BEUDAMED
    FDA Adverse Event Death Summary report: N

    CAPSUREFIX NOVUS MRI

    MDR report key: 2111233 · Received June 2, 2011

    Report

    Report Number
    2649622-2011-07713
    Event Type
    Death
    Date Received
    June 2, 2011
    Date of Event
    May 25, 2011
    Manufacturer
    MEDTRONIC PUERTO RICO, INC.
    Product Code
    NVN
    PMA / PMN Number
    P090013
    Removal / Correction Number
    ASKU
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    PA, 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 THE IMPLANT PROCEDURE ONE OF THE LEADS PERFORATED THE MYOCARDIUM WHICH LED TO CARDIAC TAMPONADE AND EVENTUALLY PATIENT DEATH. NO SPECIFIC MECHANICAL FAILURE WAS IDENTIFIED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 CAPSUREFIX NOVUS MRI IMPLANTABLE PACING LEAD NVN MEDTRONIC PUERTO RICO, INC. 5086MRI ASKU

    Patients

    Seq Age Sex Outcome Treatment
    1 90 YR Death| H| L| R