, 2010
    Manufacturer
    MEDTRONIC PUERTO RICO, INC.
    Product Code
    DTB
    PMA / PMN Number
    P930039/S009
    Removal / Correction Number
    ASKU
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    FL, 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.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT DURING A NORMAL DEVICE CHANGE OUT, THE ATRIAL LEAD HAD MINIMAL OR NO SENSING, EVEN DURING A FAST ATRIAL TACHYCARDIA EPISODE. THE ATRIAL LEAD WAS CONNECTED TO THE NEW DEVICE, AND THE MODE WAS PROGRAMMED TO VVIR MODE. NO FURTHER PATIENT COMPLICATIONS WERE 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 6949 IMPLANTABLE TACHY LEAD| 4193 IMPLANTABLE PACING LEAD