BEUDAMED
    FDA Adverse Event Injury Summary report: N

    SPRINT QUATTRO SECURE

    MDR report key: 2123880 · Received June 14, 2011

    Report

    Report Number
    2649622-2011-08196
    Event Type
    Injury
    Date Received
    June 14, 2011
    Manufacturer
    MEDTRONIC PUERTO RICO, INC.
    Product Code
    LWS
    PMA / PMN Number
    P920015/S24
    Removal / Correction Number
    Z-0475-2011
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    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): THE ACTUAL DEVICE WAS NOT RECEIVED FOR EVALUATION. WE DID RECEIVE PERFORMANCE DATA COLLECTED FROM THE DEVICE AND HAVE ANALYZED THE DATA. TWO - PATIENT ALERTS FOR OUT OF TOLERANCE SUBTHRESHOLD LEAD IMPEDANCE ON (B)(6) 2011 15:00:03 AND (B)(6) 2011 03:00:04. WEEKLY HV LEAD IMPEDANCE TREND DATA SHOWS VARYING IMPEDANCE AND AN ABRUPT INCREASE FOR MIN AND MAX SVC DEFIB IMPEDANCE= 64 TO 228 OHMS PEAK, BETWEEN (B)(6) 2010 AND (B)(6) 2011.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT THE PATIENT WENT TO THE EMERGENCY ROOM DUE TO HEARING A PATIENT ALERT. A DEVICE INTERROGATION SHOWED HIGH IMPEDANCE FROM THE RIGHT VENTRICULAR LEAD AND THE LEAD TRENDS SHOWED THAT THE IMPEDANCES VARIED. CHEST X-RAYS SHOWED AN APPARENT SUBCLAVIAN CRUSH AND A DEFINITIVE CHANGE IN SHAPE AND SIZE OF THE LEAD BODY. IT WAS FURTHER REPORTED THAT THE POCKET WAS OPENED AND IT WAS FOUND THAT THE LEAD PIN HAD BACKED OUT OF THE HEADER. THE LEAD WAS REINSERTED AND SCREWED IN. BOTH THE DEVICE AND LEAD REMAIN 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 SPRINT QUATTRO SECURE IMPLANTABLE TACHY LEAD LWS MEDTRONIC PUERTO RICO, INC. 6947 ASKU

    Patients

    Seq Age Sex Outcome Treatment
    1 51 YR Hospitalization| R 5076 IMPLANTABLE PACING LEAD