BEUDAMED
    FDA Adverse Event Injury Summary report: N

    ATTAIN OTW

    MDR report key: 1925265 · Received December 14, 2010

    Report

    Report Number
    2649622-2010-13778
    Event Type
    Injury
    Date Received
    December 14, 2010
    Date of Event
    September 27, 2010
    Manufacturer
    MEDTRONIC PUERTO RICO, INC.
    Product Code
    DTB
    PMA / PMN Number
    P010015/S012
    Removal / Correction Number
    ASKU
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    OK, US
    Reporter Occupation
    PATIENT

    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 THE PATIENT WAS EXPERIENCING "HICCUPPING", DUE TO DIAPHRAGMATIC STIMULATION FROM THE LEFT VENTRICULAR LEAD. THE LEAD CONFIGURATION WAS REPROGRAMMED, AND IS STILL IN USE. NO PATIENT COMPLICATIONS HAVE BEEN REPORTED AS A RESULT OF THIS EVENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 ATTAIN OTW IMPLANTABLE PACING LEAD DTB MEDTRONIC PUERTO RICO, INC. 4194 ASKU

    Patients

    Seq Age Sex Outcome Treatment
    1 72 YR Required Intervention (B)(4) PAIN STIM LEAD| 3550 NEURO ADAPTOR| 5076 IMPLANTABLE PACING LEAD| 7495 NEURO EXTENSION| 6947 IMPLANTABLE TACHY LEAD| 7435 NEURO PROGRAMMER| 7427 PAIN STIM IPG| 4194 IMPLANTABLE PACING LEAD