BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    CAPSUREFIX NOVUS

    MDR report key: 1926349 · Received December 14, 2010

    Report

    Report Number
    2649622-2010-14296
    Event Type
    Malfunction
    Date Received
    December 14, 2010
    Date of Event
    October 13, 2010
    Manufacturer
    MEDTRONIC PUERTO RICO, INC.
    Product Code
    DTB
    PMA / PMN Number
    P930039/S009
    Removal / Correction Number
    ASKU
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    MI, 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) UPON ANALYSIS, IT WAS REPORTED THAT THE DISTAL CONDUCTOR WAS DISTORTED, THERE WAS BLOOD/FLUID ON THE PROXIMAL CONDUCTOR (NON-OBSTRUCTING), THE OUTER INSULATION WAS BREACHED/CUT. IT WAS APPARENT THAT DAMAGE OCCURED DURING EXPLANT. THE FULL LEAD WAS RETURNED FOR ANALYSIS.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT DURING THE IMPLANT THERE WAS HIGH IMPEDANCE AND BLOOD INGRESS IN THE LEAD WHICH MADE IT DIFFICULT TO INSERT THE STYLET. THE LEAD WAS NOT IMPLANTED AND A DIFFERENT LEAD WAS IMPLANTED. NO 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 74 YR Other