FDA Adverse Event
Injury
Summary report: N
CAPSUREFIX NOVUS
MDR report key: 2130768
·
Received June 16, 2011
Report
- Report Number
- 2649622-2011-10239
- Event Type
- Injury
- Date Received
- June 16, 2011
- Date of Event
- April 22, 2011
- 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
- CT, 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 THERE WERE NO ANOMALIES FOUND AND THERE WAS BLOOD IN/ON THE HELIX/LOBE MECHANISM. THE FULL LEAD WAS RETURNED FOR ANALYSIS.
Description of Event or Problem · 1
IT WAS REPORTED THAT THE ATRIAL LEAD DISLODGED. THE LEAD WAS EXTRACTED AND NOT REPLACED. 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 | 91 YR | Hospitalization| R | SEDR01 IMPLANTABLE PULSE GENERATOR| 5076 IMPLANTABLE PACING LEAD |